UpToDate Lectures

Dr Mohamed Sabry- UpToDate in Obstetrics & Gynecology
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Naglaa, Anas & Marwan
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Table of contents
Iron Deficiency Anemia during Pregnancy 6

Methotrexate (MTX) Therapy in Ectopic Pregnancy (EP) 8
Methotrexate (MTX) Protocol in Ectopic Pregnancy (EP) 10
Induction of Labor 13
Induction of Ovulation in Practice (Lesson 1) 15
How to Differentiate Clinically between Abortion & Ectopic 27
Management of Pre-eclampsia 29
How to control BP in pregnancy 32
Regimen of MgSO4 for Fetal Neuroprotection 34
Management of Thrombocytopenia with Pregnancy 36
Anticoagulation during Pregnancy 40
Management of Bartholin Cyst/Abscess 46
Abdominal Hysterectomy Technique 49
Ureter & Bladder Injury in Gynecologic Surgery 56
Management of Sensitized Rh -ve Pregnant Women 61
Management of Recurrent pregnancy loss (RPL) 62
Compression Sutures 67
Expert Technique for Vaginal Delivery 72
Management of Complicated Ovarian Cyst (Adnexal Torsion) 73
Cesarean Scar Defect (Niche/Isthmocele) 78
Management of Missed Implanon 80
Management of Pregestational DM 82
Management of GDM 86
Management of Oligohydramnious 88
Management of PPROM 91
Management of Infected Cesarean section Wound 94
Management of Intrahepatic Cholestasis of Pregnancy (IHC) 97
Management of Small for Gestational Age (SGA) & IUGR 99
A Look at Postcoital Bleeding 103
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Understanding Menopause (Lesson 1) 105
Evaluation & Diagnosis of Menopause (Lesson 2) 107
Management of Menopausal Hot Flashes (Lesson 3) 109
Management of Atrophic Vaginitis 114
Assessment of the Ovarian Reserve 115
Management of Uterine Fibroid (Lecture 1) 118
The Most Important 35 points you should know before practice 134
5
Iron Deficiency Anemia during Pregnancy

Diagnosis
- Hb <11 gm/dL, decreased MCV & MCHC (mean corpuscular Hb conc.)>>> Microcytic
hypochromic anemia.
- Decreased s. iron, s. ferritin & increased total iron-binding capacity (TIBC)>>> diagnostic of iron
deficiency anemia.
Management
Supplementation
- Regardless of anemia status, daily oral supplementation with 30-60 mg of "elemental iron" & 400
μg of folic acid is recommended.
Oral Therapy
- Ferrous sulfate is the most commonly used.
- There are 2 types of tablets: 325 mg OR 195 mg tab. (contain 65 mg OR 39 mg of elemental iron,
respectively) & given 1-3 times daily.
- A dose of 200-300 mg of elemental iron/day should result in the absorption of up to 50 mg
iron/day.
- Ferrous fumarate & gluconate are absorbed better than ferrous sulfate & have less morbidity dt.
less elemental iron content.
- The indicator of successful therapy: 2 gm/dL increase in the Hb level in 3 wk.
- Duration: it should be continued for about 2 months after correction of the anemia to refill body
stores with iron.
Parenteral
Iron dextran (CosmoFer®)
* 1 amp. (2 ml) contain 50 mg/ml (total 100 mg/amp) given IM or IV.
* Test dose (25 mg or ½ ml) is given initially to test for hypersensitivity.
* If large doses are to be given (>100 mg/1 amp.), it should be diluted in NS solution & infused
over a 60-90 minutes.
Iron sucrose (Venofer®)

