0B-GYNE GOLD Guide in Surviving Daily Rounds SECOND EDITION say Sam, Villafuerte, MD. Obstetrics and Gynecology Resident Andrew Rufino M. Villafuerte Medical Intern2nd Edition Pending Copyright © 2017. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner. Printed in the Philippines. NOTICE Most of the contents of this book were taken from the little gold notebook of Mary Grace M. Villafuerte, MD., which were written during her integrated clinical clerkship and internship in Philippine General Hospital. Information were updated to keep up with the ever changing landscape of medicine. The contents of this book are not error free. You can use the information at your own discretion but it is recommended that you countercheck them using recommended references. This is far from being comprehensive and is meant only to be supplementary.8.4. Multifetal Pregnancy ..... SECTION 9, MEDICAL COMPLICATIONS 9.1. Gestational Diabetes Mellitus 9.2. Gravidocardiac ..... 9.3. Thyroid Storm... 9.4. Acute Pyelonephritis .. 5. Antiphospholipid Antibody Syndrome w Growth in Pregnancy (PONG) .... == te 93 SECTION 10. BPP AND BIOMETRY SUMMARY ROUNDS: GYNECOLOGY SECTION 1. MENSTRUAL CYCLE SECTION 2, ABNORMAL UTERINE BLEEDING . 2.1. Endometrial Polyp (AUB-P) 2.2, Adenomyosis (AUB-A) .. 2.3. Leiomyoma (AUB-L) . 2.4, Malignancy and Hyperplasia 2.5. Polycystic Ovarian Syndrome (AUB-0) §.. SECTION 3. VAGINAL INFECTIONS SECTION 4. COMMON BENIGN GYNECOLOGIC PATHOLOGIES ... SECTION 5, PELVIC ORGAN PROLAPSE .. SECTION 6. OVARIAN NEW GROWTH GYNE-ONCO ROUNDS Section 1. Gynecologic Surgeries .. Section 2, Cervical Cancer Section 3. Endometrial Hyperplasi:Section 4. Endometrial Cancer 133 Section 5. Ovarian Concer 138 TROPHO ROUNDS Section 1. Hydatidiform Mole Section 2. Gestational Trophoblastic Neoplasia SD BIOETHICS Four Major Principles in Bioethics ad Jonsen’s Four-Box Method ___ 2 Other Principles in Bioethics ....... oe APPENDIX Appendix A. How to Present a Case ... Appendix B, Details in the OB Sh Appendix C. OBAS Labs Appendix D. Colorado CI viRATES Birth rate Live births per 1000 females Fertility rate Live births per 1000 females aged 15-44 yo PERIODS (pediatric) Perinatal Period —_ Interval between birth and 28 days after birth Neonate From birth until 28 days after birth Infant Until 1 year of age PERIODS (maternal) Abortion <20 weeks AOG, or <500 grams Preterm <37 weeks AOG Term 37-42 weeks AOG Postterm >42 weeks AOG Puerperium Time from delivery lasting about 4-6 weeks EARLY AND LATE Early abortion <12 weeks AOG Late abortion >12 weeks AOG but <20 weeks AOG Early ultrasound done $20 weeks AOG Late ultrasound done >20 weeks AOG Early preterm <34 weeks AOG Late preterm 34-36 completed weeks AOG Early term 37 completed weeks up to 38 6/7 weeks (3 weeks) Full term 39 completed weeks up to 40 6/7 weeks (3 weeks) Late term 44 completed weeks up to 41 6/7 weeks (2 weeks) Early neonatal death Death of a live born within first 7 days Late neonatal death Death after 7 days but before 29 daysANTERIOR ABDOMINAL WALL Layers of the Anterior Abdominal Wall 1. Skin 2. Camper's fascia (fatty layer) 3. Scarpa’s fascia (membranous layer) > Colles fascia 4. Muscles Mnemonic: Fatty Camper! Blood Supply Superficial Skin, subcutaneous, epigastric artery mons pubis Deep/inferior Muscle, fascia epigastric artery EXTERNAL GENERATIVE ORGANS Male Homologues Labia minora Penile urethra, skin of penis Labia majora Scrotum Clitoris Penis Skene's glands Prostate gland Bartholin’s glands Cowper's gland Vulva Mons pubis/Mons veneris Labia majora Labia minora Clitoris Hymen Vestibule SP Feb =Borders of the Vulva Superior: Mons pubis Lateral: Labiocrural fold Inferior: Perineal body Six Openings of the Vestibule 1. Urethra 2. Vagina 3. Two Bartholin gland ducts (5 and 7 o'clock position) 4. Two Skene gland ducts (paraurethral) } «& >» Clinical Pearl: Bartholin duct cysts are surgically / managed by marsupialization. PERINEUM Urogenital Triangle (anterior triangle) boundaries e —Pubis symphysis (tip) e — Ischiopubic rami (lateral) © — Ischial tuberosities Anal Triangle (posterior triangle) boundaries © — Ischial tuberosities e — Sacrotuberous ligaments (lateral) e Coccyx (tip) Superficial Space of the Anterior Triangle contains: 1. Bartholin glands Vestibular bulbs (veins) Clitoral body and crura Pudendal vessels and nerves Ischiocavernosus muscle Bulbocavernosus muscle Superficial transverse perineal muscle 1Oan PwrDeep Space of the Anterior Triangle contains: 1. Compressor urethrae muscles 2. _Urethrovaginal sphincter muscles Posterior Triangle contains: 1. Ischioanal fossae (fat-filled space) 2. Anal canal 3. Anal sphincter complex 4. Puborectalis muscle Anal Sphincter Complex Innervation Blood supply Internal anal Pelvic splanchnic Superior, middle, sphincter nerve and inferior rectal arteries External anal Inferior branch of __ Inferior rectal artery sphincter pudendal nerve (branch of internal pudendal artery) Clinical Pearl: External hemorrhoids — distal to pectinate line Internal hemorrhoids — proximal to pectinate line Components of the Pelvic Diaphragm 1. Levator ani a. Pubococcygeus/Pubovisceral i. Pubovaginalis li. Puboperinealis iii. Puboanalis b. Puborectalis c. lliococcygeus 2. Coccygeus Components of the Striated Urogenital Sphincter Complex 1 wnDual blood supply Vaginal Blood supply Vaginal artery r 7 Gienoarery Proximal portion Middle rectal artery Posterior vaginal wall Internal pudendal artery Distal portion Clinical Pearl: The ureter lies underneath the uterine artery (Mnemonic: Bridge over water/urine). Be careful during ligation of the uterine arteries. You might ligate the ureter as well! Clinical Pearl: The ovaries are medial to the internal iliac vessels. This is helpful in locating the ovaries intraoperatively or during ultrasound examination. Ligaments 1. Round ligament (male homologue: gubernaculum testis) 2. Broad ligament 3. Cardinal or Transverse cervical or Mackenrodt ligament (thick base of the broad ligament) 4. Uterosacral ligament Clinical Pearl: The main support of the uterus is provided by the cardinal ligament and the uterosacral ligament. That is why in cases of pelvic organ prolapse, uterosacral ligament fixation is performed. Structures in the Broad Ligament (2-fold peritoneum) 4. Uterine tube (and mesosalpinx) 2. Ureter 3. Ovarian ligament (and mesovarium)4. Round ligaments 5. Uterine blood vessels, lymph nodes, and nerves 6. Ovarian blood vessels, lymph nodes, and nerves 7. Parametrium Peritoneum Mesosalpinx Around fallopian tube Mesoteres Around round ligament Mesovarium Over the uterovarian ligament Tissues Parametrium Connective tissue lateral to the uterus within the broad ligament Paracervical Lateral to the cervix tissues Paracolpium Lateral to the vagina PELVIS Parts of the Pelvis 1. False pelvis 2. True pelvis a. Pelvic inlet b. Midpelvis c. Pelvic outlet Arteries entering the true pelvis 1. Median sacral artery 2. Internal iliac artery 3. Superior rectal artery 4. Ovarian artery pelvis as a bowl of ( q \ Forget Me Not: of miso. RO So \ a _/ misoPregnancy is a state of hypervolemia ¢ Blood volume is 40-45% above the nonpregnant by 32-34 weeks AOG Secondary to blood volume expansion (both plasma and RBC) Abnormal levels of hemoglobin 4st trimester < 10 g/dL 2 trimester < 10.5 g/dL 34 trimester <11 g/dl Average Hemoglobin at term: 12.5 g/dL, abnormal if <11 g/dL ooPRESUMPTIVE EVIDENCE Symptoms 1. Morning Sickness 2. Fatigue 3. Frequency in urination 4. Quickening 5. Cessation of menses 6. Beading cervical mucus 7. Chadwick's sign 8. Changes in breast 9. Skin changes 10. Increased temperature = 6-18 weeks peak of HCG is 8-10 weeks; plateaus at 16 weeks = 1st and 3rd trimester, due to bulky uterus = 16-20 weeks Amenorrhea is not a reliable sign until 10 days or more after expected menses 6 weeks; poor crystallization or beading is due to progesterone /€),>» Ferning, a sign of increased Qs estrogen, makes pregnancy unlikely. Ferning is also observed as a result of amniotic fluid leakage. 6 weeks; vaginal mucosa becomes dark- bluish red and congested 6-8 weeks: engorgement starts due to MSH © Chloasma/Melasma - mask of pregnancy o Linea nigra - darkening of linea alba Striae gravidarum — collagen breakdown Spider telangiectasia - due to increased estrogen 6 weeks; due to increased progesteronePROBABLE EVIDENCE 1. Enlargement of = Starts at 6 weeks abdomen “=>, At 12 weeks, fundus is palpable ( Op) on bimanual exam, the uterus “=~ has become an abdominal organ . Hegar’s sign = 6-8 weeks; softening of uterine isthmus; Firm cervix now contrasts with softer fundus and isthmus . Goodell’s sign = 6-8 weeks; softening of the cervix . Braxton Hicks = 28 weeks; painless, perceptible, not contractions regular . Physical outlining of fetus . Ballottement = Evident in the 2nd semester . Detection of B- = 6 days after fertilization, 8-9 days post- hCG implantation = Pregnancy test - positive at 12.5 mlU/mL (very sensitive) Note that a positive pregnancy test is only a probable evidence of pregnancy. Rare causes of positive pregnancy test without pregnancy are: 1. Exogenous hCG injection 2. Renal failure with impaired hCG clearance 3. Physiological pituitary hCG 4, hCG-producing tumors (usually Gl, ovarian, bladder, or lung origin)POSITIVE SIGNS 1. Fetal heart tone 2. Perception of fetal movement by examiner 3. Sonographic recognition @ Eponym Signs Isthmus — Hegar's sign Normal rate: 120-160bpm Auscultation: As early as 16 weeks Doppler ultrasound: 10 weeks TV-UTZ: 5 weeks TV-UTZ: gestational sac by 4-5 weeks AOG; yolk sac by 5 weeks Early UTZ: done before 12 weeks AOG (most accurate aging too!) 6-8 weeks Softening Cervix Goodell’s sign 4 weeks Softening due to edema « Vagina Chadwick's sign 6 weeks Violaceous due to increased blood cervix, vagina; You can use this mnemonic: Hey Good Chad! Hegar - ® Forget Me Not: Anatomically arranged from superior to inferior: isthmus, isthmus, Goodell - cervix, Chadwick - vaginaHISTORY am |. Initial Prenatal Work-up x ae OO Gms GP Em ee ie Pe Ss CBC with DC/PC Blood typing Urinalysis (ideally urine culture) Fasting blood sugar HBsAg Rubella IgG VDRL, RPR ICC ELISA Pap smear . 75g OGTT at 24-28 weeks AOG . Biometry +/- BPP at 24-28 weeks AOG Clinical Pearl: 75 grams OGTT is done at 24-28 weeks AOG because human placental lactogen (HPL) is produced during this time. HPL has growth hormone-like action and causes insulin resistance, lipolysis, and increased fatty acids. Clinical Pearl: Biophysical profile (BPP) is done at 24-28 weeks AOG because pregnancies with severe complications require early testing. (In general, testing begins at 32-34 weeks AOG,) At less than 24 weeks AOG, the examiner might not be able to appreciate well all the components of the BPP. Biometry, on the other hand, can be done anytime. osta» ll. 10 Danger Signs of Pregnancy FH 1. Headache Blurring of Vision Prolonged vomiting Fever Nondependent edema oReN 6. Epigastric/RUQ pain 7. Decreased fetal movement 8. Dysuria 9. Bloody vaginal discharge 10. Watery vaginal discharge body signs and 5 lower body signs (as divided above). But later on you'll realize that they are called “danger signs” because they herald fetomaternal distress from possible infection, abortion, and even preeclampsia! (a.k.a the most dangerous complication in pregnancy). They may also signify imminent delivery (e.g. bloody show or RBOW). ® Forget Me Not: You can remember it by dividing the 10 signs into 5 upper 10 Danger Signs of Pregnancy (the logic behind) Signs of Preeclampsia 1. Headache 2. Blurring of Vision 3. Prolonged vomiting 4. Epigastric/RUQ pain 5. Nondependent edema Signs of Infection like UTI, which may cause PROM 6. Fever 7. Dysuria 8. Watery vaginal discharge Signs of threatened ancy 13Ill. Obstetric Score: G_P_(---) Gravida Para (Term — Preterm - Abortuses — Children currently alive) Gravidity Number of pregnancies irrespective of outcome Parity Number of pregnancies reaching 20 weeks © Not increased if multiples are delivered in a given pregnancy (count multiples as 1 parity, . but TPAL is affected) o Not decreased by stillbirths (count still births) © Twin abortion is counted as 1 in A of TPAL IV. Estimated Date of Confinement (EDC) Naegele’s Rule EDC = LNMP +7 days — 3 months V. Trimesters Divided into three periods of 14 weeks each ‘sttrimester Until 14 weeks AOG; . spontaneous abortions occur here 2nd trimester — Until 28 weeks AOG 3rd trimester Until 42 weeks AOG; hypertensive disorders are diagnosed here Cc Quickening Primigravid 18-20 weeks AOG Multigravid 16-18 weeks AOGHigh Risk Pregnancy 1. Extremes of age a. Young primigravidas (< 17) b. Elderly primigravidas (2 35) 2. Medical complications (HPN, DM, heart disease, asthma, infection, malignancies, etc.) 3. Poor obstetrical history a. 2 consecutive abortions 3 or more repeated abortions History of preterm delivery History of term/preterm FDU (fetal death in utero) History of term/preterm neonatal death Previous baby with congenital anomaly mpesaos 4. Placenta previa Gynecologic tumors (ONG, uterine tumors, etc.) 6. With coexisting trophoblastic disease or had trophoblastic disease within the last year = 7. Patients with problems with fetal aging, structure, and size AOG 2 41 weeks Fetal macrosomia or IUGR Unsure fetal aging Multiple gestation Fetal congenital anomalies ea9c8 8. Polyhydramnios or oligohydramniosVi Menstrual History t Forget Me Not: MIDAS: Menarche, Interval, Duration, Amount, Symptom ©; (Dysmenorthea) . Vil. Personal and Social History SMOKING increases risk for: e Placenta previa Abruptio placenta PROM Preterm delivery SGA neonate Spontaneous abortion Fetal death Fetal anomalies @ Fetal Alcohol Syndrome e Growth retardation e Facial abnormalities e — CNS dysfunction ILLICIT DRUGS increases risk for: e IUGR e SGAneonate PARTNER VIOLENCE increases risk for: e Preterm delivery e IUGR e Perinatal death 16 |PHYSICAL EXAMINATION Fundal Height (cm) | ee From top of pubis symphysis | o L1—Fundal grip to the top of the fundus; L2— Umbilical gri Between 20-34 weeks, fundus 13 -Pawlick’s ae (in cm) correlates closely with - espe gp gestational age ° elvic grip x a | Fetal Heart Tones ee (kg) o As early as 16 weeks © 20 weeks in 80% © 22 weeks in 100% |. Fundal Height \ At 12 weeks AOG, the uterus becomes an abdominal organ Se At 16 weeks AOG, the fundus is midway between the pubis symphysis and the umbilicus At 20 weeks AOQG, the fundus should be at the level of the umbilicus Ideally, bladder must be drained first, Measure fundal height if it is above the level of the umbilicus. Between 20-34 wks, fundus (in cm) correlates closely with AOG |, Fetal Heart Tones ec Doppler As early as 8 weeks eo Almost 100% by 10 weeks Stethoscope As early as 16 weeks, 80% at 20Ill. Leopold’s Maneuver L1-FUNDAL GRIP © What fetal pole occupies the fundus? © Irregular, nodular > Feet > Cephalic presentation © Hard, round, ballotable, mobile > Head > Breech presentation L2- UMBILICAL GRIP * Onwhich side is the back? © Linear, convex, bony ridge > Back o Numerous nodulations > Extremities L3 - PAWLICK’S GRIP e What fetal part lies above the pelvic inlet? o Head engaged > feel shoulder, fixed, knob-like co Head not engaged > feel round, ballotable mass L4- PELVIC GRIP e On which side is the cephalic prominence? o Opposite side as the back > Head flexed o Same side as the back > Head extended © Engaged or not? o Engaged > Hands are parallel and does not meet o Not engaged > Hands converge Leopold's Maneuver of Experienced Clinicians in identifying fetal malpresentation Sn = 88% Sp = 94%IV. Speculum Examination, Pap Smear, and Bimanual Examination PREPARATION © Wash hands . Counsel patient as to the examination Check that instruments and supplies are available Properly drape the patieni Tur on the dropiight. Put on gloves properly INSPECT AND PALPATE i Inspect and palpate the following = Labia = Clitoris = Perineum = Skene’s glands Urethra REPORT: Normai external genitalia (normal lat perineum). No lesions, masses, and pigmentations. SPECULUM EXAM 1 Inform the patient regarding the step. © Wash the speculum to lubricate. Use the proper size. © Apply downward pressure on the introitus to relax the vagine. Mommy ipapasok ko /ang po ang daliri ko. Insert the specuium on a 45 dearee angle and open the blades fully after the cervix has been identified Ipapasok ko lang po ang speculum. Hinga po sa bibig. Inspect the vaginal canal. (Check for vaginal discharge.) ( Inspect the cervix and the os. (Note color, position, smoothness, and presence or absence of discharge, check for masses.) REPORT: The vagina is pink. There are no apparent masses | or discharge. | The cervix is also pink/violaceous. There is also no apparent Masses or discharge. a ia) 19PAP SMEAR Carefully collect specimen from the ectocervix and endocervix Properly apply swabs to a previously labeled slide Fix the specimen using 95% ethanol Inform the patient that the speculum will be removed Unlock the speculum and slowly withdraw the speculum while slowly closing the blades BIMANUAL EXAMINATION Ngayon naman po i-IE kop 0 kayo. papasok ko lang po ang daliri ko. © Insert fingers