* 1 amp. (5 ml) contain elemental iron 20 mg/ml (total 100 mg/amp) given IV.
* It is safer than iron dextran & can be given to patients hypersensitive to iron dextran.
* Given max. 3 times/wk.
- Volume of product required (ml) = [Wt. (kg) X (Target Hb ‒ Actual Hb) X 2.145] /C
(Where C =conc. of elemental iron (mg/ml) in the product being used)
e.g. if we have patient 75 kg & her Hb now 7 & we want to make it 14, this is our equation>>>
[75 x (14-7) x 2.145]>>> iron deficit is 1126 mg> /20 mg (if we will use iron sucrose) = 56 ml>> /5
ml (the volume in 1 ampule Venofer) =11 amp. iron sucrose (Venofer).
6
IV Dosing
- For iron dextran (CosmoFer), you can give a total dose infusion of 1000 mg (10 ampules) in 250
mL of normal saline over ONE hour. Although this is not FDA-approved dosing, but was tried in
>5000 administrations without complications.
- A test dose is required first (0.5 mL [25 mg]). We prefer to administer the test dose over 5 minutes
while observing the patient. If no symptoms occur during the first 5-10 minutes, it is extremely
unlikely that an infusion reaction will occur. After the test dose, we administer the remainder of a
1000 mg dose over one hour.
- Take care this single large dose is applicable only for low molecular weight Iron dextran
(CosmoFer) & Ferumoxytol (Feraheme) & neither for Ferric gluconate nor Iron sucrose (Venofer).
- Number of adverse events attributed to IV iron are in fact due to premedications (using Avil &
dexamethasone in the solution from the start without allergic reactions) . So, we do not give any
premedications to patients without a history of asthma or more than one drug allergy.
- For Iron sucrose (Venofer), we give it over multiple doses of 200-300 mg (2-3 ampules) at once in
one solution & max. 3 times/wk without any need for a test dose.
Blood Transfusion
- Indication for transfusion: if Hb <7-8 gm/dL.
- Transfusions is rarely indicated unless there is hypovolemia from blood loss OR an operative
delivery must be performed on a patient with anemia.
Monitoring of treatment
- For patients receiving oral iron, we often re-evaluate the patient 2 wk after starting.
- For IV iron, we generally see patients 4-8 weeks after the iron has been administered. We do not
obtain repeat iron parameters for at least 4 weeks, because IV iron interferes with most assays of
iron status.
Best Regards
#UpToDate_Lectures
7
Methotrexate (MTX) Therapy in Ectopic Pregnancy (EP)

Pharmacology in brief
- MTX is a folic acid antagonist widely used for treatment of neoplasia, severe psoriasis &
rheumatoid arthritis.
- Dose: 50 mg/m2 OR 1 mg/kg.
- Antidote: leucovorin (folinic acid), it rescue bone marrow & GIT mucosa from MTX.
- Routes of administration: the most common route is IM, but it can be given IV, IM, orally or by
direct local injection into the EP sac transvaginally or laparoscopically.
- Adverse reactions: usually mild & self-limited in the form of stomatitis (commonest),
conjunctivitis & elevated liver enzymes.
Indications
- Hemodynamically stable EP.
- Desire for future fertility.
- hCG ≤5000 mIU/ml.
- EP mass size < 3-4 cm.
- No fetal cardiac activity.
Contraindications
- Leucopenia (WBC <3000), thrombocytopenia (platelets <100,000) OR severe anemia.
- Active pulmonary disease & peptic ulcer:
- Heterotopic pregnancy with coexisting viable IUP.
- Breastfeeding.
- Suspected rupture EP.
- Relative contraindications: β-hCG >5000 mIU/ml, GS >3.5 cm & +ve cardiac activity.
- Liver enzymes >2 times normal OR creatinine >1.5 mg/dl as:
* MTX is renally cleared.
* In women with renal insufficiency, a single dose of MTX can lead to bone marrow suppression,
acute respiratory distress $ (ARD$), bowel ischemia & even death.
* Renal & liver disease slows the metabolism of MTX & result in pancytopenia & skin & mucosal
damage.
* Chronic renal disease or liver disease are contraindications.
Important points
- The fertility rates after treatment of EP with salpingostomy, salpingectomy or MTX are similar.
- Treatment with MTX doesn’t appear to compromise ovarian reserve.
- Expectant management is contraindicated if the serum hCG is >200 mIU/ml. We treat these
women with MTX or surgical therapy.
8
Factors that decrease efficacy
- High hCG concentration: is the most important factor associated with treatment failure. Women
with hCG >5000 mIU/ml are more likely to require multiple courses of MTX or experience
treatment failure.
- Fetal cardiac activity.
- Large EP size.
- Peritoneal fluid: U/S finding of free peritoneal fluid is an exclusion criterion for MTX treatment as
it may be blood (tubal rupture or abortion).
- Isthmic location of the EP mass rather than ampullary (early rupture).
- High pretreatment folic acid level (will oppose MTX action).
Best Regards
#UpToDate_Lectures
9
Methotrexate (MTX) Protocol in Ectopic Pregnancy (EP)

Pretreatment Investigations
- Viable IUP must be excluded.
- Serum hCG: as part of the diagnostic evaluation & to establish a baseline to monitor the effect of
therapy.
- TVUS: as part of the diagnostic evaluation.
- Bl. group & Rh: to determine the need for anti-D Ig.
- CBC, kidney & liver function tests: to assess for CI to MTX.
Pretreatment Instructions
- Discontinue folic acid supplements.
- Avoid NSAID & give paracetamol if an analgesic is needed.
- Avoid sexual intercourse & strenuous exercise.
Single Dose Protocol (the preferred for tubal EP)

- Administration of a single IM dose of MTX.
- 15-20% of women will require a 2nd dose & patients should be aware of this before starting the
protocol.
- The overall rate of resolution of EP is approximately 90% for both single- & multiple-dose
protocols.
- Advantage: less side effects, requires less monitoring & doesn’t require folinic acid rescue
(leucovorin).
Method
• Day 1 is the day that MTX is administered (1 mg/kg & maximum 1.5 mg/kg IM).
‫ ﻛﯿﻠﻮ إدﯾﮭﺎ أﻣﺒﻮﻟﯿﻦ وھﻜﺬا ﻋﻠﺸﺎن‬80 ‫ ﻛﯿﻠﻮ إدﯾﮭﺎ أﻣﺒﻮل وﻟﻮ ﻣﺮﯾﻀﺔ ﺗﺎﻧﯿﺔ وزﻧﮭﺎ‬50 ‫ ﻣﺠﻢ ﺑﺎﻟﺘﺎﻟﻲ ﻟﻮ ﻋﻨﺪﻧﺎ ﻣﺮﯾﻀﺔ وزﻧﮭﺎ‬50 ‫اﻷﻣﺒﻮل‬
‫ﻣﺘﺤﺘﺎﺟﺶ ﻟﺠﺮﻋﺔ ﺗﺎﻧﯿﺔ ﻣﻊ اﻟﻮزن اﻟﺰﯾﺎدة‬
• On Days 4 & 7, serum hCG is measured.
• On Days 7, if <15% hCG decline from day 4 to 7, give 2nd dose of MTX.
(%15) ‫ ﺑﺲ ﻣﻦ ﻗﯿﻤﺘﮫ‬390 ‫ ﻓﻲ اﻟﯿﻮم اﻟﺮاﺑﻊ وﻓﻲ اﻟﯿﻮم اﻟﺴﺎﺑﻊ اﻟﮭﺮﻣﻮن ﻧﺰل أﻗﻞ ﻣﻦ‬2600 ‫ﯾﻌﻨﻲ ﻟﻮ ﻣﺮﯾﻀﺔ ﻛﺎن اﻟﮭﺮﻣﻮن ﻋﻨﺪھﺎ‬
‫ ﻧﻌﻄﻲ اﻟﻤﺮﯾﻀﺔ ﺟﺮﻋﺔ ﺗﺎﻧﯿﺔ‬2210 ‫وأﺻﺒﺤﺖ اﻟﻨﺘﯿﺠﺔ ﻓﻲ اﻟﯿﻮم اﻟﺴﺎﺑﻊ أﻛﺘﺮ ﻣﻦ‬.
• If ≥15% hCG decline from day 4 to 7, check hCG weekly until undetectable.
• On Days 14, if <15% hCG decline from day 7 to 14, give 3rd dose of MTX.
• We give a maximum of 3 doses in the single protocol.
• If 3 doses have been given & there is a <15% hCG decline from day 14 to 21, we perform a
laparoscopic salpingostomy or salpingectomy.
10
Important Points Regarding Single-dose protocol
- It is common to observe an increase in hCG levels in the first days following therapy (until Day
4); this is due to continued hCG production by syncytiotrophoblast despite cessation of production
by cytotrophoblast.
- If an additional dose of MTX is indicated, we don’t repeat pretreatment investigations.
- Folinic acid rescue (leucovorin) is not required for women treated with the single-dose protocol,
even if multiple doses are ultimately given.
- If the hCG doesn’t decline to zero or rising, TVUS should be performed & a new pregnancy
should be excluded.
- There is no clinical benefit from routine serial TVUS examinations. However, TVUS evaluation
for peritoneal fluid is indicated for women with severe abdominal pain.
- After treatment, the EP is often increase in size & may persist for weeks on serial TVUS
examinations. ‫ ﻣﺘﺘﺨﻀﺶ‬This probably represents hematoma rather than persistent trophoblastic tissue
& is not predictive of treatment failure.
- Falling hCG levels don’t exclude the possibility of tubal rupture.
- If tubal rupture is suspected, immediate surgery is required.
Multiple Dose Protocol