properly. © Describe the: = External genitalia, = Vagina, 2 Cervix: size and consistency < Palpate the uterus and describe: «= Size, shape, location, consistency, mobility and tenderness REPORT: Normal external genitalia. The vagina is smooth and parous. The cervix is smooth, 3x3cm, closed, and non-tender. __The uterus is small/eniarged to AOG, non-tender. O Palpate the adnexa and describe: = Ovaries: size, mobility, consistency, tenderness and presence of mass |_ REPORT: No adnexal masses or tenderness. RECTOVAGINAL EXAMINATION “Mommy ipapasok ko lang po ang isang daliri ko sa inyong puwetan. Hinga po sa bibig ng malalim... Tatanggalin ko lang po ang daliri ko.” Slowly inserted the middle examination finger into the rectum with the index finger in the vaginal canal. — Check for tenderness or masses in the cul-de-sac and parametria — Explain findings to the patient.REPORT: Good sphincter tone. Intact rectal vault. No intraluminal mass. Rectovaginal septum is intact. Parametria is soft, thin, smooth, pliable, with no masses. There is no fullness on the cul-de-sac. No blood per examining finger. ASSESSMENT Basis of Age of Gestation (AOG) Last normal menstrual period (LNMP) — if regular Early ultrasound (eUTZ) Late ultrasound Quickening Fundal height Bap CS) E> PLAN FOR THE PATIENT I. Frequency of Prenatal Check-up < 28 weeks Monthly (during the first 2 trimesters) 28-36 weeks — Every 2 weeks > 36 weeks Every week (when close to term) I. Recommended Weight Gain Total Weight Gain Range a acon eu Singleton Twins = Underweight <18.5 28-40 Ibs Normal weight — 18.5-24.9 25-35 Ibs 37-54 lbs Overweight 25-29.9 15-25 Ibs 31-50 Ibs Obese 230 11-20 Ibs 25-42 Ibs 21Ill. | Weight Retention After Pregnancy Average weight gain in pregnancy 28.6lbs 4.8kg Weight loss at delivery 12 Ibs 5.5 kg (H) 2 weeks postpartum 9 Ibs 4kg Between 22-6 week postpartum 5.5 Ibs 2.5 kg Average retained weight 3 lbs 1.4 kg H - Highest 1V, Recommended Dietary Allowances (RDA) , © Dietary Fe and lodine are not enough to supply pregnancy requirements. e With potential toxic effects include: Fe, Zn, Se, Vitamin A, B6, C, D (>10,000 IU Vitamin A per day may be teratogenic) * Twice the amount of RDA should be avoided. Calories Increase 100-300 kcal/day Protein 5-6 g/day Cc) Iron 27 mg elemental Fe /day —/ 60-100 mg if large, twins, started late, irregular, or decreased hemoglobin Start giving at 24 trimester (avoid vomiting which peaks during 1s‘ trimester) Folic acid 400 meg > 4mgq if with history of neural tube defects Start giving preconception until 1 trimester =a V. Coitus Not hazardous unless placenta previa, preterm labor, abortion VI. Caffeine Intake Max: 3 cups of 5 oz. percolated coffee Vil. Travel » Safe up to 36 weeks AOG = 7 22MUST-KNOW TERMS Fetal Lie Relation of the fetal long axis to that of the mother Fetal Presentation Portion of the body that is foremost within = the birth canal Fetal Attitude Posture or habitus Fetal Position Relationship of fetal presenting part to the right or left of birth canal Warning! The fetal position in layman's terms is actually fetal attitude. Don't confuse yourself. When we say fetal position, we mean left occiput transverse, right occiput anterior, etc. Predisposing factors for Transverse Lie: © Multiparity © Placenta previa @ Hydramnios » Uterine anomalies Cephalic Presentations » Vertex/occiput (posterior fontanel) © Sinciput (anterior fontanel) i © Brow ° Face Predisposing factors for Face Presentation: ® Fetal malformation (anencephaly) * Cord coil © High parity (lax abdomen) 23Breech Presentations « Frank ¢ Complete ¢ Footling Incidence of Breech decreases with AOG Incidence AOG 25% 28 weeks 17% 30 weeks 11% 32 weeks 3% Term Landmarks in Identifying Fetal Position Presentation Landmark Vertex Occiput Face Mentum Breech Sacrum Shoulder Scapula (Back up, back down) Fetal Position Position Incidence Internal rotation Left occiput transverse 40% 90 degrees Right occiput transverse 20% 90 degrees Occiput anterior 20% 45 degrees Occiput posterior 20% 135 degrees Clinical Pearl: Caput succedaneum is local edema. Molding refers to bony changes in the fetal head, which results in shortened suboccipitobregmatic diameter. 24PHASES, DIVISIONS, AND STAGES |. PHASES OF PARTURITION Phase 1 Phase 2 Quiescence Activation Prelude to parturition Preparation for labor © Contractile unresponsiveness « Uterine preparedness for labor © Cervical softening © Cervical ripening Phase 3 Phase 4 Stimulation Involution Processes of labor Parturient recovery ¢ Uterine contraction Uterine involution ¢ Cervical dilatation © Cervical repair Fetal and placental expulsion « Breastfeeding 1. QUIESCENT PHASE Prelude to parturition Begins even before implantation Contractile unresponsiveness Cervical softening: © Increased compliance yet maintaining structural integrity; ' © Increased vascularity © Stromal hypertrophy o Glandular hypertrophy and hyperplasia Braxton-Hicks contractions may be felt 2. ACTIVATION PHASE Preparation for labor During the last 6-8 weeks of pregnancy Myometrial unresponsiveness suspended: oxytocin receptors increase, Formation of the lower uterine segment > Lightening: “the baby dropped” Cervical ripening, effacement, and loss of structural integrity: collagen fibril diameter is 25decreased leading to increased spacing between fibrils © Treatment to promote cervical ripening: = Prostaglandin E2 (PGE2) and Prostaglandin F (PGF2c) = Progesterone antagonist 3. STIMULATION PHASE e Processes of labor e Synonymous to active labor e Uterine contraction ¢ Cervical dilatation, fetal and placenta expulsion (3 stages of labor) 4. INVOLUTION PHASE Parturient recovery (the puerperium) e Uterine involution e Cervical repair e Breastfeeding Il. STAGES OF LABOR Definition-of Labor: Uterine contractions that bring about demonstrable effacement and dilatation of the cervix LB First Stage Second stage Third stage qa Starts with painful Starts with 10cm Delivery of regular contractions —_ cervical dilatation placenta and membranes Ends with cervical Ends with fetal dilatation delivery ae / ecovical ripening @. Dinoprostone 261. FIRST STAGE ¢ Starts when painful contractions become regular (5 minutes apart for 1 hour, i.e. 12 contractions per hour) e Ends with cervical dilatation Inothers, labor initiation is heralded by “bloody show” — spontaneous release of blood-tinged mucus plug from the cervical canal ¢ Contractions are painful possibly because of: co Hypoxia of the myometrium © Compression of the nerve ganglia © Cervical stretching during dilatation © Stretching of peritoneum overlying fundus ¢ Ferguson reflex: mechanical stretching of the cervix enhances uterine activity e Interval between contractions diminishes gradually from approximately 10 minutes Distinct upper and lower uterine segments > physiological retraction ring e When the thinning of the lower uterine segment is extreme as in obstructed labor, the ring is prominent > pathological retraction ring (of Bandl) © Elongation of the ovoid uterus > increased fetal axis pressure -> straightens the fetal vertebral column 2. SECOND STAGE ¢ Begins with complete cervical dilatation (10 cm) « Ends with fetal delivery ¢ Uterine contraction averages from 30-90 seconds, averaging around 1 minute. Interval between contractions is around 1 minute or less. ¢ The most important force in fetal expulsion is produced by matemal intraabdominal pressure. « Station describes descent of the fetal biparietal diameter in relation to a line drawn between two maternal ischial spines 273. THIRD STAGE * Delivery of placenta and membranes CC Ill. SEVEN CARDINAL MOVEMENTS OF LABOR 4. Engagement BPD passes thru the pelvic inlet; in many nulliparas, engagement happens even before labor begins 2. Descent Due to 4 forces: = Pressure of amniotic fluid = Pressure of fundal contractions = Maternal effort = Straightening of fetal body 3. Flexion OFD shifts to SOBD 4, Internal rotation Occiput moves toward pubis symphysis §, Extension Due to 2 opposing forces: = Pressure of fundal contractions = Resistance of pelvic floor 6. External rotation © BSD to APD of pelvic outlet (Restitution) 7. Expulsion BPD - biparietal diameter, OFD — occipitofrontal diameter, SOBD — suboccipitobregmatic diameter, BSD — bisacromial diameter, APD - anteroposterior diameter 28IV. FUNCTIONAL DIVISIONS OF LABOR Friedman's curve (1955) Fetal descent Cervical dilatation Hours 1, PREPARATORY DIVISION e Latent phase and acceleration phase (of cervical dilatation) © Little change in cervical dilatation but marked change in cervical CT components e Sedation and conduction analgesia are capable of arresting this division 2. DILATATIONAL DIVISION e Phase of maximum slope (of cervical dilatation) © Occurs most commonly after 6 cm dilatation (according to Zhang curve, 2010) e Unaffected by sedation 3. PELVIC DIVISION Deceleration phase (of cervical dilatation) and second stage of labor © Includes the cardinal movements of labor 28PLACENTA DELIVERY |. SIGNS OF PLACENTAL SEPARATION (in order) ap |. Uterus becomes globular and firmer ey 's sign) PA: 2. Sudden gush of blood 3. Uterus rises in the abdomen 4. Lengthening of the umbilical cord 1 », Forget Me Not: Mnemonic: up-down-up-down: meaning you look up to / the uterus, down to the perineum to check for the gush of blood, up again to the uterus and down again to check for the lengthening of the cord. Il. MECHANISMS OF PLACENTAL EXPULSION 1. Schultze Mechanism © Blood from the placental site pours into the membrane sac and does not escape externally until after extrusion of the placenta o Retroplacental hematoma follows the placenta or is found within the inverted sac la ( 1 )Forget Me Not: Mnemonic: “Shiny Schultze” \s 2. Duncan Mechanism o Placenta separates first at the periphery and the blood collects between the membranes and the uterine wall and escapes from the vagina. ( Vrorget Me Not: Mnemonic: ‘Dirty Duncan” © Placenta descends sideways, maternal surface appears first 31ABNORMAL LABOR PATTERNS Latent Phase Abnormalities Nullipara Multipara Prolongation disorder Prolonged latent >20 hours >14 hours phase Active Phase Abnormalities Protraction disorders Protracted active <1.2 cm/hour <1.5 cm/hour phase Protracted descent <1 cm/hour <2 cm/hour Clinical Pearl: Prolongation and protraction disorders are not dystocia per se, but their presence herald a possible dystocia. In fact, 30% of those with protraction disorders turned out to have cephalopelvic disproportion (CPD). Arrest disorders Prolonged >3 hours >4 hour deceleration phase Secondary arrest of >2 hours >1 hour dilatation of no cervical dilatation (must be in active phase) Arrest of descent >1 hour >1 hour of no increase in descent (must be in deceleration phase/2" stage of labor) Failure of descent No descent in deceleration phase or 2" stage _ of labor 32Precipitous Labor Expulsion of fetus in <3 hours Associated with: Abruptio placenta ¢ Meconium passage ¢ Postpartum hemorrhage e Low APGAR Management: ¢ B-mimetic ¢ MgSO4 Lateral decubitus CAUSES OF INADEQUATE LABOR 1. POWER: Expulsive forces a. — Uterine dysfunction b. Maternal effort PASSAGEWAY: Cephalopelvic disproportion a. Contracted pelvic inlet (DC < 11.5¢m) b. Contracted midpelvis (BSD < 8cm) © Suspicious: <10cm e Inferred: o Prominent ischial spine o Convergent pelvic sidewall o Narrow sacroiliac notch c. Contracted pelvic outlet (BTD < 8) 2 Often associated with midpelvis contraction d. Narrow pelvis (pubic arch < 90°) 3. PASSANGER: Abnormal presentation, position and development of the fetus: fetopelvic disproportion a Excessive fetal size (macrosomia is >4000g in GDM; of morbidity) 33Transverse lie (conversion can occur in <39 weeks) Compound presentation Persistent occiput posterior position Persistent occiput transverse position Hydrocephalus Fetal abdomen as a cause of dystocia ¢ Hydrops fetalis © Wilm’s tumor [ree re Clinical Pearl: Fetal size alone is seldom a suitable explanation of Qs failed labor. Other factors must be considered. Clinical Pearl: Asynclitism is the lateral deflection of the sagittal suture, posteriorly toward the sacral promontory or anteriorly toward the symphysis pubis. ANTERIOR ASYNCLITISM: sagittal suture approaches the sacral promontory and the anterior parietal bone presents itself on the examiner's fingers. (@e~ Warning! There is a difference between cephalopelvic disproportion wy (CPD) and fetopelvic disproportion (FPD). CPD happens when the problem is the pelvis (“maliit ang sipit-sipitan’). This is usually diagnosed during the first pregnancy. This is important because this may be an ‘ indication for CS delivery and a contraindication for VBAC. FPD, on the other hand, happens when the problem is a macrosomic fetus such as in GDM. This is usually diagnosed when there is dystocia on a tested pelvis. DIAGNOSIS: IMPORTANT POINTS 3 e — History of early or prelabor rupture of membranes e — Nulliparity (untested pelvis) e Estimated fetal size e Pelvimetry Labor pattern on partogram ‘MANAGEMENT Prolongation disorder Bed rest Protraction disorder Expectant and support Arrest disorder CPD: CS No CPD: oxytocin COMPLICATIONS Maternal Complications of Dystocia « — Intrapartum chorioamnionitis Postpartum pelvic infection Increased risk for Uterine atony Increased risk for uterine tears in hysterotomy Uterine rupture (especially if high parity and with prior CS) Pathologic retraction ring of Bandl (leads to rupture of LUS) Fistulas (vesicovaginal, vesicocervical, rectovaginal; due to pressure necrosis) e Pelvic floor injury > anal/urinary incontinence; POP ¢ — Postpartum lower extremity nerve injury (common fibular n.) eooeeee Perinatal Complications of Dystocia e — Peripartum fetal sepsis ¢ — Caput succedaneum and molding e Nerve injury, fractures, and cephalohematoma ADVICE e Cannot VBAC if CPD — Risk of uterine rupture for succeeding CS e — Spacing of children 12-18 months 35SHOULDER DYSTOCIA DRILL ALARMER; In proper order (from least to most ee A-Ask for help L- Lift legs (McRoberts maneuver) A- Anterior shoulder disempaction R — Rotation of the posterior shoulder M - Manual extraction of the posterior arm E-Episiotomy R - Roll on all fours ASK FOR HELP Call for help, including anesth and pedia May apply gentle traction Drain the bladder LIFT LEGS McRoberts Maneuver Remove the legs from the stirrups and sharply flex them onto the abdomen Causes straightening of the sacrum, rotation of the pubis symphysis toward the maternal head, and a decrease in the angle of pelvic inclination Although it does not increase pelvic dimensions, it frees the impacted shoulder. ANTERIOR SHOULDER DISEMPACTION Abdominal Mazzanti maneuver With the heel of clasped hands, suprapubic pressure is applied by another member of the team to the posterior aspect of the anterior shoulder Pressure may be sufficient to abduct the shoulderVaginal Rubin's maneuver - Physician's hand reaches the most anterior fetal shoulder, which is then pushed toward the anterior surface of the fetal chest 2 This abducts the shoulder, which reduces the shoulder-to- shoulder diameter. ROTATION OF THE POSTERIOR SHOULDER Delivery of the posterior shoulder Pressure applied to anterior aspect of the posterior shoulder and an attempt is made to rotate the posterior shoulder to the anterior position Woods corkscrew maneuver Delivery of the posterior shoulder (as above) then progressively rotating the posterior shoulder 180 degrees in a corkscrew fashion MANUAL EXTRACTION OF THE POSTERIOR ARM Hand grasped, swept across the chest, and delivered EPISIOTOMY ROLL ON ALL FOURS Gaskin maneuver - Moving the mother to an all fours position with the back arched, widening the pelvic outlet - Allows easier access to the posterior shoulder, anterior shoulder disempaction is by gravity 37HELPER-O H- Help E - Episiotomy L- Legs P - Pressure E - Enter R - Remove O - Other maneuvers Call for help; anesth and pedia May apply traction Drain bladder (Done later) Grab legs and flex thigh (McRoberts) Apply suprapubic pressure Internal maneuvers e.g. Woods screw maneuver Delivery of the posterior arm Cleidotomy, Zavanelli maneuver, Symphysiotomy OTHER MANEUVERS (When all else fails...) Cleidotomy Fracturing the clavicle with scissors = Usually done for a dead fetus Symphysiotomy - Symphyseal cartilage is cut = This widens the symphysis pubis = Possible morbidity: Urinary tract injury Zavanelli maneuver - Return the head to the occiput ant. or post. position Give acute tocolysis - Flex the head and slowly push it back to the vagina Caesarean delivery is then performed 38Monitoring can be: Intermittent auscultation (IA) at defined time intervals or intermittent EFM - for low risk © Continuous electrical fetal monitoring (EFM) - for high risk Goal of Intrapartal Surveillance To detect potential fetal decompensation and to allow timely intervention by assessing fetal heart rate because changes in fetal HR precedes brain injury GUIDELINE FOR INTRAPARTAL FHR MONITORING Low risk Auscultation patients First stage of labor: every 15 minutes for a duration of 1 minute soon after a contraction e Second stage of labor: every 5 minutes or every after contraction