- 4 MTX doses alternating with oral leucovorin (the antidote) are used.
- It is used for interstitial pregnancies & cervical pregnancy (relatively more trophoblastic tissue
than tubal pregnancy).
- Advantage: lower failure rate.
- Disadvantage: more adverse effects (so, leucovorin is used).
Method
• Administers MTX (1 mg/kg/day) IM or IV on Days 1, 3, 5 & 7 & oral leucovorin (0.1 mg/kg) on
Days 2, 4, 6 & 8.
• HCG is checked on Days 1, 3, 5 & 7.
• If <15% hCG decline from day 1 to 3 (suspected), give MTX 2nd dose followed by leucovorin the
next day.
• If ≥15% decline from day 1 to 3, stop treatment & begin surveillance (weekly hCG) as in the
single protocol.
• These last 2 steps are applied at every point along the course.
• On Days 14, if <15% hCG decline from day 7 to 14, give 5th dose of MTX followed by
leucovorin the next day.
• If 5 doses have been given & there is a <15% hCG decline from day 14 to 21, proceed with
laparoscopic surgery.
Precautions during Therapy

- Avoid vaginal intercourse & new conception until hCG is undetectable.
- Avoid foods & vitamins containing folic acid.
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- Avoid NSAID, as the interaction with MTX may cause bone marrow suppression, aplastic anemia
& GIT toxicity.
- Avoid pelvic exams during surveillance of MTX therapy due to theoretical risk of tubal rupture.
- Avoid sun exposure to limit risk of MTX dermatitis.
Pain After Treatment

- Mild to moderate abdominal pain of short duration (1-2 days) 6-7 days after receiving the
medication is common.
- The pain may be due to tubal abortion or tubal distention from hematoma formation & can be
controlled with paracetamol.
- If severe pain in hemodynamically stable woman, no need for surgical intervention.
‫ ﺑﺲ ﻻزم ﺗﺨﺘﺎر اﻟﻤﺮﺿﻰ ﺑﺘﻮﻋﻚ ﺻﺢ ﻣﻦ اﻟﺒﺪاﯾﺔ ﺣﺴﺐ اﻟﻤﻌﺎﯾﯿﺮ اﻟﻠﻲ ﻗﻠﻨﺎ ﻋﻠﯿﮭﺎ‬،‫إﺣﻨﺎ ﻣﺶ ﻋﺎﻣﻠﯿﻦ ﻛﻞ ده ﻋﻠﺸﺎن ﻧﻔﺘﺤﮭﺎ ﻓﻲ اﻵﺧﺮ‬
‫ﻗﺒﻞ ﻛﺪا‬.
- Findings suggestive of hemoperitoneum raise the suspicion of tubal rupture.
- Women with severe pain should be evaluated with TVUS & closely observed for hemodynamic
changes which may accompany a tubal rupture.
3 Parameters predicted hemoperitoneum ≥300 ml in women with EP

1. Moderate to severe pelvic pain.
2. Fluid above the uterine fundus or around the ovary.
3. Serum Hb <10 g/dl.
When ≥2 criteria are present, the probability for hemoperitoneum ≥300 ml is 92%.
Interval to Conception
- We advise women not to conceive for 3 months.
- On the other hand, there is no evidence of teratogenic risk to those who conceive sooner.
- EP pregnancies treated with MTX have a timely return of menses & superior rates of conception
compared with those treated with salpingostomy.
- These women should take folic acid daily, according to routine preconceptional recommendations.
#UpToDate_Lectures
12
Induction of Labor
- Administration of oxytocin is probably the most common method of labor induction after a
ripening process of unfavorable cervices.
Bishop Score (See the table down)
- A score ≥8 suggests the chances of having a vaginal delivery are good and the cervix is considered
favorable or ripe for induction. If the Bishop score is ≤6, the chances of having a vaginal delivery
are low, and the cervix is considered unfavorable or unripe for induction.
A simplified Bishop score can be calculated using only dilation, station, and effacement. Using
these 3 variables, a simplified Bishop score ≥5 has a similar predictive value for vaginal delivery as
a classic Bishop score ≥8.
- Based on the simplified Bishop score, you can start induction by oxytocin if the V/E findings are
cx dilation 3-4 cm, 60-70% effaced & -2 station, Not before these findings.
Comparison
A network meta-analysis comparing the use of misoprostol, dinoprostone & Foley catheter for
cervical ripening concluded that no method was clearly superior when the rates of failure to achieve
vaginal delivery within 24 hours, uterine hyperstimulation with FHR changes & cesarean delivery
were all taken into account.
1. Vaginal misoprostol followed by vaginal dinoprostone were the most effective methods for
achieving delivery within 24 hours; however, these methods had the highest rates of uterine
hyperstimulation with adverse FHR changes.
2. The Foley catheter was the least effective method for achieving delivery within 24 hours, but had
the lowest incidence of uterine hyperstimulation with FHR changes.
3. Oral misoprostol was the best method for reducing the risk of cesarean delivery and caused less
uterine hyperstimulation with FHR changes than vaginal misoprostol.
4. The author's preference is to use vaginal PGE1 (misoprostol).
- Prostaglandins are not used for cervical ripening or labor induction in term pregnancies with a
prior cesarean birth or other prior major uterine surgeries (eg, extensive myomectomies and
hysterotomies) because of the increased risk for uterine rupture.
Dosing
1. Misoprostol (Cytotec) is a prostaglandin E1 analog available as 200 mcg tablets, which can be
broken to provide 25 mcg (the same dose of vagiprost tablet). We administer 25 mcg every 3-4
hours. The WHO suggests 25 mcg every 6 hours. Oxytocin can be initiated, if necessary, 4 hours
after the final misoprostol dose.
2. Prostin E2 gel or tablets (3 mg dinoprostone) are PG E2 analogs.
Cervidil is a vaginal insert containing 10 mg of dinoprostone in a timed-release formulation (the
medication is released at 0.3 mg/h). The insert is left in place until active labor begins, or for 12
13
hours. Oxytocin can be initiated anytime beyond 30 minutes after removal of the insert. An
advantage of the vaginal insert over the gel formulation is that the vaginal insert can be removed in
cases of uterine tachysystole or abnormalities of the fetal heart rate tracing.
- A workshop convened by the NICHHD & ACOG proposed that failed induction is defined as
failure to generate regular contractions approximately every 3 minutes and cervical change after at
least 24 hours of "oxytocin" administration. Membranes should be artificially ruptured. After
rupture of membranes, the induction may be considered failed if regular contractions and cervical
change do not occur after at least 12 hours of oxytocin administration. The workshop’s goal was to
provide evidenced-based criteria for reducing the number of CS performed for failed induction in
the latent phase of labor. By allowing the latent phase to extend for 24 hours or more and
administering oxytocin for 12-18 hours after membrane rupture, many of these cesarean deliveries
can be avoided.
- The time devoted to cervical ripening is not included when calculating the length of induction or
diagnosing failed induction. So, we do not perform latent phase cesarean delivery (ie, failed
induction) unless regular contractions and cervical change have failed to occur after 12-18 hours of
oxytocin administration.
Practical Method for Applying Oral Misoprostol