e Maternal pulse should be differentiated from fetal pulse. e Frequency and duration of maternal contractions should be noted. High risk Continuous EFM patients e Documented systematic assessment every hour 39HOWTO DO INTRAPARTAL FHR MONITORING oS 1. BASELINE HEART RATE Definition Indeterminate Normal baseline HR Bradycardia Tachycardia 2. BASELINE VARIABILITY Definition Absent Minimal Modefate (normal) Marked 3. ACCELERATION Definition If2 32 weeks AOG If < 32 weeks AOG Prolonged acceleration wy Mean FHR rounded to increments of 5 beats per minute during a 10 minute segment excluding segments that differ by >25 bpm. In documenting, minimum baseline duration is 2 minutes. If baseline duration was taken less than 2 minutes 110-160 Less than 110 More than 160 Fluctuations with irregular amplitude and inconstant frequency Amplitude range undetectable Amplitude range detectable, but < 5 beats/min Amplitude range 6-25 beats/min Amplitude range >25 beats/min Visually apparent abrupt increase in FHR above baseline, with the time from the onset of the acceleration to its acme <30 seconds Peak is 2 15 beats/min above the baseline; Lasts 2 15 seconds but < 2 minutes from onset to return to baseline Peak is = 10 beats/min above the baseline; Lasts 2 10 seconds but < 2 minutes from onset to return to baseline Lasts 2 2 minutes but < 10 minutes in duration 40Change in baseline 3. DECELERATIONS Gradual decelerations = Early deceleration = Late deceleration Variable deceleration If the acceleration lasts > 10 minutes Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction; Gradual FHR is defined as from onset to the FHR nadir is > 30 seconds (calculated from the onset of the nadir to the return) The nadir of the deceleration occurs at the same time as the peak of the contraction (it’s like the inverse graph of the contraction) = HEAD COMPRESSION > vagal nerve activation Deceleration is delayed in timing, with the deceleration occurring after the contraction = UTEROPLACENTAL INSUFFICIENCY > Hypoxia Maternal hypotension Excessive uterine activity Placental dysfunction Maternal diseases (HPN, DM. collagen-vascular) Visually apparent abrupt decrease in FHR; An abrupt decrease is defined as from onset to the FHR nadir is < 30 seconds (calculated from the onset of the nadir to the return) oooo = CORD COMPRESSION PATTERNS occlusion of vein > reduced fetal blood fetum > acceleration 4Prolonged deceleration Change in baseline *SINUSOIDAL PATTERN Definition occlusion of artery > fetal systemic hypertension > deceleration Decrease in FHR from the baseline is = 15 beats/minute, lasting 2 2 minutes but < 10 minutes in duration If the deceleration lasts 2 10 minutes Visually apparent, smooth, sine-wave-like undulating pattern in FHR baseline with a cycle frequency of 3-5 minutes that persists for 20 minutes or more =SEVERE FETAL ANEMIA co Fetal intracranial hemorrhage o Severe fetal asphyxia © Severe fetal anemia from Rh alloimmunization o Fetomaternal hemorrhage © Twin-twin transfusion syndrome o Vasa previa with bleeding 4, UTERINE CONTRACTIONS Definition Normal Tachysystole Quantified as the number of contractions present in a 10 minute window, averaged over a 30 minute period 5 contractions in 10 minutes (averaged over 30 minute window) > 5 contractions in 10 minutes (averaged over 30 minute window) *Tachysystole should always be quantified as to the presence or absence of associated FHR decelerations. 42THE THREE TIER SYSTEM FHR INTERPRETATION SYSTEM CATEGORY | FHR: Normal tracings = Strongly predictive of normal fetal acid-base status at the time of observation = Can be followed in a routine manner without any specific action required = Includes all of the following: Baseline 110-160 beats/min Variability Moderate Decelerations Absence of any late or variable decelerations e Early decelerations may or may not be present Acceleration May or may not be present CATEGORY II FHR: Indeterminate tracings = Not predictive of abnormal fetal acid-base status = Cannot be classified as Category | or Il = Requires continued surveillance and reevaluation ® Includes any of the following: Baseline Tachycardia Bradycardia (not accompanied by absent baseline variability) Variability e Minimal baseline variability © Absent baseline variability not accompanied by recurrent decelerations Marked baseline variability Decelerations —» Periodic or episodic decelerations o Recurrent variable decelerations accompanied by minimal or moderate baseline variability © Prolonged deceleration 2 2 min but < 10 min 43o Recurrent late decelerations with moderate baseline variability © Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,” or “shoulders” Acceleration e Absence of acceleration after fetal stimulation CATEGORY III FHR: Abnormal tracings = Predictive of abnormal fetal acid-base status » Requires prompt evaluation and initiation of expeditious attempts to resolve the abnormal FHR pattern, such as: © Provision of maternal oxygen exchange in maternal position © Treatment of maternal hypotension = Includes either. Baseline As below Variability Absent baseline FHR variability along with any of the following: e Recurrent late decelerations ¢ Recurrent variable decelerations e Bradycardia Sinusoidal pattern Decelerations As above NONSTRESS TEST (NST) The tracing is labeled as nonstress test when there is no contraction within the 20 minute trace. The interpretation would then be labelled as either reactive or nonreactive (as below). If there was contraction, the tracing is called an intrapartal monitoring, and interpreted as Category I-III. Reactive 22 accelerations within 20-40 minutes Nonreactive <2 accelerations 44RESUSCITATIVE MEASURES 'f the trace does not look good, like if there is minimal variability or if there are decelerations: ad 1. Put the patient on a left lateral decubitus position Go 2. Oxygen support 3. Discontinue oxytocin 4. IV fluid bolus (200cc) INTRAPARTAL MONITORING SHEET Date and time of trace Reading Service/ConsultanyOOD — Baseline FHT in increments of 5 (e.g. 145-150) Name of the patient © Variability (absent, minimal, moderate, Age, OB score, marked) complete Dx © Accelerations (+/-) LMP Decelerations (early, late, variable, to Latest vital signs as low as _) Latest IE findings Contractions (every __min, lasting _, Current medications mild, moderate, strong) Impression Reassuring, Nonreassuring, Pathologic, Suspicious (Signature of Resident) 45ACTIVE MANAGEMENT OF LABOR (in cephalic and singleton) Decreases Caesarean delivery rate 1. Amniotomy Increases the risk of cord prolapse and infection For ineffective labor (no increase in dilatation) Not for patients at latent phase 2. Oxytocin e Before giving, exclude CPD While giving, check FHR and contractions © Avoid in: © Abnormal fetal presentation © Uterine overdistention o High parity © Uterine scar e When to stop? © When contractions are 5x in 10mins o When contractions are 7x in 15mins co When contractions are longer than 60-90 secs co If fetal heart rate is non-reassuring ¢ How to give © 10-20 units in 1L = 10-20 mU/mL o Start at 6 mU/mL © Increase in 40 minute interval to 42 mU/mL © In PGH: = 10 units in 1L = Start at 8 drops/min (cc/hr) = Titrate by 2 cc/hr every 15-20 minutes = GOAL: q3-4 min contractions, moderate to strong, 60-90s, but $7 contractions in 15 mins 46Definition of Terms Induction of Labor Augmentation of Labor Stimulation of contraction Stimulation of spontaneous before spontaneous onset of |_contraction (already occurring) labor that is inadequate because of failure of cervical dilatation/descent of fetus INDUCTION OF LABOR Indications for Induction of Labor 1. Ruptured BOW without spontaneous onset of labor 2. Maternal HPN 3. Nonreassuring fetal status 4. — Postterm gestation Contraindications for Induction of Labor i Uterine factors a. Uterine scar, classical CS b. Placenta previa 2. — Fetal factors a. Macrosomia b. Fetal congenital anomaly 3. Maternal factors a. Maternal size b. Pelvic anatomy c. Active genital herpes Failed Induction of Labor © 12 hours of oxytocin after ruptured BOW without progress 47BISHOP SCORING SYSTEM Predicts labor induction outcome because the condition of the cervix is important for the success of induction 0 1 2 3 Dilatation Closed 1-20m 3-4 cm 25cm Effacement 0-30% 40-50% 60-70% 280% Consistency Firm Medium Soft - Position Posterior Mid Anterior - Station 3 2 si +1 or +2 interpretation Score of 9: high likelihood of successful induction ‘$4: unfavorable cervix, may be an indication for cervical ripening Defining Terms Dilatation Average diameter of cervical opening Effacement Degree of decrease in cervical length Position Relationship of cervical os to fetal head Station Level of presenting part in relationship to the ischial spine (which is station 0); 1cm per station; +5 is at the level of introitus Preinduction Cervical Ripening I; Prostaglandin E2 ° Dinoprostone e Preparations: © Intracervical/intravaginal gel 2.5 mL (0.5mg) gel 30 minutes g6h (max of 3 doses), 1X © 10mg vaginal insert (0.3 mg/hr) x 12 hrs (removed 30 minutes before oxytocin administration) » Mechanism of action © Changes connective tissue © Dissolution of collagen bundles © Increase water content at submucosa » — Side effect: hyperstimulation © 6 contractions in 10 minutes x 20 minutes 48Usually seen within 1 hour post-administration Note: Oxytocin administration should be delayed by 6-12 hours oo Il. Synthetic Prostaglandin E1 e — Intravaginal, 2ug Misoprostol ¢ Side effect © _Hyperstimulation © Increased fetal heart rate ¢ Banned in the Philippines; abortifacient Mechanical Dilatation of Cervix . Hygroscopic osmotic dilatation e Membrane stripping ¢ — Transcervical catheter attached to dangling urine bag with 300mL water 49Early and Late Abortion Early <12weeks Do curettage S Late >12weeks — Expectant management; Formed bony spicules can lacerate the uterus if curettage is done Awoman will ovulate as early as 2 weeks post-abortion. 501H4(-) Aoueufeud Jo subis juasqy anssy Ajeau jo aBesseg LHa (+) Ha (+) LH (+) SIOUO ajqeiseuddeup, ajqeoaiddeun) ajqeloaiddeun Jo paumdny painjdny yeu yoeqUy MOd * # # Sov 9 sai paso|d pasoig uado uado uadg, paso|d uoneyelp Bumods + ++ ++ + “fe bf pass| : ajajdwiog, + ajajdwioou +H a|qeyiAau| ++ jueulWu) oa pouayeasys suoyoequod uology yo sadAy juasayig @)Location 97% occur in the fallopian tubes o 81% ampullary © 12% isthmic © 5% fimbrial © 2% cornuallinterstitial * 3% occur in the ovary, cervix, and peritoneal cavity Clinical Pearl: Tubal rupture which occurs within the first few weeks is common in isthmic pregnancies, whereas abdominal pregnancies are those that are usually carried to term. incidence based on risk factors: e Prior ectopic pregnancy (25%) Postsalpingectomy (15-25%) Post-reversal of sterilization (4%) Clomiphene (1.3%) Copper IUD (5%) Pelvic organ prolapse (5%) Progesterone rel. IUD (23%) Other risk factors e Those causing peritubal adhesions © Prior tubal infection or STD (especially Chlamydia) o Smoking o AA/ endometriosis CLINICAL MANIFESTATIONS Classic triad: 1. Delayed menstruation 2. Pain 3. Vaginal bleeding or spotting 62« May be subtle or absent o + Syncope/vertigo o Diaphragmatic irritation may present as pain in the neck or shoulder $ ¢ Symptoms which points to ruptured ectopic: © Cervical motion tenderness © Hypotension and bradycardia © Bulging posterior fornix (blood in the cul-de-sac) DIAGNOSIS e Laboratory Test 1. B-HCG: © (+) pregnancy test at 10-20 mlU/mL © Discriminatory level of B-HCG is 1,500 mlU/MI 2. Serum progesterone © > 25 ng/ml excludes ectopic pregnancy (Sn = 93.5%) o <5 ng/ml FDU/ectopic © 10-25 ng/mL is the usual level in ectopic pregnancy e Sonography o To assess the location and the size 4. Transvaginal ultrasound wili reveal: Gestational sac at 4.5-5 weeks Yolk sac at 5-6 weeks Fetal pole with heartbeat at 5.5-6 weeks 2. Transabdominal ultrasound = Can only recognize uterine pregnancy at 28 days after timed ovulation (5-6 menstrual wks) , Clinical Pearl: Consider ectopic pregnancy when the ) } patient has: XY = (+) HCG * Nouterine pregnancy = Fluid in the cul-de-sac = Abdominopelvic mass Triaminar pattem on TV-UTZ (Sn = 38%, Sp = 94%) 53Medical Management METHOTREXATE e Folic acid antagonist - e Contraindicated in patients with: © Abdominal hemorrhage Intrauterine pregnancy Breastfeeding Immunodeficiency Chronic renal disease Chronic hepatic disease Chronic pulmonary disease Blood dyscrasia Peptic ulcer disease 0000 le) el o1/0; ¢ Predictors of success: o Initial B-HCG is the single best prognostic indicator of successful treatment using one dose of methotrexate B-HCG level Failure rate <1,000 mlU/mL 1.5% <2,000 mIU/MI 5.6% <5,000 mlU/mL 3.8% <10,000 mIU/MI 14.3% © Ectopic pregnancy size Size Success rate <3.5 93% >3.5 87-90% o Fetal cardiac activity: associated with an increased failure rate 55Single dose: 50mg/m? methotrexate, IM Two doses: 50mg/m? methotrexate, IM on day 1 and day 4 Multiple doses : = 10mg/m? methotrexate, IM on days 1, 3, 5, and 7 = Leucovorin 1mg/kg IM on days 2, 4, 6 and 8 = Stop if B-HCG is >15% = Start surveillance q7 days Side effects include: Liver toxicity (12%) Stomatitis (6%) Gastroenteritis (1%) Myelosuppression ° 000 “Separation pain’ is mild, and is relieved by analgesics EXPECTANT MANAGEMENT in e Tubal pregnancy only e Low serum B-HCG © Diameter of ectopic mass is NOT >3.5 No intraabdominal bleeding or rupture *These will lead to spontaneous resolution CA Criteria for Medical Management \ 4. Stable patient . B-HCG <1,500 . <3.5om . <6 weeks . No fetal heart rate/beat aRwn PROGNOSIS Conception rate post-ectopic pregnancy drops to 60% © 35% if G1 2 80% if G4 and above 56MISCELLANEOUS TOPICS ON ABDOMINAL PREGNANCY ¢ — Follows early tubal rupture or abortion e SSx: pain, nausea and vomiting, bleeding, decreased or absent fetal movement e Elevated maternal serum alpha-fetoprotein ON PELVIC INFLAMMATORY DISEASE. e Increases the risk for ectopic pregnancy ¢ Can be caused by STD ¢ Medications: 1. Doxycycline 100mg BID for 4 days (for Chlamydia) 2. Ceftriaxone 250mg IM (for gonorrhea) © For the partner, give: 4. Doxycycline 100mg BID for 7 days 2. Ceftriaxone 250mg IM e But now, according to POGS o Ertapenem 1g in 3.2mL 1% lidocaine IM o OR Ertapenem 1g in 10mL sterile water, transfer to 50mL NSS x 30 mins, IV ON PERSISTENT TROPHOBLAST - Incomplete removal of the trophoblast - Hence, there is a risk for persistent ectopic pregnancy - Risk factors include: o Small pregnancy (<2cm) © Early therapy (<42 menstrual days) o Serum B-HCG > 3,000 mIU/mL. © Implantation medial to the salpingostomy site Diagnosis of Persistent Ectopic Pregnancy 2 B-HCG >1,000 miU/mL on day 7 post-symptoms B-HCG >15% of original on day 7 post-symptoms B-HCG >10% of original on day 9 post-symptoms Progesterone > 1.5 ng/mL on day 9 post-symptoms 57DIFFERENT CRITERIA Rubin’s criteria for cervical pregnancy 1. Placenta intimately attached to the cervix" 2. (+) Endocervical glands opposite the placental attachment 3. Placenta attached below: a. The insertion of uterine arteries b. The anterior deflection of the bladder to the peritoneum 4. Fetal elements not within the corpus Spiegelburg’s criteria for ovarian pregnancy 1. Tubes and fimbriae are normal 2. Gestational sac is connected to the uterus via the ovarian ligament 3. Gestational sac occupy the location of the ovary 4. (+) ovarian tissue on the wall of the gestational sac Studdiford’s criteria for abdominal pregnancy 1. Tubes and ovaries are normal without signs of past or present pregnancy 2. No retroperitoneal fistula 3» Pregnancy related to peritoneal surface and early enough to eliminate secondary implantation Criteria for heterotropic pregnancy 4. Fundus enlarged to AOG 2. (+) Symptoms of pregnancy despite excision of ectopic 3. 