Take one tab misoprostol 200 mcg & dissolve it in a 200 ml water & give 25 ml to the patient every
3-4 hrs till favorable cervix for oxytocin.
- This technique for administration was offered as the prostaglandin is not equally distributed in the
tablet. So, if you divided the tablet (200 mcg) into 4 hard parts, the total 200 mcg concentration may
be in one single part. Thats why, its better to dissolve the the tablet in water to be equally distributed
in the solution then apply for the patient. Each 25 ml solution will contain 25 mcg PG E1.
Best Regards
Mohamed Sabry
#UpToDate_Lectures
14
Induction of Ovulation in Practice (Lesson 1)

Anovulatory Disorders
- Most experts have moved away from this terminology (WHO class 1, 2, 3) & assign women to 1
of the 4 most common ovulatory disorders:
1. Hypogonadotropic hypogonadism (hypothalamic amenorrhea).
2. PCOS.
3. POI (primary ovarian insufficiency; premature ovarian failure).
4. Hyperprolactinemia.
Hypogonadotropic hypogonadism
- Include functional hypothalamic amenorrhea (such as anorexia nervosa, exercise & stress) &
isolated GnRH deficiency.
- Hormonal abnormalities include low serum estradiol & low or low-normal FSH dt. presumed
decreased hypothalamic secretion of GnRH.
- AMH levels are low to normal as no follicular development.
- Reversing the lifestyle factors that contribute to the anovulation (low weight, excessive exercise or
any condition that leads to energy deficiency) should be attempted before considering ovulation
induction with medications.
‫ﺑﺎﻟﺘﺎﻟﻲ ﻻزم ﻧﺴﺄل اﻟﻤﺮﯾﻀﺔ ﻋﻠﻰ ﺣﯿﺎﺗﮭﺎ اﻟﻌﺎﻣﮫ ﺑﺘﻌﻤﻞ ﻓﯿﮭﺎ اﯾﺔ ﻗﺒﻞ ﻣﺎ ﻧﻌﻄﻲ أدوﯾﺔ ﻏﺎﻟﯿﺔ وﻧﺪﺧﻞ ﻓﻲ ﻗﺼﺔ طﻮﯾﻠﺔ ﻣﻦ ﻓﺸﻞ اﻟﻌﻼج‬.
- They are unlikely to respond to clomiphene citrate, but you can give one course of clomiphene
prior to initiating pulsatile GnRH or Gn therapy.
- For those who ovulate, clomiphene citrate can then be continued.
- For those who do not ovulate, we suggest pulsatile GnRH as first-line therapy. If pulsatile GnRH
is unavailable in your place, Gn therapy should be initiated, with both LH & FSH (these women do
not respond to FSH alone).
Polycystic ovary syndrome (PCO)