2CL 4, (+) hemoperitoneum despite termination in IUP 5. Abdominal pain, adnexal mass and tenderness, peritoneal irritation with evidence of IUP 28 weeks Nee oeRitgen’s maneuver e@ — perineal support EPISIOTOMY Midline Mediolateral Surgical repair Easy More difficult Faulty healing Rare More common Postoperative pain Minimal Common Anatomical results Excellent Occ. faulty Blood loss Less More Dyspareunia Rare Occasional Extensions Common Uncommon PLACENTA DELIVERY SIGNS OF PLACENTAL SEPARATION (in order) 1. Uterus becomes globular and firmer (Calkin's sign) 2. Sudden gush of blood 3. Uterus rises in the abdomen 4. Lengthening of the umbilical cord BIRTH CANAL LACERATION First degree Involves the fourchette, perineal skin, and vaginal mucous membrane Second degree + Fascia and muscles of the perineal body Third degree + External anal sphincter Fourth degree Extends thru the rectal mucosa 59VAGINAL LACERATION REPAIR KEY STEPS S 1, Anesthesia @G 2. Anchor stitch and ligate bleeder 3. Vaginal mucosa closure 4. Fascia and muscle closure 5. Skin closure 6. Final anchor stitch Figure of 8 Continuous interlocking Continuous (uninterrupted) Subcuticular 60SVD advantages over CS: « Lower post-operative pain e Lower risk for postpartum infection e Less blood loss . Promotes breastfeeding Indications for Cesarean section e Previous cesarean delivery e Labor dystocia e Fetal distress e Breech presentation Estimated Rupture Rate based on Previous Incision Classical 2-9% cy T-shaped 4-9% Low vertical 1-7% Low transverse 0.2-1.5% Estimated Rupture Rate If with prior uterine rupture 2-6% at low segment If with prior uterine rupture 9-32% at upper uterus For s/p 1 CS 0.2-0.9% 0.9% if attempting trial of labor For sip 2CS 0.9-1.8% 1.8% if attempting trial of labor 61ae to Consider for VBAC 1-2 previous LSCS No other uterine scars or previous uterine rupture Previous CS Scar is at least 18 months of age Clinically adequate pelvis Double set-up available (ready for CS; OB and anesthesiologist available) e Previous indication for CS is absent e Cephalic presentation 62Breech Presentation Persists at term in 3-4% of singleton deliveries e Three types: Hips Knees Frank breech Flexed Extended Complete Flexed Flexed breech (one or both) Incomplete Flexed Below the breech breech (one or both) (one or both) RISK FACTORS Early gestational age Abnormal amniotic fluid volume Multifetal gestation Hydrocephalus Anencephaly Uterine anomalies Placenta previa Fundal placental implantation Pelvic tumors High parity (uterine relaxation) Prior breech delivery Risk of Breech Delivery First breech 34% Second breech 10% Third breech 27% 63MODE OF DELIVERY Clinical Trials Hannah Trial (2000) PREMODA Trial (2006) N= 2,083 N>8,000 Planned cesarean delivery was —_No differences in corrected associated with lower risk of neonatal mortality rates and perinatal mortality and lower neonatal outcomes risk of “serious” neonatal according to delivery route morbidity Factors Favoring Cesarean Delivery in Breech Fetus Lack of operator experience e Patient request for CS delivery e Large fetus > 3800 or 4000 g e Apparently healthy and viable fetus either with active labor or with indicated delivery e — Severe IUGR e Fetal anomaly incompatible with vaginal delivery e Prior neonatal death or neonatal birth trauma e Incomplete or footling breech presentation e —— Hyperextended head e Pelvic contraction or doubtful pelvimetry e Prior CS e Primigravid breech Risk of Cord Prolapse Cephalic 0.4% Vaginal delivery S Frank breech 0.5% Vaginal delivery Complete breech 5% cs Footling 15% csDIFFERENT MANEUVERS Methods of Delivery through the vagina * Spontaneous breech delivery ° Partial breech extraction © Total breech extraction Maneuvers in the Delivery of the Aftercoming Head CA Modified Prague maneuver - Two fingers of one hand grasping the shoulders of the back-down fetus from below while the other hand draws the feet up and over the maternal abdomen Mariceau maneuver - Index and middle finger of one hand are applied over the maxilla, to flex the head, while the fetal body rests on the palm of the hand and forearm - Gentle suprapubic pressure simultaneous applied by the assistant helps to keep the head flexed Forceps to Aftercoming head o Piper forceps: with a downward shank © Laufe forceps 65e Time from delivery lasting about 4-6 weeks UTERINE INVOLUTION Immediately postpartum 1 week postpartum 2 weeks postpartum 4 weeks postpartum 100g (involution is complete) 66 AePLACENTA PREVIA Placenta goes before the fetus into the canal Types of Previa Placenta previa totalis Totally covering the os Placenta previa partialis Partially covering the os Placenta previa marginalis Placental edge lies <1cm to the os *Gray area 1.1-2cm from the os; Trial of labor in double set-up Low-lying placenta 2-3em from the os Risk Factors for Placenta Previa = Cigarette smoking = Multifetal gestation = Maternal age >35, = Multiparity = Previous CS delivery ey Warning! In a patient who has vaginal bleeding and has no ultrasound to OG) say that her placenta is high-lying, a speculum examination must first be done prior to internal examination. If you insert your fingers into a previa, it will bleed profusely! A speculum examination of a patient with placenta previa will reveal meaty tissues at the os. a ABRUPTIO PLACENTA Separation of the placenta from its implantation site before delivery Clinical Manifestations * Sudden abdominal pain » Vaginal bleeding = Uterine tenderness Q) Clinical Peart: Placenta previa presents as painless Wy bleeding while placenta accreta presents as painful bleeding. 67Risk Factors for Abruptio Placenta Prior abruption Increased age and parity Preeclampsia Chronic hypertension Chorioamnionitis PPROM Multifetal gestation Low birthweight Hydramnios Cigarette smoking Thrombophilias Cocaine use Uterine leiomyoma PLACENTA ACCRETA, INCRETA, AND PERCRETA Abnormal placental implantation and adherence Placenta accreta Villi attached to the myometrium Placenta increta Villi invade the myometrium Placenta percreta Villi penetrate through the myometrium and to or through the serosa 68Hypertensive disorders © Complicates 5-10% of all pregnancies @ One of the deadly triad (with hemorrhage and infection) 1. Hypertensive disorders — 16% maternal mortality 2, Hemorrhage - 13% 3. Infection (Abortion - 8%, sepsis — 2%) HPHrovr TYPES OF HYPERTENSIVE DISEASE (DIAGNOSIS) Gestational Hypertension Preeclampsia and eclampsia syndrome Chronic owoetenson of any Soi0gy reecampsa Scermoeses BP = 140/90 after 20 weeks AOG (mid- pregnancy) in previously normotensive women No evidence of preeclampsia (no proteinuria) Hypertension resolves 12 weeks postpartum BP = 140/90 after 20 weeks AOG in previously normotensive women Proteinuria o 2 300mg/24h, or © Protein:creatinine ratio = 0.3, or © Dipstick 1+ persistent OR Thrombocytopenia <100,000/uL Renal insufficiency Crea >1.1dL Or 2x baseline Liver involvement AST, ALT 2x Cerebral symptoms Headache, visual disturbances, convulsions Pulmonary edema BP 2 140 O weeks AOG = posipartum New onset proteinuria (no proteinuria <20 sects A0G) or 69on chronic ¢ Sudden increase in proteinuria or in BP (if hypertension with proteinuria <20 weeks AOG), or e Thrombocytopenia (if with proteinuria <20 weeks A ‘ 0G) Blood pressure in Pregnancy e Usually decreases during the second and early third trimesters Late third trimester: BP returns to normal (difficult to distinguish whether hypertension is chronic or is due to pregnancy if patient i was not seen <20 weeks) |. PREECLAMPSIA Epidemiology ; © Seen in 3.9% of all pregnancies q © Most dangerous; Contributes 12.3% of maternal mortality © 50% of gestational hypertension leads to preeclampsia Pathology: system-wide endothelial leak Risk Factors: ¢ Young and nulliparous women Genetic predisposition Maternal weight, Obesity, Metabolic syndrome Multifetal gestation Hyperchromocysteinemia Preeclampsia in previous pregnancy Classification ‘ Nonsevere Severe Diastolic BP < 110 mmHg 2 110 mmHg 70 Systolic BP < 160 mmHg 2 160 mmHg Thrombocytopenia Absent Present Proteinuria None to positive None to positive Oliguria, or Absent Present pulmonary edema Serum creatinine Normal Elevated Signs z P dyepnea YL breath sounds>12 meqs/L Altered consciousness Antidote: Calcium gluconate 1g SIVP Aspirin (to prevent progression to superimposed preeclampsia) Complications © Abruptio placenta e End organ damage Intrauterine growth restriction (IUGR) e Increased risk for CS ECLAMPSIA Diagnosis © Generalized seizures not attributed to any other cause in a woman with preeclampsia Epidemiology © 10% develop before overt proteinuria can be detected ¢ May appear before, during, or after labor ¢ Most common at 3rd trimester (antepartum) ¢ |fpostpartum, usually within 48 hours (10-25% develop 48 hours postpartum) Eclampsia at first trimester is associated with molar or hydropic degeneration of placenta Management © STEP 1: Give MgSO4 ¢ STEP 2: Control severe hypertension (IV meds: Hydralazine or Nicardipine) © Goal BP: 140/90 - 155/105 mmHg * Ultimately, delivery is the treatment! * Therefore, an indication for Caesarean section 72lll. PREECLAMPSIA SUPERIMPOSED ON CHRONIC HYPERTENSION Epidemiology ¢ Compared with “pure preeclampsia,” this commonly develops earlier in pregnancy ¢ Italso tends to be more severe © Itis also often accompanied by fetal-growth restriction Risk Factors: ¢ Older women HELLP SYNDROME * Acomplication of hypertensive disorders in pregnancy ¢ Indication for Caesarean section © Components of the syndrome: o Hemolysis © Elevated Liver enzymes © Low Platelet count Tennessee Criteria LDH >600 IU/L s ASTIALT >2x elevated Platelet count <100,000/uL Partial HELLP syndrome: fulfilling 2 out 3 criteria Complete HELLP syndrome: fulfilling 3 out of 3 criteria Mississippi Criteria (2006) Platelet count = AST/ALT LDH | <50 270 2 600 IU/L I 50-100 270 2600 IU/L I 100-150 240 2600 IU/L Complications Increased risk for complications compared to those without these findings ¢ 40% of HELLP had adverse outcomes o Eclampsia - 6% 73Abruptio placenta - 10% Acute kidney injury - 5% Pulmonary edema - 10% Subcapsular liver hematoma - 1.6% . Others: stroke, coagulopathy, ARDS, and sepsis 74Obstetrical Hemorrhage Leading reason for admission of pregnant women in ICUs © Single most important cause of maternal death worldwide and is responsible for half of all postpartum deaths in developing countries Estimated Blood Loss (1962 study) Vaginal Repeat — Repeat CS with delivery cs hysterectomy <500 mL. >60% ~10% 500-1000 mL >30% ~60% ~25% 1000-1500 mL >5% ~20% ~25% >1500 mL ~10% <50% Est. blood loss is commonly only approximately half of the actual loss. Estimated blood loss in excess of “average” or 500 mL should alert the obstetrician. © 6% volume% decrease in the postpartum hematocrit is a clinically significant blood loss with vaginal delivery. This decrease signifies > 1000 mL loss in average-sized women. TIMING OF HEMORRHAGE |. ANTEPARTUM a. Placenta previa b. Abruptio placenta Il. POSPARTUM a. Uterine atony (Tone) eS b. Genital tract lacerations (Trauma) c. Retained products of conception (Tissue) d. Coagulopathy (Thrombin): *Coagulation is not necessary for hemostasis unless there are lacerations in the uterus, birth canal, or perineum 75DEFINITION OF TERMS Preterm is <37 weeks AOG. Late preterm is 34-36 weeks AOG Threatened preterm labor is preterm RUC but cervix is closed COMPLICATIONS Preterm may cause: e 45% spontaneous labor e 35% spontaneous PROM ¢ 20% others: HPN, previa, abruptio Complications: e Hyaline membrane disease e Intraventricular hemorrhage Necrotizing enterocolitis * Developmental delays e Retinopathy of prematurity © Obesity ELBW <1,000 grams VLBW <1,500 grams LBW <2,500 grams There is 95% survival if: e >1,000 grams e >28 weeks, if female >30 weeks, if male Threshold of Viability 26 weeks, 750 grams Inpedia, DNR if <23 weeks and <400 grams\ 76Survival Rate Sweden USA 2004-2007 2003-2007 22 weeks 1.7% 10% 6% 23 weeks 10% 53% 26% 24 weeks 26% 67% 55% 25 weeks 43% 82% 72% 26 weeks 85% 84% (Q>) \ ee J) of gestation. Qs Clinical Pearl: Survival is a function of both weight and age 14. Maternal/Fetal Indication (30-35%) a. e@renog Pre-eclampsia Chronic hypertension DM Abruptio placenta Placenta previa Fetal distress SGA 2. Spontaneous unexplained oreterm labor, intact BOW (40-45%) a. b. c. Progesterone withdrawal Oxytocin initiation Decidual activation 3. PPROM (30-35%) a. wang intramnionic infection LSES Low BMI (<19.8) Nutritional deficiencies Smoking 4. Twins and higher order muitifetal birth 7Saar ae of Progesterone Withdrawal At near term, there is increased sensitivity of fetal-adrenal system to ACTH Increased fetal cortisol Cortisol stimulates 17 a-hydroxylase Leads to decreased progesterone and increased estrogen (reversal of E/P ratio) 5. Increased prostaglandin Pon 6. LABOR Antecedents e Threatened abortion e Lifestyle ¢ Interval between pregnancies: <18 mos, >59 mos Prior preterm delivery increases the risk of another preterm 1st baby <35 weeks 5x increased risk <34 weeks 16x increased risk 1s and 24 baby — <34 weeks 41x increased risk e Infection © Causes of chorioamnionitis: = Ureaplasma urealyticum = — Mycoplasma hominis © Cut-off in pregnancy: = ESR>60 = CRP> 12SCREENING AND DIAGNOSIS Screening e Sonography: cervical length and fetal fibronectin (with NPV) Diagnosis 1. Contractions o 4in 20 minutes or 8 in 60 minutes o Plus progressive changes in cervix = Dilatation = Effacement = Funneling (T > Y >V > U) © Bulging of the membrane within the endocervical canal at least 25% of the cervical length = Cervical length o Mean at 24 weeks: 3.5 cm o Abnormal if s 2.5 cm Cervical dilatation = 1¢m Cervical effacement = 80% Fetal fibronectin (FFN) o Positive if >50 ng/mL (between 24-34 weeks) © Cervicovaginal sample < o Reflects stromal remodeling in cervix prior to labor o Note: FFN in <20 weeks AOG is normal; co Note: (+) FFN: increased risk of PT delivery at 7-10 days ree INCOMPETENT CERVIX / CERVICAL INSUFFICIENCY = — Recurrent, painless, cervical dilatation = Dilatation without contraction » — Usually at second trimester (midtrimester) = _ Management: Cerclage © Ideal time: 14-22 weeks AOG o Because cervix shortens as AOG progresses © Absolute contraindication for cerclage: Uncontrolled uterine contractions because if done, may lead to: * Uterine rupture = Cervical laceration ®) 79PREVENTION Progesterone » 17-hydroxyprogesterone caproate (Proluton) 250mg IM qiweek (ti2 = 7 days) * — Vaginal progesterone 100-200mg OD (ti = 13 hrs) © — Start at 16-20 weeks until 36 6/7 weeks AOG or until delivery MANAGEMENT CORTICOSTEROIDS e WHO: at risk of preterm delivery (24-34 weeks AOG) e WHAT: single course of: (a) o Dexamethasone 6mg IM q12 x 4 doses > o Betamethasone 12mg IM q24h x 2 doses (prevents/decreases risk for |VH) e WHY: decreases risk for HMD, NEC, fetal sepsis 2 WHEN: all pregnant 24-34 weeks AOG at risk (unless delivery is imminent in $ 1 hour) © Single rescue dose can be given if: = previous was 2 weeks ago = gestational age <32 6/7 weeks = Will deliver in 7 days © Optimal benefit begins at 24 hours, lasts for 7 days TOCOLYTIC e Primary goal: delay delivery to: o Finish course of corticosteroids © Arrange maternal transfer » Secondary goal: delay delivery to decrease perinatal morbidity and mortality associated with prematurity e WHEN: <34 weeks e — Contraindications: Abruptio co. Severe preeclampsia © intrauterine infection 2 Lethal congenital anomaly co Advanced cervical dilatation (> 4cm) 80o. Fetal compromise © Placental insufficiency 1. Nifedipine ¢ Calcium channel blocker « Loading dose: 30mg e Maintenance dose: 10-20mg a4-6hrs e Avoid in placenta previa e Less side effects 2. B-mimetic Terbutaline is the gold standard (?) (@ \\ Warning! Terbutaline should not be given for more than 48-72 hours { because of the worrisome side effects. Black box warning: it may v cause Pulmonary Edema e lsoxuprine (Duvadilan) can be given e Don’tuse in placenta previa © Side effects: i. Chest pain ii, Dyspnea ili, Tachycardia ‘ iv. Palpitation v. Tremor vi. Headache vii. Hypokalemia vill. Nausea and vomiting Magnesium sulfate (MgSO4) « Ineffective in tocolysis e For neuroprotection (in $32 weeks): decreases risk for CP © — Given 8-10 megs (2g/hour for 24 hours) In patients with History of Preterm Labor © Do cervical length monitoring starting 16 weeks o May do cerclage at 14-22 weeks ¢ Give 17 hydroxyprogesterone caproate 25mg IM qweekly until 36 weeks 81If cervical length is short, give micronized progesterone (Utrogestan) intravaginal OD o Usual dose: 200 meg co Maximum dose: 800 mcg 82Timing of Division and Corresponding Outcomes <72 hours 48th day >8 days Later Diamnionic, dichorionic Diamnionic, monochorionic Monoamnionic, monochorionic Conjoined twins 83DIAGNOSIS , Pregestational or Overt DM FBS 2126 mg/dL RBS with classical signs 2200 mg/dL 4 HbAtc 26.5% GDM © 75g OGTT aD POGS !ADPSG = WHO FBS 292 mg/dL 92 95 ; 1 hour postprandial 2180 mg/dL 180 180 2 hours postprandial 2140 mg/dL 153 155 : COMPLICATIONS Maternal Complications © Diabetic retinopathy o Microaneurysms © Blot hemorrhages : © Cotton wool exudates (proliferative) Diabetic nephropathy (pregnancy does not worsen nephropathy) ; Diabetic neuropathy/gastropathy (uncommon) Diabetic ketoacidosis (1%) { e Preeclampsia (3-4x increase) Infections (2x increase) : ° Wound complications (2-3x increase)Fetal Complications Macrosomia © Fetal weight >4,500 grams in non-GDM o Fetal weight >4,000 grams in GDM © Not synonymous to large for gestational age © Spontaneous abortion (3x increase) ¢ Preterm delivery (5x increase) © Malformations (2x increase) o Cardiovascular (52%) o Musculoskeletal (12%) © Urogenital (9%) o CNS (4%) o Others Stillbirth (3-4x increase) usu. at = 35 wks AOG Hydramnios (AFI > 24cm in the 3" trimester) Respiratory Distress Syndrome (delayed lung maturation) Hypoglycemia (<45 mg/dL) Hypocalcemia (<8 mg/dL) Hyperbilirubinemia and Polycythemia Hypertrophic cardiomyopathy (usually resolves) Long-term cognitive impairment Pathophysiology behind Macrosomia Maternal hyperglycemia > Fetal hyperinsulinemia > Macrosomia Pathophysiology behind Hydramnios Fetal hyperglycemia > Polyuria > Hydramnios Congenital anomaly (i.e. esophageal atresia) > decreased intake of amniotic fluid > Hydramnios 85MANAGEMENT Treatment Goals e For pregnant and with GDM Preprandial/FBS $95 mg/dL Premeal $100 mg/dL 1 hour postprandial $140 mg/dL 2 hours postprandial $120 mg/dL e For pregnant and with preexisting DM Preprandial/FBS/bedtime 60-99 mg/dL Peak postprandial 100-129 mg/dL HbAtc 6.0% Treatment Approach: Four Cornerstones of DM Management 4. Lifestyle modification © Isometric exercise © Medical nutrition therapy Underweight 40kcal/kg Normal BMI 30 kcal/kg Overweight 24 kcal/kg Obese 12-15 kcal/kg CHO 40-55% CHON 30-25% Fats Rest Divided into three meals and two snacks Nn . Fetal wellbeing studies (do baseline biometry with Doppler, CAS) starting 32-34 weeks AOG o NST daily (twice weekly) © Biometry q10-14 days o BPP twice weekly © FMC (fetal movement counting) 3. Monitoring of glycemic control (CBG) 4x: fasting and after meals Monitoring of end-organ damage 86Pharmacologic If diet modification and exercise fails It takes 2 weeks for diet alone to cause a significant change in the serum glucose levels. Drug of choice: Insulin Insulin does NOT cross the placenta. Metformin does. Insulin Regimen: Basal insulin (NPH) First trimester 0.7-0.8 units/kg Second trimester 0.8-1.0 units/kg Third trimester 1.0-2.0 units/kg Start with regular insulin, 2/3 given at breakfast, 1/3 given at night Note: In FDU patients, check for GDM postpartum by 75g OGTT at 6 weeks postpartum. 87New York Heart Association Classification Class | Asymptomatic Class II Symptomatic at ordinary activities Class Ill Symptomatic at less than ordinary activities Class IV Symptomatic at rest Critical Periods which might lead to cardiac decompensation Om 1. End of second trimester (hypervolemia) 2. During labor (pain) 3. Immediately after labor (increased venous return) 4. 6 weeks postpartum (normalization of cardiac output) Early Anesthesia = At the onset of pain = — Prevents cardiac decompensation = — Pathophysiology: Pain leads to increased sympathetic activity (increased HR, B), which may lead to decompensationBURCH-WARTOFSKY CRITERIA Thermoregulatory Dysfunction Cardiovascular Dysfunction 37.2 - 37.7 5 Tachycardia 37.8 - 38.2 10 HR99-109 5 38.3 - 38.8 15 HR110-119 10 38.9 - 39.3 20 HR 120-129 15 39.4 - 39.9 25 HR 130-139 20 240 30 HR2140 25 . CNS Effects CHFIAfib Absent 0 Absent 0 Mild (agitation) 10 — Mild (pedal edema) 5 Sees eee Rea 20 Moderate (bibasilar rales) 10 Severe (seizure, coma) 30 — Severe (pulmonary edema) 15 Gl-Hepatic Dysfunction Atrial fibrillation 10 Absent 0 Precipitant History erate (diarrhea, vomiting, 10 F eee eet y Negative o Severe (unexplained jaundice) 20 Positive 10 Interpretation: <25 — Storm unlikely 25-44 — Impending storm >45 Highly suggestive of storm 89CLINICAL MANIFESTATIONS © Chills e Fever Flank pain e Nausea and vomiting e + signs of lower urinary tract infection Costovertebral angle tenderness LABORATORY FINDINGS Urinalysis shows: © 25 WBC/hpf of centrifuged urine e 210,000 CFU/mL bacteriuria DIAGNOSTICS O Urine GSCS MANAGEMENT = Hydrate = UO must at least be 50 cc/hr = Antibiotics (Cefuroxime) for 10-14 days = Post-treatment urine GSCS must be obtainedCRITERIA FOR DIAGNOSIS (1 Clinical and 1 Laboratory) Clinical Criteria Vascular 2 1 episodes of arterial, venous, or small vessel thrombosis thrombosis of any tissue or organ Pregnancy 2 1 unexplained deaths of a morphologically morbidity normal fetus =10 weeks AOG 2 1 preterm births of a morphologically normal fetus <34 weeks AOG because of eclampsia, severe preeclampsia, or placental insufficiency 2 3 unexplained consecutive spontaneous abortions <10 weeks AOG Laboratory Criteria __ Lupus anticoagulant (LA) ~ Anticardiolipin (aCL) Anti-82GPI antibodies At intermediate or high titers on 2 occasions, 12 weeks apart TREATMENT = Warfarin for life + Aspirin 80mg daily = Target INR of 2.5-3.5 = IVIG 400mg/kg for 5 days may prevent abortions 91Golden Period to Operate: 14-20 weeks AOG Rationale: 1. The source of progesterone has now moved from the corpus luteum to the placenta 2. Less chance of spontaneous abortion (because spontaneous abortion is common during the first trimester) 3. Physiologic cyst is unlikely during this time. 4. Corpus does not occupy the whole abdomen (hence, operation is easier) ONG Complications = — Torsion: constant or episodic lower abdominal pain = — Hemorrhage/Intracystic bleed = Rupture 92BIOMETRY 1s trimester 2" trimester 3" trimester CRL is most accurate (variance of 3-5 days) BPD is most accurate (variance of 7-10 days) If head shape is flattened (dolichocephaly), or rounded (brachycephaly), HC is most accurate FL is most accurate CRL - crown-rump length, BPD - biparietal diameter, HC - head circumference, FL - femoral length BIOPHYSICAL PROFILE (BPP) Component Nonstress test Fetal breathing Fetal movement Fetal tone Amniotic fluid volume Score 2 Score 0 22 accelerations of 215 O or 1 acceleration beats/min for 215 within 20-40 minutes seconds within 20-40 mins 21 episode of rhythmic <30 seconds of breathing lasting =30 breathing within 30 seconds within 30 mins minutes 23 discrete body or limb <3 discrete movements within 30 movements minutes 21 episode of extremity 0 extension/fiexion extension and events subsequent return A pocket of amniotic Largest single fluid that measures at vertical pocket least 2cm in two planes 2cm perpendicular to each other (2x2 cm pocket) 93Interpretation of BPP CC Score 10 8 (normal AFV) 8 (decreased AFV) 6 Interpretation Normal Normal Chronic fetal asphyxia Possible fetal asphyxia Probable fetal asphyxia Almost certain fetal asphyxia Management BPP weekly (twice a week if the patient has DM or post-term) Deliver If abnormal AFV, deliver If normal AFV at >36 weeks with favorable cervix, deliver If <36 weeks, repeat BPP: If <6, deliver If >6, observe and repeat per protocol Repeat BPP on same day: If < 6, deliver Deliver95= Average cycle duration is 28 days (25-32 days) OVARIAN CYCLE |. Follicular or Preovulatory Ovarian Phase a. b. C. d. Se 2M oocytes present at birth 400,000 follicles at onset of puberty RATE: Lose 1000 follicles/month until age 35 Only 400 follicles are normally released during the female reproductive life >99.9% undergo atresia Recruitment of Primordial Follicles (gonadotropin) Antral follicles (due to growth factors) Primary follicles (GDF9 and BMP-15) Cohort (group of antral follicles undergoing a semi- synchronous growth due to FSH rise: “selection window’; Cohort produces Estrogen) 2-Cell Hypothesis for Estrogen Biosynthesis Receptor Produces Theca cell LH receptor Androstenedione Granulosa cell FSH receptor Estrogen Progesterone have luteinizing hormone receptors. Granulosa cells surround the ® Forget Me Not: Theca cells have theca lutein cells, hence they e. follicle, hence it is logical that they stimulate the follicle (follicle stimulating hormone receptor). Granulosa cells are the ones producing estrogen. Visual mnemonic: Imagine the granules in your chicken joy which are full of estrogen! Graafian follicle 95% of estrogen secreted by this dominant follicle 96Il Ovulation = Due to gonadotropin surge (LH and FSH) = .LH secretion peaks 10-12 hours before ovulation o Resumption of meiosis o Release of the first polar body = PROCESS: 4. Expansion © Formation of hyaluronan-rich ECM o Cells move outward © Cells lose contact of each other 2. Proteases weaken the basement membrane ill. Luteal or Postovulatory Ovarian Phase = Luteinization: Corpus luteum develops © Theca lutein o Granulosa lutein (vascularized) = Hypertrophy > more hormones are produced = LHis the primary leutropic factor maintaining the corpus luteum (logical, hence the name LH) 97= Encompasses any significant deviation from normal frequency, regularity, heaviness, and duration of menstrual bleeding. It is used to describe all abnormal menstrual signs and symptoms arising from the uterine corpus. Normal Limits of the Four Main Clinical Dimensions of Menstruation Clinical Descriptive Norma! Limits Dimensions Terms (5 — 95 percentiles) Frequency of Frequent <24 menses (days) Normal 24-38 Infrequent > 38 Regularity of Absent - menses (in days) Regular +2 to 20 days Irregular Variation > 20 days Duration of flow Prolonged >8.0 (days) Normal 4.5-8.0 Shortened <4.5 Volume of monthly Heavy > 80 ; blood loss (mL) Normal 5-80 4 Light <5 DEFINITION OF TERMS New Terminologies _ Old New ; Menorrhagia Heavy menstrual bleeding Metrorrhagia Intermenstrual bleeding Menometrorrhagia Heavy irregular bleedingAcute vs. Chronic AUB Acute AUB Chronic AUB Acute bleeding in a woman Symptoms present in the who is not pregnant, requiring majority of the last 6 months urgent and emergent medical intervention PATHOPHYSIOLOGY Hemostasis: Absence of any, or all, of these factors may result in heavier menstruation. 1. Higher thromboxane level (PGF2) in relation to prostacyclin (PGE2) 2. Fibrin clot formation 3. Stabilization of the hemostatic platelet plug CC FIGO CLASSIFICATION SYSTEM FOR CAUSES OF AUB Structural Nonstructural = Polyp = Coagulopathy = Adenomyosis * Ovulatory dysfunction Oa Leiomyoma = Endometrial = Malignancy & Hyperplasia * latrogenic = Not yet classified POLYP (AUB-P) See Section 2.1 ADENOMYSOSIS (AUB-A) See Section 2.2 LEIOMYOMA (AUB-L) See Section 2.3 MALIGNANCY AND HYPERPLASIA (AUB-M) See Gyne Onco rounds 99COAGULOPATHY (AUB-C) e Encompasses spectrum of systemic disorders © 13% prevalence rate — von Willebrand disease among women with heavy menstruation Women on chronic anticoagulant drugs are also placed in this category OVULATORY DYSFUNCTION (AUB-O) e Usually manifests as a combination of unpredictable bleeding and varying amount of flow, which in some cases result to HMB. e Itis associated with a nonsecretory endometrium. e Most common after menarche or just before the menopause © After menarche: immature HPO axis feedback > unpredictable progesterone production © Before menopause: decline of inhibin and rise in FSH disturbs ovulation Some may be due to endocrinopathies (e.g. PCOS, hyperthyroidism, etc.) ENDOMETRIAL (AUB-E) e Predictable and cyclic AUB, typical of ovulatory cycles, and without other identified causes e IfHMB ~> disorder in the mechanisms of local hemostasis If IMB or prolonged bleeding > deficiencies in the molecular mechanisms of endometrial repair e The role of infection and other local inflammatory disorders in the genesis of AUB is still not well defined. IATROGENIC (AUB-I) e Usually manifests as irregular bleeding or more commonly as “breakthrough bleeding” e May occur secondary to IUD or other pharmacologic agents that: o Directly impact endometrium, o Interferes with blood coagulation mechanisms, or © Influence the systemic control of ovulation (steroids) NOT YET CLASSIFIED (AUB-N) e Other uterine entities: chronic endometritis, AV malformations, myometrial hypertrophyDIAGNOSIS 1. History * Detailed menstrual history (MIDAS), contraceptive history, comorbidities, family history © Pregnancy must always be included * Symptoms such as intermenstrual and postcoital bleeding, pelvic pain and/or pressure symptoms suggest structural or histologic abnormality e Risk factors for endometrial carcinoma should be sought 2. Physical examination Assess for anemia, thyroid disease, and coagulopathies e Abdominal palpation, pelvic, and bimanual examination 3. Diagnostics (Non-imaging) e CBC in all women with AUB (iron deficiency is an associated problem at a MBL of 60-80 mL) e Pregnancy test should be done in women of reproductive age group © Abortion o Ectopic pregnancy o Placenta previa © Abruptio placenta © Gestational trophoblastic disease © Coagulation tests may be considered only in women with HMB at an early age (since menarche) and have a personal or family history suggestive of coagulopathy © Thyroid screening should only be done in the presence of SSx of thyroid disease. 4, Imaging procedure ¢ UTZ: 1 line in Dx structural abnormalities 101Exophytic mass Variable size (0.5-3 cm in diameter) Single or multiple Sessile or pedunculated Most commonly arise in the fundus Found in all age groups, but mostly in older women RISK FACTORS © Tamoxifen use O Infertility CO Hormone Replacement Therapy (estrogen-only and combined) PATHOLOGY = Overgrowth of endometrial glands and stroma with vascular core * Glands may be hypertrophic, atrophic or secretory/functional (of no clinical significance) = Exact mechanism why they increase bleeding are poorly understood Development = Thought to be related to hyperestrogenism = Mutations in chromosomal regions 6p21 and 12a15, sites in which HMGIC and HMGIY genes are located Progression to carcinoma = Rarely progress to carcinoma (endometroid or serous) = More rarely progresses to carcinosarcoma = Occasional reports of metastatic carcinoma (breast lobular CA) 102Risk Factors for progression to carcinoma Postmenopausal (5% vs 1-2% in premenopausal) © Symptomatic vaginal bleeding (4.5%.vs 1.5% in asymptomatic) 1 Tamoxifen use (association) O Obesity (association) CLINICAL MANIFESTATIONS = May be asymptomatic * AUB (intramenstrual, menometrorrhagia, postmenopausal) if they ulcerate or undergo necrosis = May be associated with dysmenorrhea = Prolapsing mass into the endocervical canal DIAGNOSIS * TV-UTZ = Sonohysterogram (SIS) = Hysteroscopy = Endometrial Biopsy in = 35 yo ~ Nomenclature AUB-Po: absent in ultrasound and/or hysteroscopic imaging AUB-P:: present in ultrasound and/or hysteroscopic imaging TREATMENT « <1cm regresses spontaneously " Hysterosocopic guided polypectomy = Hysterosocopic guided curettage Goals of Treatment 1. To relieve the patients of AUB symptoms 2. To decrease risk of infertility, EM hyperplasia and CA 3. To unmask possible bleeding from EM hyperplasia or CAPATHOPHYSIOLOGY e Several hypotheses have been introduced: © An increase in the endometrial surface © Altered PGE/PGF2a balance o Hampered myometrial contractility co Abnormal myometrial angiogenesis associated with fragile DIAGNOSIS e Enlarged uterus 4 e History of dysmenorrhea Ultrasound criteria comprise the minimum requirement for its diagnosis (AUB-A;) = coarse echo pattern on UTZ © Pathological: glands in the myometrium, 1 low power field . (~2.5m) beyond basement membrane 104PATHOPHYSIOLOGY © Increased surface area of the endometrium due to mechanical distortion © Ulceration and hemorrhage of endometrium overlying the submucous fibroids © Interference by the myomas with normal uterine hemostasis o Mechanical compression of the venous drainage by the myomas at any site © Dilatation of the venous plexuses draining the endometrium DIAGNOSIS © Typically presents as HMB, which may be sufficiently severe to cause anemia _ © Location Submucosal Intramural Subserosal Parasitic (independent of the uterus) Submucous myomas are highly vascularized. Bleeding cannot be stopped promptly by myometrial contractions because of their intracavitary position. ° oo°0 105FIGO CLASSIFICATION OF MYOMA iC SM — submucosal O-other Hybrid (impact both endometrium and serosa) wnse aoe wy Pedunculated intracavitary < 50% intramural = 50% intramural Contacts endometrium; 100% intramural Intramural Subserosal 2 50% intramural Subserosal <50 % intramural Subserosal pedunculated Other (specify e.g. cervical, parasitic) Two numbers separated by a hyphen. By convention, the first tefers to the relationship with the endometrium while the second refers to the relationship with the serosa 106Amenorrhea Hirsutism Obesity Insulin resistance Infertility In the absence of enzymatic disorders or Cushing’s syndrome, or tumors DIAGNOSIS Rotterdam Criteria (2 out of 3) Menstrual irregularity Hyperandrogenism Polycystic ovaries on UTZ 10780h sfep 1 x aig Bugos ual} ‘Od asop 67 auo ajozepiuoey sKep / x Aep Jad auo ‘Aioysoddns JeulBea Bug} ejozeuoaip) :ajozy sfep 1 x aig Swoos ajozepluonayy juewabeuey 788} JIUM OAHISO © sije0 anja %OZ< © abieyosip Aiajyem uly, © Sy40, excision is done to rule out malignancy © Treatment of Abscess: IND + antibiotics © Post-op: may do warm sitz bath for pain relief 109NABOTHIAN CYST © Cervical retention cyst Due to intermittent blockage of endocervical gland ¢ Commonly found in menstruating females e Usually asymptomatic © Requires no treatment CERVICAL POLYP e Usually asymptomatic © May present with intermenstrual spotting e Rx: office polypectomy ANATOMIC ANOMALIES OF UTERUS e Septate (35%) © Bicornuate (26%) © Arcuate (18%) e Unicornuate (10%) © Didelphys (8%) ENDOMETRIOMA e Ectopic endometrial tissue in the ovary “Chocolate cysts” Indications for surgery: severe pain, infection ENDOMETRIOSIS e Endometrial tissue (glands and stroma) outside the endometrial cavity e Chronic pelvic pain and infertility © Three main theories: 4. Halban theory - lymphatic spread 2. Meyer theory — metaplastic transformation 3. Sampson theory - retrograde menstruation 110PATHOLOGY = Loss of anterior vaginal wall support DIAGNOSIS = Sensation of fuliness = Urinary symptoms = Soft bulging mass at anterior vaginal wall POP-Q STANDARD MEASUREMENT Aa Ba c Anterior vaginal Most distal position of Most distal edge of wall 3cm proximal remaining upper cervix or vaginal cuff to the hymen anterior vaginal wall scar (3 to +3 om) (-3to +tv!) gh pb tvl (genital hiatus) (perineal body) (total vaginal length) measured from Measured from Depth of vagina when middle of external | posterior margin of gh point D or C is urethral meatus to to midline of ana! reduced to normal posterior midline opening position hymen Ap Bp D Posterior vaginal Most distal position of Posterior fornix wall 3cm proximal remaining upper (NA if post- to the hymen posterior vaginal wall hysterectomy) (-3 to +3 cm) (-3 to +tvl) 111STAGES Stage0 No prolapse E Stage 1 Most distal prolapse is >1cm above (inside) the hymen Stage 2 Prolapse + 1cm from the hymen Stage 3 Prolapse is >1cm beyond the hymen but < (TVL-2cm) Stage 4 Complete eversion/procidentia MANAGEMENT = Uterosacral ligament fixation 112M features Irregular solid tumor Presence of ascites M3 Atleast four papillary structures M4 Irregular multilocular solid tumor with largest diameter = 100mm MS Very strong blood flow (Color score 4) At least one M feature B features B1 — Unilocular B2 Presence of solid components, of “ which largest component has largest 1 diameter <7 mm B3 Presence of acoustic shadows B4 — Smooth unilocular tumor with largest diameter < 100mm B5 _No blood flow (Color score of 1) At least one B feature Predictive value (95% Cl) 98 (88-98) 97 (93-99) 88 (80-93) 84 (77-90) 88 (82-92) 87 (84-90) Predictive value 99 (98-99) 100 (90-100) 95 (92-97) 99 (97-100) 98 (96-99) 97 (96-98) Rule 1: In 2 M features are present in absence of B feature, mass is classified as malignant. Rule 2: In 2 B features are present in absence of M feature, mass is classified as benign. Rule 3: If both M features and B features are present, or if no B or M features are present, result is inconclusive and second stage test is recommended. 113hh Ajoiue6Goyse yBly Jo pexiyy 9109 aluaboyse + Ajjojuaboyoe MO] Jo yuaosnjnuog AoiuaBoyog Ayoluaboyoea yBiq AjoiuaBoyoe paxiyy 2109 o1uaboyse yym Ajioiuaboysa Mo} Ayoluaboyoa Mo quaosninuos AyoiuaBoyog (wuigz) OIL (wus ¢>) uy. JO auON winjdag, JueuBbyeyy 9-9 ‘auiapiog G-p ‘uBluag ¢-0 :uonejasdiazuy wuz suone|ided ym sk, € SSW pllOg zg ON i b wuwe> senueinBeu! Jews YIM SO, Jo ysAo paul|-yjoous 0 Burmopeys aunjonuys |12M UYANYAT "6 zau09s e aney Aew s}sA0 uBbiuag Jayj0 pue (s}sXo plowsap) sewiojese} aunjeyy Aoueubyeu jo ysu paseasoul :G}-6 ‘AoueuBbyew Jo ysu Mo] :g-p :uonejasdsazuy (wigs) OIL (wes) uly eydas ON wnjdag S Jos ANjsou “Y/N v js AWSOw “Y/N (wwg<) sequeljided iS) (wwe<) yo1uL (wwes) sonueinBou! YW z (wwes) uyL yjoous L ssauyoiy) |IeM aunjonjs |}eM Jeuu] JNOSSVS NO YO4 IWFLSAS ONITUMOR MARKERS = Cannot be used for definitive diagnosis of cancer * Useful in determining effectiveness of therapy or appearance of recurrence Gynecologic Other neoplasms neoplasms CA-125 Epithelial tumors Ovarian cancer CA 19-9 — Mucinous tumors Colon cancer Pancreatic cancer AFP Yolk sac tumors Liver cell cancer Nonseminomatous germ Cell tumors of testis B-hCG Choriocarcinoma Trophoblastic tumors, nonseminomatous testicular tumors LDH Dysgerminoma 115This page is intentionally left blank. 116GYNE-ONCO ROUNDSTYPE | - EXTRAFASCIAL HYSTERECTOMY Removal of cervix, adjacent tissues and a small cuff of the upper vagina in a plane outside the pubocervical fascia Minimal disturbance of the bladder and the ureter Performed for patients with preinvasive or microinvasive disease cervical carcinoma and for endometrial cancer Woe Il- MODIFIED RADICAL HYSTERECTOMY Remove more paracervical tissue while preserving blood supply to distal ureters and bladder Ureters freed from paracervical position but not dissected out of pubovesical ligament Uterine artery is ligated medial to ureter Uterosacral ligament are transected midway The medial halves of cardinal ligaments are removed Upper 25% of vagina removed Suitable for microinvasive CA and postirradiation recurrences limited to cervix ies Ill - RADICAL HYSTERECTOMY Aka. Meigs- ‘Okabayashi procedure Wide radical excision of the parametrial and paravaginal tissues Uterine artery is ligated at its origin on internal iliac artery Dissection of ureter from pubovesical ligament Uterosacral ligaments resected at the pelvic sidewall Upper 25-30% of vagina removed TYPE IV - EXTENDED RADICAL HYSTERECTOMY Complete removal of all periuretral tissue and more extensive excision of paravaginal tissues Difference from Class III: o _Ureter completely dissected from pubovesical ligament o Superior vesical artery is sacrificed o 50-75% of vagina removed o Preservation of the bladder is still possible 118GL II] Ssejo se awes I ssejo se aues juawyoeye {e} payoasues smuajn je payasues) juowebl lesesosayn) IIL ssejo. se owes ssejo se awes Jemapis oiajad ye payasay, Jajain 0} JeIpaw pajoasay smuayn ye pajoesey euyaweleg Al ssejo se awes Aaye Jeolsan Jouadns jo uoyeBy pue uiBuo ye uonebi7 Araye oujseBodAy woy Guo ye payeby] Jayeun 0} jeipew payer] snueyn ye payebry Aape auyeyn peaowal Jajaun |eysiq paAowad ans [esjounued IN Jappelq Ou! ‘Aqua jun pajoassip Ajayajdwog jauun} leujawesed Ul pajoouu/) 49421, pajoase Jappelq BU} JO UOIHOg pajoasal ou yng ‘pazijiqow Ajayajdwiog peziqow Ajayajdwiog Ajjemed Jappeig | UONBsaJUXO adf) se aweg I adfy se owes panowal Z/|, 0} €/| soddn) paaowas wo Z-|, saddr) Poy|powW ponowiol anssi} [EWU —_jeloseyes)x3 | eulbe, owen adAy AWOLOAYALSAH 40 SAdAL FAIS- Most common gynecologic malignancy in the Philippines RISK FACTORS Early onset of sexual activity Multiple sexual partners History of STI OCP use History of vulvar or vaginal dysplasia Smoking (associated with SCCA but not adenoCA) fst oO oo00 ETIOLOGY Human papillomavirus (HPV) o Necessary but not sufficient cause co. There are 15 high risk types = Type 16 causes 60% = Type 18 causes 10% = Others cause <5% individually 4) Forget Me Not: Cervical cancers are mostly caused by HPV types 16 and 18 \e/ while benign genital warts (condyloma acuminata) are mostly caused by HPV ~~ types 6 and 14. /@» Warning! Do not confuse condyloma acuminata with condyloma latum. ey Condyloma acuminata is a papillomavirus-induced lesion (genital warts) while ~~ condyloma latum is caused by syphilis. 120PATHOLOGY = Squamous cell carcinoma (80%) = Adenocarcinoma (15%) . = Adenosquamous and neuroendocrine CA (5%) Adenocarcinomas have shown no significant difference in clinical behavior from SCCA VACCINATION G Qe) Bivalent Quadrivalent Nonvalent u (Cervarix) (Gardasil) (Gardasil-9) types 16 and 18 types 16 and 18, quadri + 31, 33, 45, 6 and 11 52, 58 Not yet known if protection is lifelong. Pap smear is still recommended even in vaccinated women. CDC recommendation: o Boys and girls age 11-12, as early as 9 yo o Catch-up for those age 13-26 SCREENING: PAP SMEAR © Low sensitivity o Reduces incidence of cervical CA by 50-70% o Samples are taken from the transformation zone. (> Warning! Do not confuse transformation zone with the squamo-columnar wg junction (SCJ). The SCJ is a histological site. It moves, due to metaplasia, y during puberty. The transformation zone is the area from the old SCJ to the new SCJ. It is the site of active cellular transformation. 121aw Ideal Materials Used | } eal Materials Use CZ Ectocervix Ayer's spatula Endocervix Cytobrush Ectocervix and Endocervix Cervical broom (simultaneously; for liquid media) ACS/ASCCP/ASCP Recommendation: Age 21-65 <21 21-29 30-65 >65 NOT done even if early onset of sexual activity Every 3 years Co-testing with HPV every 5 years Cytology alone every 3 years (acceptable) NOT recommended if: o Had 3 consecutive negative Pap smear o Had 2 consecutive negative HPV test o No history of CIN 2/3 or CIN2+ in the past 20 years PSCP 2012 Recommendations (Philippines) <21 21-29 30-65 >65 No screening Annual screening using conventional cytology or biennial screening with liquid based cytology Screening for vaginal cancer in women who had TH for benign conditions, except premalignant cervical lesions, is not recommended. 122BETHESDA SYSTEM (2001) Reporting (aa Adequacy of Specimen @& Satisfactory for evaluation Unsatisfactory for evaluation General Categorization Negative for intraepithelial lesion or malignancy Squamous cell Atypical squamous cell (ASC) ASC of undetermined significance (ASCUS) ASC cannot exclude HSIL (ASC-H) Low-grade squamous intraepithelial lesion (LSIL) High-grade squamous intraepithelial iesion (HSIL} Squamous cell carcinoma Gianduiar cell Atypical glandular cells, specify site of origin, if possible Atypical glandular cells, favor neoplastic Adenocarcinoma in situ (AIS) Adenocarcinoma, endocervical Adenocarcinoma, endometrial Adenocarcinoma, nonspecific Others MANAGEMENT ALGORITHMS ASC-US LSIL ASC-H HSIL AGC SUMMARY 2014 Updates Repeat pap smear or HPV DNA testing Colposcopy +/- biopsy and ECC Colposcopy + biopsy and ECC Immediate LEEP or Colposcopy + biopsy and ECC Coiposcopy + biopsy and ECC +/- EM biopsy (235yo) HPV DNA testing *No ECC for pregnant patients 123ASC-US Algorithm Repeat cytology Negative: Routine screening at 12 mos Positive: Colposcopy ; Negative: Repeat cotesting after 3 yrs AE Positive: Same as LSIL LSIL Algorithm LSIL with Repeat cotesting at 1 year preferred negative HPV Colposcopy with ECC acceptable LSIL with no HPV test ; LSIL with Colposcopy with ECC acceptable positive HPV ASC-H Algorithm No CIN 2,3 Manage accordingly eolpescony CIN 2,3 Manage accordingly HSIL Algorithm Observation with Other No colposcopy and results CIN cytology at 6 HSIL Colpo- 5 ‘i Diagnostic 2,3. month intervals persists for 5 ed for up to 2 years 24 months cere! oN Manage accordingly Or Immediate LEEP AGC Algorithm Colposcopy with biopsy + ECC + Endometrial Biopsy if 235 years old or with abnormal bleeding f with atypical endometrial cells: endometrial and endocervical sampling 124Management of Biopsy Proven CIN CIN 1 preceded by ACUS or LSIL, HPV 16 and 18 positive HPV Negative, Age appropriate Ffup without treatment, Cytology negative _retesting Cotesting at 1 year HPV positive or ASCUS or worse Colposcopy 5) No CIN 2,3 Manage accordingly a med Manage accordingly Colposcopy If persists for at least 2 CIN 1 years, follow-up or treatment CIN 4 preceded by ASC-H or HSIL HPV negative Age appropriate Cotesting Cytology negative testing at 12 and HPY positive or any cytologic 24months —_ abnormality except HSIL copescony HSIL LEEP/Cone CIN 2 and 3 preceded by ASC-H or HSIL Excision methods Adequate acceptable colposcopy —_Ablational methods Cotesting at 12 months acceptable and 24 months Inadequate colposcopy Diagnostic Cotesting at 12 or Recurrent CIN 2,3 or Excisional months and 24 ECC is CIN 2,3 procedure months i. Cotesting at © HPV negative Repeat cotesting at 3 12 and 24 Cytology negative years months Any test abnormal Colposcopy with ECC. 125DIAGNOSIS cancer is diagnosed by biopsy. cancer is staged clinically. 'y indicated, proctosigmoidoscopy and Secon should be 0 rule out bowel/bladder invasion. Metastatic work-up includes: a. imaging studies b. Renal function tests c. Liver function tests d. KUB-IVP e. Barium enema f. CXR . Special diagnostic imaging studies may be done to guide treatment planning. Imaging is optional for patients with Stage IB1 tumor or smaller. These imaging studies will NOT be part of the staging. a, UTZ & b. MRI c. CT Scan d. PET scan e. f. i . PET-CT scan f. Bone scintigraphy 126FIGO 2009 STAGING OF CERVICAL CANCER Stage | Strictly confined to the cervix (extension to the corpus should be disregarded) Stage IA Identified based on microscopic examination of tissue preferably a cone, which must include the entire lesion; deepest invasion < 5 mm and width < 7mm IA1 Deepest invasion $ 3.0 mm and width < 7 mm 1A2 Deepest invasion > 3.0 mm and not > 5 mm, and width <7 mm Stage IB Clinically visible lesions confined to the cervix or preclinical cancers > IA 1B1 Clinically visible lesion < 4 cm in greatest dimension IB2 Clinically visible lesion > 4 cm in greatest dimension Stage Il Invades beyond the cervix, but not to the pelvic wall or lower 1/3 of the vagina Stage IIA No obvious parametrial involvement HA4 Clinically visible lesion < 4 cm in greatest dimension WA2 Clinically visible lesion > 4 cm in greatest dimension Stage IIB Obvious parametrial involvement Stage Ill Extends to the pelvic wall and/or involves lower 1/3 of the vagina and/or causes hydronephrosis or nonfunctioning kidney Stage IIIA Involves lower 1/3 of vagina, with no extension to pelvic wall Stage IIIB Extension to pelvic wall, and/or causes hydronephrosis or nonfunctioning kidney Stage IV Extends beyond the true pelvis or has involved mucosa of the bladder or rectum Stage IVA Spread of growth to adjacent pelvic organs Stage IVB Spread to distant organs “Lymphovascular space invasion (LVSI) does not alter the FIGO classification. 127TREATMENT 1. The primary treatment of early stage cervical cancer is either surgery or concurrent chemotherapy and complete radiotherapy (chemoradiation). 2. The primary treatment of late stage cervical cancer is concurrent chemotherapy and complete radiotherapy (chemoradiation). 3. For patients who are unable to receive chemotherapy, radiation treatment alone may be given. Stage IIB-IVA Concurrent chemotherapy and pelvic EBRT (external beam radiotherapy) + brachytherapy [Chemoradiation] Paraaortic lymphadenopathy (size > 1.0 cm) by MRI, CT scan, or PET scan confirmed by FNA or extraperitoneal or laparoscopic lymphadenectomy: EFRT (extended field radiotherapy) + brachytherapy + concurrent platinum-based chemotherapy e Standard chemotherapy drug to use for concurrent treatment with radiotherapy: Cisplatin given weekly during pelvic EBRT. e Other chemotherapy regimens that can be used for concurrent treatment with radiotherapy (for locally advanced cervical cancer): © Cisplatin-Gemcitabine weekly for 6 weeks during pelvic RT and then 2 adjuvant cycles of Cispiatin day 4 plus Gemcitabine D1-8 every 21 days. Carbopiatin every 3 weeks or weekly Cisplatin-Paclitaxe! weekly for 6 cycles Capecitabine twice daily (Monday to Friday, weeks 1-8) during radiation followed by 6 cycles of Capecitabine twice daily D1-14 every 21 days e Concurrent chemotherapy and pelvic EBRT with concomitant boost followed by RHBSO (radical hysterectomy bilateral salpingo- oophorectomy), BLND (bilateral lymph node dissection) + PALS (paraaortic lymph node sampling) 6-8 weeks after may be recommended in areas lacking brachytherapy facilities. 000 128PROGNOSTIC FACTORS ¢ FIGO stage is the most important determina of prognosis for carcinoma of the cervix ° Other | factors: “Tumor and patient characteristics (e.g. tumor size is prognostic for local recurrence and death for patients treated with surgery or radiation) Involvement of lymph nodes 0 Lymph-vascular space invasion Histologic type (adenocarcinoma has poorer prognosis) Stage No of patients (n) 5-year survival la 902 95.01% Ib 4657 80.1% Il 3364 64.2% Ml 2530 38.31% VV 492 14% FOLLOW-UP & Weekly while on chemoradiation or radiotherapy © Two weeks post-completion of brachytherapy After completion of treatment, recommended follow-up is as follows: © ROS and physical and pelvic exams = Low risk (treated with surgery alone, no adjuvant treatment) - every 6 months for the first 2 years then yearly thereafter = High risk (advanced stage, treated with primary chemotherapy, radiation therapy or surgery plus adjuvant therapy) - every 3 months for the first 2 years followed by every 6 months for the 3" - 5% year, then yearly thereafter o Pap smear yearly © CT scan or PET-CT scan is recommended when recurrence is suspected. e Use of vaginal dilator 2-4 weeks after RT is suggested for women who are sexually active. 129ELDERLY PATIENTS (2 65 YEARS) ¢ Concurrent chemoradiation may be given to elderly patients with ECOG s 2 because it does not increase the risk of thromboembolic disease, fistula formation, cystitis/proctitis, pelvic necrosis, ureteral obstruction, and bowel obstruction. ECOG (Eastern Cooperative Oncology Group) Performance status Grade 0 1 ECOG Fully active, able to carry on all pre-disease performance without restriction Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours Capable of only limited self-care, confined to bed or chair more than 50% of waking hours Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair Dead 130Endometrial Proliferative Phase (Follicular) = Immediately after menses = 1-2mm thick (stratum basale) Endometrial Secretory Phase (Luteal) =~ After ovulation = Thick endometrium: 8-14 mm thick, glycogen-rich RISK FACTORS 1 _Unopposed estrogen exposure o Obesity co Nulliparity co Late menopause co Exogenous estrogen without progesterone Chronic anovulation PCOS Estrogen-producing tumors Tamoxifen Hypertension Diabetes mellitus Lynch II syndrome (Hereditary nonpolyposis colon CA) ogQoo0o0g0 o Warning! Incessant ovulation is different from anovulation. Incessant ovulation is a ( vy risk factor for ovarian CA due to repeated microtrauma. Anovulation is a risk factor for ‘endometrial CA due to thickening of the endometrium without sloughing. CLINICAL MANIFESTATIONS = Postmenopausal bleeding = Enlarged uterus = — IEis unremarkable = Stigmata of chronic anovulation: Obesity © Acanthosis co Acne o Hirsutism ° 131DIAGNOSIS = Thickened Endometrium cut-off: >4mm = — Histopath is required = Via Endometrial biopsy/sampling (Pipel) MANAGEMENT Premenopausal Women Hyperplasia — Simple hyperplasia: OCP x 6 cycles without MPA (cyclical) 10-20mg OD x 14 days atypia Do UTZ and sample endometrium after 3 mos: = Normal: MPA 5mg x 10days/mos x 12 mos = Persistent: increase dose 40-100mg daily x 3 months then do repeat biopsy Hyperplasia Continuous MPA 10-20 mg OD x 3 months with atypia Megestrol acetate 40-200mg per day desirous of + DMPA 150mg IM every 3 mos pregnancy: — LNG(levonorgestrel)-IUS for 1-5 years Do UTZ and sample endometrium after 3 mos: = Normal: decrease MPA 10mg OD x 14 days for 12 more months = Persistent: increase MPA to 40-100mg daily for 3 months OR shift to Megestro! acetate 40mg 2-4x/day (160mg total per day) for 3 months then do EM sampling; if persistent, do EH + BSO If not desirous of pregnancy: EH + BSO. Postmenopausal Women Hyperplasia __If desirous of uterine preservation or if poor without surgical risk, same as in premenopausal atypia If not desirous of uterine preservation, EHBSO Hyperplasia +EHBSO with atypia 132- Most common invasive cancer of the female genital tract worldwide - Third most common genital tract malignancy in the Philippines, next to cervical cancer and ovarian cancer PATHOGENESIS Incidence Age Clinical setting Morphology “Precursor Mutations Behavior Type | (Endometrial) 80% of cases 55-65 = Obesity = Diabetes = Hypertension = Infertility = Unopposed estrogen Endometroid Hyperplasia PTEN (30-80%) KRAS (25%) PI3K (40%) Indolent Lymphatic spread Type Il (Serous) 20% of cases 65-75 = Atrophy = Thin physique Serous Clear cell Mixed mullerian tumor Serous endometrial intraepithelial carcinoma TP53 Aggressive Intraperitoneal and lymphatic spread 133PREDISPOSING FACTORS Unopposed estrogen (i Obesity Diabetes © PCOS, chronic anovulation Early menarche U. Late menopause Nulliparity Infertility Tamoxifen use Insulin resistance > Decreased sex hormone binding globulins, resulting in an increased free estrogen Peripheral conversion of DHEA to estrogen Insulin resistance > Decreased sex hormone binding globulins, resulting in an increased free estrogen Also, in the presence of excess estrogen, insulin-like GF has neoplastic effects; Associated with estrogen excess stimulating endometrial hyperplasia Family history of HNCC (hereditary nonpolyposis colon CA) Hypertension (association only) CLINICAL MANIFESTATION e Irregular or postmenopausal bleeding with excessive leukorrhea e Late signs: o Pelvic pain o Enlarged corpus co Urinary/Bowel symptomsDIAGNOSIS Histologic examination of tissue from biopsy or curettage “Office endometrial biopsy is the reconimended first step Endocervical curettage is no longer necessary. Hystéroscopy is employed only when endometrial biopsy and/or endometrial curettage has negative results. Gold Standard: Hysteroscopic guided biopsy i eo »\ Warning! Endometrial biopsy, Dilatation and curettage, and Fractional curettage are \°@, three different things! Endometrial Biopsy Dilatation and Fractional 2 curettage curettage* Office procedure Needs Needs anesthesia anesthesia May use Pipel (plastic Cervical suction) or ripening or use De Novac’s curette of Hegar dilator (metal with serrations) Endometrial sampling Endocervical sampling plus endometriai sampling Prevents late Risk of rupture diagnosis (no need to schedule an OR) *Not used anymore for the diagnosis of endometrial CA Indications for endometrial curettage: © Cervical stenosis e Distorted pelvic anatomy because of associated pelvic pathology ¢ Patient intolerance to pain Endometrial biopsy yields insufficient sample e Patient was diagnosed with EM hyperplasia + atypia 135FIGO 2009 STAGING OF ENDOMETRIAL CANCER Stage | Tumor confined to the corpus uteri Stage IA No <&0% myometrial invasion Stage IB 250% myometrial invasion Stage Il Tumor invades cervical stroma, but does not extend beyond uterus Stage Ill Local and/or regional spread of the tumor Stage IIIA Tumor invades serosa of the corpus uteri and/or adnexae Stage IIIB Vaginal and/or parametrial involvement Stage IIIC Metastases to pelvic and/or para-aortic lymph nodes WIC4 (+) pelvic LN IIC2 (+) para-aortic LN + pelvic LN Stage IV Tumor invades the bladder and/or bowel mucosa and/or distant metastases Stage IVA Tumor invasion of bladder and/or bowel mucosa Stage IVB Distant metastases, including intra-abdominal and/or inguinal lymph nodes MANAGEMENT Stage | EHBSO, PFC, LND Stage Il For good surgical risk: RHBSO, PFC, LND For poor surgical risk: preop pelvic RT and vaginal brachytherapy, then PFC and EHBSO with LN Stage Ill EHBSO, PFC, LNE, Debulking and adjuvant: Stage IIIA + Chemotherapy and Pelvic EBRT Stage IIIB + Chemotherapy and Pelvic EBRT + vaginal brachy WIC1 + Chemotherapy and Pelvic EBRT + vaginal brachy IlIC2____ + Chemotherapy and EFRT + vaginal brachy Stage IV EHBSO, Debulking 136WHO HISTOLOGICAL CLASSIFICATION (SIMPLIFIED) A\LONG Ovarian CA Surface Epithelial Serous 20-50% 35-40% - Stromal Tumors — Mucinous 15-25% 6-10% Endometrioid 5% 15-25% Granulosa cell tumors Often functional Sertoli-Leydig cell tumors sexiCords Fibroma Often hormonally Stromal Tumors aoe Thecoma inactive Fibrothecoma linical Pearl: Serous epithelial-stromal tumor is the most ;ommon malignant ovarian tumor. Germ Cell Tumors e Dysgerminoma e — Embryonal carcinoma co Extraembryonic = Yolk sac tumor = — Nongestational choriocarcinoma o Embryonic = — Mature teratoma (benign) > Dermoid cyst = |mmature teratoma (malignant) Metastatic © — Usually from mullerian origins: uterus, fallopian tube, contralateral ovary, pelvic peritoneum e — Extramullerian o Breast co Gl (Krukenberg tumor) 138BILATERALITY OF OVARIAN TUMORS Epithelial Serous cystadenoma : 10% Serous cystadenocarcinoma 33-66% Mucinous cystadenoma 5% Mucinous cystadenocarcinoma 10-20% Endometerioid carcinoma 13-30% Benign Brenner (transitional cell) 6% Germ cell Dermoid 12% Immature teratoma 2-5% Dysgerminoma 5-10% Sex Cord Stromal tumors Rare Clinical Pearl: Serous ovarian tumors are usually bilateral. 70% are benign. 30% are malignant. Mucinous ovarian tumors are usually unilateral. Majority are benign. In endometrioid ovarian tumors, only 30% are bilateral. It usually happens with the background of endometriosis. HISTOLOGIC GRADING Histologic grading for Serous carcinoma (WHO 2014) Low-grade serous carcinoma (LGSC) High-grade serous carcinoma (HGSC) Histologic grading for Endometrioid carcinoma (FIGO 1988) FIGO Grade 1 Well-differentiated FIGO Grade 2 Moderately differentiated FIGO Grade 3 Poorly differentiated ing. Grade is for B°G, histologic (FIGO 2014).MANAGEMENT OF OVARIAN CARCINOMA (POGS 2015) Epitelial tumors of Low Malignant Potential (Confined to borderline tumors of serous and mucinous varities) Stage Status | Young/Desirous of pregnancy e Reproductive function not desired I-IV Stage |A- IB (G1, G2) Ic ‘ (G1, G2) IA-IC (G3, clear cell, high grade squamous), II-III VV Primary Treatment USO/BSO, complete Surgical staging THBSO, complete surgical staging THBSO, complete surgical staging and/or tumor debulking Frankly Malignant Epithelial Carcinomas Status Young/Desirous of pregnancy Reproductive function not desired Young/Desirous of pregnancy Reproductive function not desired Primary Treatment USO/BSO, complete surgical staging THBSO, complete surgical staging USO/BSO, complete surgical staging THBSO, complete surgical staging THBSO, complete surgical staging THBSO, tumor debulking - Adjuvant None None Adjuvant None None Chemo- therapy Chemo- therapy Chemo- therapy 140144= Proliferation of placental tissue (either villous or trophoblastic) + little fetal development = 2.4/1000 pregnancies in the Philippines (2002-2008): = 14/1,000 pregnancies in PGH RISK FACTORS 6 4. Maternal age: J curve (due to defects in ovoid function) < 15 years old 20x higher risk > 40 years old >10x higher risk > 50 years old 200x higher risk 2. Paternal age > 45 yo is a risk factor for CHM (inconsistent) 3. Reproductive and Obstetric History = Prior molar pregnancy © 5-40x increase risk for next © After 1s HM, 0.6-2.6% of patients have 2"¢ = History of miscarriage or twin pregnancies in nulliparous * Artificial insemination 4. Racial factors = Southeast Asian 7-10x higher than Europe or North America) 5. Diet: decreased consumption of animal fat and beta-carotene (Southeast Asian) ‘@ Forget Me Not: Mnemonic: PROMD. Paternal age, Race, OB history, a) Maternal age, Diet. 142PATHOLOGY Histologically: cystic swelling of chorionic villi with variable trophoblastic proliferation Se COMPLETE MOLE Diandric Diploidy: Results from fertilization of an egg that has lost its female chromosome Endoreplication: 90% are homozygous 46XX (due to androgenesis: duplication of 23X sperm} 10% are heterozygous, and may be 46XX or 46XY (fertilized by 2 sperm cells) No fetal tissues: Embryo dies very early in development 2.5% risk of developing choriocarcinoma 15% risk of developing invasive mole Histopathologic Findings: © Lack of fetal or embryonic tissues o Hydropic (edematous) villi o Diffuse trophoblastic hyperplasia INCOMPLETE MOLE Diandric triploidy: Results from fertilization of an egg‘with 2 sperms (usually triploid) Dispermy: Results from fertilization of an egg with 2 sperms (usually triploid) Fetal tissues typically present. NO increased risk for choriocarcinoma With increased risk for invasive mole Histopathologic Findings: . Presence of fetal or embryonic tissues 2. Less diffuse, focal hydropic swelling of villi 3. Focal trophoblastic hyperplasia 4. Less pronounced trophoblastic atypia at implantation site sence of trophoblastic loping and stromal inclusions 143DIAGNOSIS |, HISTORY AND PHYSICAL EXAMINATION History = Amenorrhea Vaginal bleeding in the 1s trimester (+) Pregnancy test Absence of fetal movement and heart tones Passage of “sago-like” materials Physical Examination = — Uterine size > AOG (40-50%) = Anemia secondary to occult hemorrhage Other Classical Signs and Symptoms Presence of theca 20% B-HCG is lutein cysts homologous to LH Hyperemesis 15-25% — High levels of B- HCG Preeclampsia 12-27% Hyperthyroidism 27% B-HCG is i homologous to TRH Respiratory distress 2% from trophoblastic emboli to the lungs Notes: = Diagnosed during early pregnancy (average of 9 weeks) by UTZ = Partial H. Mole has less prominent features, usually mistaken for incomplete or missed abortion 144Il PELVIC ULTRASOUND = — Most accurate noninvasive imaging modality for H. mole = Sn = 50-86% = Typical appearance: Complex, echogenic intrauterine mass containing many small cystic spaces appearing as small anechoic spaces: “snowstorm appearance” COMPLETE MOLE INCOMPLETE MOLE 80% diagnosed by UTZ 70% missed by UTZ Prominent in 2" trimester. These findings gives 90% PPV: grape-like/hydropic villous ¥ Focal cystic changes in the placenta changes occur Y Gestational sac T:AP ratio > 1.5 May also show growth retarded fetus with multiple congenital anomalies attached to a hydropic placenta II ELEVATED B-HCG >100,000 IU/L in CHM, less elevated in PHM. Combination of elevated B-hCG and UTZ findings is highly suggestive (> Forget Me Not: As discussed before, B-hCG in pregnancy plateaus at \ & _/ approximately 10 weeks AOG with levels peaking at 100,0001UIL and then ~ falling thereafter. Therefore, >100,000 is elevated! * — Outside pregnancy, elevated B-hCG (> 100,000 IU/L) signifies the following: i GTN ii. Nongestational tumors secreting hCG ii. False-positives iv. Menopause (secondary to LH elevation) 145RGICAL PATHOLOGY = Histopathologic diagnosis is mandatory! = Samples from sharp curettage must be sent separately from samples from suction curettage. = — Immunostaining if histopathologic diagnosis is in doubt ~ P57kip2 —_ maternally PHM and hydropic abortion « derived gene =“ PHLDA2~s maternally += PHM and hydropic abortion derived gene = — Cytogenetic examination (ploidy studies by ISH or flow cytometry) differentiates CHM from PHM. Ky Clinical Pearl: Differentiating the three! How to differentiate CHM from PHM. Flow cytometry (diploid or triploid) and Immunostaining How to differentiate CHM from Hydropic abortion: {Immunostaining How to differentiate PHM from Hydropic abortion: Flow cytometry (diploid or triploid) CHM PHM Hydropic abortion Diploid Triploid Diploid P57kip2 (-) P57kip2 (+) P57kip2 (+) PHLDA2 {-) PHLDA2 (+) PHLDA2 (+) 146 ~~MANAGEMENT “ay Forget Me Not: To remember what labs need to be done, know first what \s / are the complications of H. mole. Mnemonic for the 7 medical complications “of H mole: HEAD-PHP Medical Complications of H. Mole ‘zg 1. Hyperemesis gravidarum (26%) @ 2. Electrolyte imbalance from hyperemesis —~ 3. Anemia (75%) 4. DIC 5. Preeclampsia (27%} 6. Hyperthyroidism (7%) 7. Pulmonary insufficiency (2%) LABORATORIES Anemia cBo Preeclampsia CBC with P AST, ALT LDH Urinalysis 4 Mg (because you will give MgSO4) f Crea (Mg is renally excreted) Hyperthyroidism {14, TSH Electrolyte imbalance Electrolytes Hyperemesis Serum 8-hCG level Dic PT, PTT Urinalysis Rule out preeclampsia Ruie out infection (for methotrexate) Chest X-ray Rule out metastasis Rule out pulmonary hemorrhage Rule out congestion Rule out infection (for methotrexate) Preoperative: BT, crossmatching, 12-L ECG 147Il. SURGICAL EVACUATION = Definitive treatment = — Suction curettage under GA ile Pb Anesthesia Patient placed in semi-Fowler's dorsal lithotomy position (upper body is 30deg tilted, lower body is also 30 degrees tilted, to prevent emboli) Cervical dilatation (laminaria or Hegar dilator or intracervical Foley catheter; NOT prostanoids, which increased the risk for pulmo embo) Oxytocin 10 U at the start (20 IU/L in Compre Gyne) Place hands on uterus to assess size and tone Sharp curettage after suction curettage *Avoid the use of hysterometer which may lead to perforation Submit histopath of sharp and suction curettage separately = Hysterectomy Only indication: > 40 yo with completed family size & consent © >40 yo women: 37% risk of GTN o >50 yo women: 56% risk of GTN o Post-hysterectomy: still with 3-5% risk of postmolar GTN Theca lutein cysts are best left alone. They regress spontaneously after 8 weeks post-ovulation. = Medical evacuation plus Hysterotomy (classical CS in <28wks AOG) is NOT recommended because of: oo0000 Severe blood loss Incomplete evacuation Trophoblastic dissemination Development of postmolar disease requiring chemo Necessitates CS for subsequent deliveries 148Ill CHEMOPROPHYLAXIS - _ Reduces the risk of progression to GTN in those with CHM who are at high-risk of malignant transformation by 14-45% (level | evidence) Given in: (1) High risk of postmolar GTD (2) Post-evacuation surveillance is doubtful = Risk of malignancy: CHM 15 - 25% PHM 0.5-4% * High Risk for postmolar trophoblastic disease . Age240yo Uterine size larger than AOG by = 6 weeks Serum B-hCG 2 100,000 mIU/mL Theca lutein cyst = 6 cm Any medical complication associated (HEAD-PHP) Recurrent hydatidiform mole Documented H.mole with a coexisting normal twin (must be given after delivery of the twin) NOams¢ _* Methotrexate, IM, 1 course: drug of choice © _Contraindications: Sco 1. Hgb < 100 mgidL, Het < 0.30 @& 2. WBC <3x 10° / 3. Absolute neutrophil count < 1.5 4. Platelet count < 100 5. Active infection 6. Renal/liver dysfunction o If with hypersensitivity or liver toxicity, alternative is actinomycin D | Forget Me Not: These are the contraindications for methotrexate because \s_/ the side effect of methotrexate is myelosuppression. Also, methotrexate is renally excreted. It can cause liver failure. 149= Methotrexate Regimen: Vo Low dose 0.3 - 0.4 mg/kg/day for 5 days (max of 20 mg/day) Pulse 50 mg/m? IM SD 8-day regimen — 1mg/kg/day on Day 1,3,5,7 Folinic acid 0.2 mg/kg/day on Day 2,4, 6, 8 Regimen Efficacy Toxicity Low dose ttt nn Pulse + +++ 8-day regimen +4 + Because of this, the low dose regimen is preferred. = Methotrexate Pharmacology Pharmacodynamics: Folic acid analogue that binds to dihydrofolate reductase dihydrofolate reductase. Dihydrofolate Tetrahydrofolate (Tetrahydrofolate is involved in de novo synthesis of purine nucleotides, and AA serine and methionine, thus MTX interferes with DNA formation) Elimination: Renal; excretion is inhibited by the ff drugs: ° ° ° ° Aspirin NSAIDs Penicillin Cephalosporin Side Effects: ° ° ° ° Mucositis or stomatitis Diarrhea Liver failure Immunosuppression Antagonist: Leucovorin (reduced folate) ° Used in conjunction with methotrexate to rescue normal cells from toxicity 150 i ee ee aFOLLOW-UP Serial B-hCG MONITORING 1 week Post-curettage - @ q2 weeks until B-hCG <5 mlU/MI, 2 consecutive times qi month x 6 months (6 times) q2months x 6 months (3 times) ia for the Diagnosis of Postmolar Trophoblastic Neoplasia Plateauing B-hCG levels for 4 consecutive weekly measurements over a period of at least 3 weeks (0, 7, 14, 21) Rising B-hCG levels for 3 consecutive weekly measurements. over a period of at least 2 weeks (0, 7, 14) 3. Ahistologic diagnosis of choriocarcinoma Contraception = To eliminate confusion on increase in hCG due to pregnancy = Low dose COC preferred because it suppresses endogenous LH, which may interfere with measuring B-hCG = DMPA or implant may be recommended for women who have difficulty in complying with COCs, but should be cautioned regarding the possibility of breakthrough bleeding = — |UD is NOT recommended because of possible uterine rupture Advice on Pregnancy = May be allowed after 6 months of normal serum B-hCG level = For every succeeding pregnancy, an early UTZ should be performed because of the risk of another molar pregnancy After 1 molar pregnancy 4-2% risk for a second mole After 2 molar pregnancies 15-20% risk for a third mole = For each succeeding pregnancy following a molar gestation, B- hCG should be monitored at 6 weeks postpartum to detect any occult GTN. = Placenta in subsequent pregnancies should be submitted for histopath 151Includes: °o Invasive mole Choriocarcinoma Piacentai site trophoblastic tumor (PSTT) co Epithelioid trophoblastic tumor (ETT) ® — Incidence is 2000-fold greater following CHM or PHM. = — 22.4/40,000 in the Philippines oo PATHOLOGY Choriocarcinomea Malignant neoplasm of trophobiastic celis Proiiferating syncytioirophoblasis and cylotrophobiasis No chorionic vill invasive Moie Mole that penetrates or ever: perforates the uterine wai © Trophobiastic hyperpiasia ° © Persistence.of piacental vilious struciures ° PsTT ETT Rare neoplastic proliferation of intermediate tropnobiasis that invade the myometrium at the placental site © Malignant trophoblastic cetis infiltrating the endomyometrium INVASIVE MOLE Rare neoplasm which is the malignant counterpart of the intermediate trophobiasts of the chorion leave = — Mole that penetrates or even perforates the uterine wall = Locally destructive and may invade parametrial tissue and blood vessels > may embolize to distant sites such as the heart or lungs but not grow as metastases Responds well to chemotherapy 152CHORIOCARCINOMA * — Malignant neoplasm of trophoblastic cells derived from previously normal or abnormal pregnancy, such as an extrauterine ectopic pregnancy ° = May be preceded by: 50% preceded by hydatidiform mole eS 22% preceded by normal pregnancy 2.5% preceded by ectopic pregnancy Rarely nongestational choriocarcinoma may develop from germ cells in the ovary or the mediastinum 25% preceded by previous abortion = Rapidly invasive and Metastasize quickly (in descending order) 010) O16) © Lungs (50-80%) o Vagina o Brain o Liver (10%) o Bone o Kidney = — Responds well to chemotherapy (@ Warning! Do not take specimens for biopsy on the metastases. Doing so may \y ‘W/ cause hemorrhage. PLACENTAL SITE TROPHOBLASTIC TUMOR = — Neoplastic proliferations of extravillous trophoblasts (aka intermediate trophoblasts), which are found in nonvillous sites like: © placental implantation site o Islands of placental parenchyma © placental membranes = May be preceded by: © 50% preceded by normal pregnancy o Preceded by spontaneous abortion co Preceded by hydatidiform mole 153,DIAGNOSIS Clinical, Radiologic, or Biochemical |. SIGNS AND SYMPTOMS = Vaginal bleeding (58-59%) Anemia Uterine enlargement Acute abdomen secondary to tumor previa Infection from necrotic tumor Symptoms of metastases Lungs Cough, chest pain, dyspnea, hemoptysis, respiratory distress or pulmonary insufficiency Vagina Bluish, cystic mass Brain Laieralizing signs, Signs of intracranial bleed Il SERUM B-HCG as tumor marker (high Sn and Sp) Ill. TV-UTZ with color flow Doppler is used to detect: co ~Myometrial invasion o Recurrence o Response to chemotherapy Result: “Abundant vascularity with low resistance indices." IV. Histopathology is NOT necessary! \V. Metastatic work-up. = CXR-PAL = Whole abdominal UTZ = Organ-specific CT or MRI with contrast Cranial CT done if with: o —_Lateralizing signs © Pulmo mets 2 3cm (ZQ Warning! Chest CT is done only when initial CXR is negative. Chest CT alters \e y the staging but not the WHO prognostic score. 184SSL s6mup z= 8< ureig ‘J8AI] 000'00L2 ele Brup aj6us ss a 19 Kaupiy ‘usajds Ge G> Oe 000'00L> 000'01> ch 9OP wie] ology Ove z b 109g uoneoysouBoud ul pasn jou si ueas 15 }sayD ‘ys YBIy J = YSU MO] {> :uoye}eudieU) Bun] > 000'1> > 3/0 Op> Adesayjowayo pajiey snoinelg sasejsejaw Jo saquiNN, SOSPISP}OW JO OS wo (sniajn Bulpnjout) azis sown, yso61e7 Qou-d juawjeasy-aq Aoueubaid xapul Woy SyJUOW |eAso}U| AoueuBbiaid juapasajuy aby siojoe4 oysouBbog Adesayjoweyo juabe aj6urs 0} aouejsisal ajqissod sa1palq INALSAS SNINODS JILSONDOUd OHM BurBe}s 10 pasn s} ueds {9 jseyQ SISe}Se}aW JBYIO, Al ebeIS sisejsejaw Areuow|ng abeys sueBio oijad 0} spua}x3 11 Be) smuajn ay} 0} pauyuog | abe INISVLS DINOLVNY 0002 O54MANAGEMENT |. LABORATORIES = Other laboratories (as in H. mole) = Complete metastatic work-up Il. CHEMOTHERAPY = — Cornerstone of management Stage I-III Single agent chemotherapy Low Risk (methotrexate or dactinomycin) Stage II-IV Combination outright chemotherapy High Risk (EMACO) Methotrexate o First-line single agent chemotherapy o 5-day regimen every 7-10 days o Achieves complete remission on 88% after 4-5 cycles Actinomycin, pulsed co Second-line single agent chemotherapy o 5-day regimen or biweekly If still with resistance: EA or EMACO / és EMACO regimen ) Actinomycin 500 mcg x 30 minutes Etoposide 100 mg/m? x 1 hour Methotrexate 100 mg/m? IV bolus 200 mg/mé 912 hours Cyclophosphamide 600mg/m? Oncovin (Vincristine) 1.0 mg/m? D1, D2- EMA D6, D7-CO Day 3-5: Rest day; Rest day 5 - repeat labs If with resistance to EMACO: o Repeat metastatic workupo EMAJEP regimen (salvage therapy) (In Phils, we give EP first then EMA after because EMA is the more toxic combination) co TPITE regimen PacliTaxel CisPlatin co BEP regimen Bleomycin Etoposide CisPlatin o FAEV regimen - Floxuridine Actinomycin Etoposide Vincristine Predictive Factors of Poor Prognosis Despite EMACO: = Tumor age > 12mos = Metastasis to >2 organ systems = — Incomplete previous treatment EMACO Mechanism of Action Actinomycin Etoposide Topoisomerase II inhibitor Methotrexate DHT reductase inhibitor Cyclophosphamide Nonspecific cell cycle inhibitor Oncovin (Vincristine) Inhibits microtubule formation II CONSOLIDATION THERAPY = — Given after the first normal B-Hcg * — Targets the remaining tumor cell population = — Minimizes risk of relapse Low risk 2 cycles High risk 3 cycles IV. SUPPORTIVE MANAGEMENT d 2g IV 98 for severe bleeding 187V. SURGERY AND RT = — Adjunctive treatments Indications for Adjuvant Surgery ° ° ° ° ° Remove a resistant or persistent focus Decrease tumor burden in patients with limited metastasis, Decrease number of chemo courses Control bleeding Relieve bowel or urinary obstruction Treat infection Indications for Hysterectomy ° ° ° ° Uterine perforation and profuse bleeding Drug resistant uterine focus High risk metastatic who have small extrauterine tumor burden, not desirous of pregnancy >35 yo with completed family size Operative Procedure Options ° ° ° ° ° ° ° Hysterectomy Wedge resection Uterine artery ligation or internal iliac ligation Thoracotomy/Throacoscopy: for solitary drug-resistant pulmonary focus Craniotomy to decrease ICP in brain mets Oversewing of actively bleeding vaginal lesion Selective arterial embolization Brain Metastasis ° ° High Dose EMACO with concomitant RT High Dose EMACO with Intrathecal methotrexate 158ULTRA HIGH-RISK GTN = Associated with early death within weeks starting chemo = — Associated with resistance to EM : = FIGO prognostic score >12 = May include the ff: Suspected or histopath Dx of choriocarcinoma © Multiple pulmo mets or associated hemoptysis co Brain mets © Large volume liver mets © Profuse vaginal bleeding o B-hCG>1M o Interval since last antecedent pregnancy >2.8y FOLLOW-UP Response to Treatment Adequate One log fall, or >50% fall from baseline Partial <50% fall from baseline Plateau <10% rise or fall from baseline Biochemical remission 3 consecutive normal levels Resistance 2 plateauing values, 1 rising weekly, or Appearance of new metastasis Serial B-hCG MONITORING a1 month x 6 months (6 times) q2 months —_x 6 months (3 times) q3 months —_x second year (4 times) q6 months Thereafter Radiographic Monitoring CXR Yearly if with residual TV-UTZ g6 months if with intact uterus Advice on Pregnancy = — Avoid during the first 2 years following biochemical remission = Low dose COC preferably used 159o9t asi | ‘sneajeid Z si aouejsisoy Juawjeall 0} asuodsey sieak Z Jaye pamolly Jayearay syjuow 9b (saul) p) 1284 puooas x syjuow gb (sawn ¢) syjuow g x syjuow zb (sawn g) syuow 9 x yuow .b (sKep Q|-zb uawiBa Aep g :jua6e ajBurs 4!) Adesayjowayo, Adesayjowayo, queubley) eisejdoay asejqoydo) jeuoeysag sasu z ‘sneaje|d ¢ oydos, 0} jeviajay ayejpauuuy 40) suoMeoipul SUJUOW g Jaye PAMo|yy (sewn ¢) syuou g x syjuow zb (sawn 9) syjuow 9 x yuow }b SAU] AANNIASUOD 2 'IWINIW g 5 DOU Ihun sy9am 2D aBeyaino-sog oom | (asunoo | ‘uawiBei Aep ¢) sixe|Aydosdoway9, abeyaino uojons ublueg JO WOyPHEPAH siayj0 AnueuBed U0 esiApy dn-moj|o4 ayexayjoyjayy juawabeuey) asinog VISWIdOAN DILSVISOHdOUL TVNOILVISAD “SA FTO INYOAIGILVGAH161FOUR MAJOR PRINCIPLES OF BIOETHICS (Beauchamp and Childress, 2008) Principle of Respect for Autonomy Priniciple of Nonmaleficence Principle of Beneficence Principle of Justice JONSEN’S FOUR-BOX METHOD (2002) Medical Indications ‘Principles of Beneficence and Nonmaleficence’ 1. Whatis the patient's medical problem? History? Diagnosis? Prognosis? Is the problem acute? Chronic? Critical? Emergent? Reversible? What are the goals of treatment? What are the probabilities of success? What are the plans in case of therapeutic failure? In sum, how can this patient be benefited by medical and nursing care and how can harm be avoided? Sawer Patient Preferences ‘Principle of Respect for Autonomy’ 1. |s the patient mentally capable and legally competent? Is there evidence of incapacity? 2. If competent, what is the patient stating about preferences for treatment? 3. Has the patient been informed of benefits and risks, understood this information, and given consent? 4, If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making? 1625, 6. i. Has the patient expressed prior preferences, e.g. Advanced Directives? Is the patient unwilling or unable to cooperate with medical treatment? If so, why? In sum, is the patient's right to choose being respected to the extent possible in ethics and law? Quality of Life ‘Principles of Beneficence and Nonmaleficence and Respect for Autonomy’ ls 2: 3, 4, 5. 6. What are the prospects, with or without treatment, for a return to normal life? What physical, mental, and social deficits is the patient likely to experience if treatment succeeds? Are there biases that might prejudice the provider's evaluation of the patient's quality of life? Is the patient's present or future condition such that his or her continued life might be judged undesirable? Is there any plan and rationale to forgo treatment? Are there plans for comfort and palliative care? Contextual Features ‘Principles of Loyalty and Fairness/Justice’ 1 id CONOR Are there family issues that might influence treatment decisions? Are there provider (physicians and nurses) issues that might influence treatment decisions? Are there financial and economic factors? Are there religious or cultural factors? Are there limits on confidentiality? Are there problems of allocations of resources? How does the law affect treatment decisions? |s clinical research or teaching involved? Is there any conflict or interest on the part of the providers or the institution? 163OTHER PRINCIPLES IN BIOETHICS Inviolability of Human life = Physicians are in the unconditional service of life, as the Hippocratic oath proclaims, “he shall never poison anyone” = Atthe personal level, all men are fundamentally equal. mune of Totality Prinicple which rules the conduct of man in the stewardship of the use and integrity of his body (e.g. in issues of mutilation) = “The good of the parts is essentially subordinate to the good of the whole” = Three conditions must be met: 1. That such organ, by its deterioration in function, may cause damage to the whole organism or at least pose a serious threat to it 2. That there be no other way than taking the indicated action against it of obtaning the desired good result 3. That the damage being avoided to the whole be proportional to that which is caused by the mutilation Conscientious objection = In the refusal of a specific therapy which is adjudged immoral, the decision of the patient should be respected. (e.g. blood transfusion in Adventists) Professional Secret «= Refers to the duty of medical personnel not to divulge the secrets of patients which they have come to know in the exercise of their profession « — “Professional” secret, unlike a private secret, pertains to public order or the common good. The common good limits the sphere of secrecy (2.9. desire to hurt oneself, desire to hurt others)Principle of Double Effect = — Explains the permissibility of an action that causes serious harm = Four conditions must be met: < 1. The act itself must be morally good or at least indifferent 2. The physician may not positively will the bad effect but may permit it 3. The good effect must be a result of the action, not of the bad effect. Otherwise, the physician would be using a bad means to a good end. 4, The good effect must be sufficiently desirable to compensate for the allowing of the bad effect 165Callahan and Caughey. (2013). Blueprints Obestetrics & Gynecology 6th edition. China: Lippincott Williams & Wilkins Cunningham et al. (2014). Williams Obstetrics 24th edition. USA: McGraw- Hill Education. Jonsen, AR, Siegler, M, Winslade, WJ. Clinical Ethics. A Practical Approach ‘to Ethical Decisions in Clinical Medicine 5th ed. New York: NY: McGraw Hill; 2002. Kumar, Abbas, and Aster. (2015). Robbins and Cotran Pathologic Basis of Disease 9th editior®. Canada: Saunders, Elsevier Inc. POGS Clinical Practice Guidelines167Introduce the case This is a case of (diagnosis) in a (age) year old G_P_(----) at (AOG) weeks AOG by LNMP who consulted for (chief complaint). Past medical and family medical history Past medical and family medical history are unremarkable. (Note history of HPN, DM, CVD, BA, allergy, TB. CA, goiter, bleeding disorder, previous hospitalizations or surgeries). Also note comorbidities (preeciampsia severe, mitral valve prolapse, etc.). Personal social history The patient is a nonsmoker, not an alcoholic beverage drinker. and denies illicit drug use. She is a college graduate who currently works as a (occupation). The patient had her first coitus at age (age) with 1 nonpromiscuous ~ sexual partner (NPSP). There is no history of OCP or IUD use and STD. Menstrual History The patient had her menarche at age (age) with subsequent periods occurring at (regular) intervais, lasting for (duration) days, soaking (number) pads per day. Patient usually experiences dysmenorrhea on her first day. LNMP was (date); PMP was (date). Obstetric History The patient is a G_P_(----). This is her (second) pregnancy. The first of which was an uncomplicated pregnancy last delivered via (mode of delivery, include indication) by a doctor local hospital. Live baby (sex), (birthweight), (AGA/SGALGA with/without complications. aBORD The first of which resulted in spontaneous abortion at (AOG), dilatation and curettage done at PGH. Physical Examination The patient has stable vital signs. Essentially normal systemic physical examination. Focusing on the abdomen, the fundic height is (cm), cephalic in presentation, (range of est. fetal weight), (fetal heart tones) at the RLQ. On internal examination, patient has (IE findings) Assessment Pregnancy uterine (PU), (weeks) AOG by (LMP, early or late UTZ), (cephalic or breech) in presentation, {not] in labor Short Term Plan Long Term Plan 169NORMAL PELVIMETRY Pubic arch >90 Ischial spines Blunt Diagonal conjugate >11.5 _ Sidewalls Parallel Bituberous diameter >8.5 Sacral inclination Posterior Bispinous diameter 29.5 Sacral notches Wide Coccyx Movable — Sacral width Wide Sacral curvature Hollow PROCEDURE Manner of svD Abdominal Delivery Interventions ME or MLE repair LSCS, BTL (if applicable) Indications Tight perineum, Repeat CS, placenta __degree laceration previa, etc. Blood Loss <500 co <1000ce Causes Placental separation Surgical incision FINAL DIAGNOSIS PU, delivered FT via SVD, live baby boy, 40 weeks by PA, 3000¢. AGA, cephalic in presentation, APGAR 7 becoming 9ola a oloojoia 0 BT G CBC oO CBC UA Oo UA 9 _B-hCG (undiluted) Preeclampsia Gravidocardiac BT BT CBC CBC UA + stat alb UA TP PT, PIT AST, ALT, LDH, © AST, ALT, LDH, BUN, Crea, Na, K, BUN, Crea, Na, K, Cl, Ca, Mg, Alb, Cl, Ca, Mg, Alb, RBS RBS © 24 hour urine: TV, 12-LECG TP. Crea © Simultaneous serum =O CXR BUN, Crea © 2D Echo Preterm 0 CBC+ESR olen jo 42LECG AST, ALT, LDH, BUN, Crea. Na. K Ca Mg Ab, RES ooojoR CBC UA + stat ketone BUN, Crea, Na, K, Cl, RBS 0 HbAtc ooooa Tropho BT CBC UA BT Pi AST, ALT, LDH, BUN, Crea, Na, K, Cl, Ca, Mg, Alb, RBS 12-LECG © CXR a a nojoo0c0 a £14, TSH B-hCG (diluted) Gyne Onco BT CBC UA PT, PTT CXR TV-UTZ AST, ALT, LDH, BUN, Crea, Na, K, Cl, Ca, Mg. Alb, RBS, Alk Phos 17110‘ percentile 500 625 750 850 950 1050 1150 1250 1375 1550 1700 1875 2050 2250 2375 2550 2650 2750 90" percentile 1185 1260 1375 1450 1550 1625 1750 2000 2250 2500 2750 3000 3150 3325 3500 3620 3670 3750 172This page is intentionally left blank. 173