- Represent the largest group of anovulatory women encountered in clinical practice (70-85 % of
cases).
- Serum estradiol & FSH levels are normal, whereas LH may either be normal or elevated.
- The criteria for diagnosis have been referred to as the "Rotterdam criteria"
.... 2 of the following 3 are required to make the diagnosis of PCO:
1. Oligo- &/or anovulation.
2. Clinical $/or biochemical signs of hyperandrogenism.
3. Polycystic ovaries (by U/S).
- In obese women with PCO, weight loss should be attempted before starting treatment with
ovulation induction agents as it restores spontaneous ovulation in many women.
- Women with PCO should be screened for impaired glucose tolerance before starting ovulation
induction because of the associated risk of pregnancy complications.
‫ﯾﺒﻘﻰ ﻻزم ﻧﺨﻠﯿﮭﺎ ﺗﺨﺲ وﻧﺸﻮﻓﻠﮭﺎ اﻟﺴﻜﺮ ﻗﺒﻞ ﻣﺎﻧﺪﯾﮭﺎ ﺗﻨﺸﯿﻂ‬.
15
Primary ovarian insufficiency
- Defined as menopause before age 40 years.
- In most cases, the follicle pool is exhausted dt. accelerated follicle loss of unknown origin.
- The only effective option is IVF with donor oocytes.
‫ﯾﺒﻘﻰ دي ﻧﻨﺴﺎھﺎ وﻣﻨﺘﻜﻠﻤﺶ ﻓﯿﮭﺎ ﺗﺎﻧﻲ‬
- Only we have to replace the estrogen deficiency dt the increased risk of osteoporosis &
cardiovascular disease.
Hyperprolactinemia
- These women are anovulatory because hyperprolactinemia inhibits Gn secretion dt. inhibition of
GnRH.
- So, if you measured FSH & LH, you will find them low normal or decreased.
- The measurement can be performed at any time.
- The usual normal range for serum prolactin is approximately 5-20 ng/mL.
- If an initial prolactin level is slightly elevated (21-40 ng/mL) or only borderline high, the test
should be repeated before the patient is considered to have hyperprolactinemia as the hormone
increase during sleep, strenuous exercise & with emotional or physical stress.
- MRI of the head should be performed in a patient with any degree of hyperprolactinemia to look
for a mass lesion in the hypothalamic-pituitary region, unless the patient is taking a medication
known to cause hyperprolactinemia.
- If the MRI shows a normal hypothalamic-pituitary region & there are no obvious causes of
hyperprolactinemia, the diagnosis of idiopathic hyperprolactinemia is made.
- The treatment of choice for anovulatory women with hyperprolactinemia is dopamine agonists.
To be Continued ,,,
#UpToDate_Lectures
16

Goals of ovulation induction
- Induce monofollicular rather than multifollicular development & subsequent ovulation with a
singleton pregnancy. ‫ﯾﻌﻨﻲ ﻣﺶ ﺑﺎﻟﻜﺘﺮه ﻋﻠﺸﺎن ﻣﺸﺎﻛﻞ اﻟﺘﺤﺮﯾﺾ‬
- Take care, PCOS represents a risk factor for developing OHSS following ovarian stimulation with
Gn.
- Start with the least invasive & simplest treatment option; subsequent options should depend upon
ovarian response .
......First line>>>Weight loss for high BMI
......First line>>>Clomiphene or Letrozole with or without metformin
......Second line>>>FSH injections
......Second line>>>Ovarian drilling
......Third line>>>IVF
Patient Selection
- Women with hypothalamic amenorrhea (↓ GnRH) are hypoestrogenemic & are therefore unlikely
to respond to Clomid. Instead, pulsatile GnRH is the first-line therapy & if pulsatile GnRH is
unavailable, Gn therapy should be initiated, with both LH & FSH (these women do not respond to
FSH alone).
‫ﺑﺎﻟﺘﺎﻟﻲ ﻻزم ﺟﺪا ﻧﻄﻠﺐ ﻋﻤﻞ‬
FSH & LH
‫ ﺷﮭﻮر ﻧﺸﺤﻦ اﻟﺴﺖ ﻛﻠﻮﻣﯿﺪ‬6 ‫ﻗﺒﻞ أي ﺗﺤﺮﯾﺾ ﻋﻠﺸﺎن ﻧﺴﺘﺒﻌﺪ اﻟﺴﺒﺐ ده وﻣﻨﻘﻌﺪش‬.
- For women with PCOS, starts with exercise & weight loss, if high BMI, followed by ovulation
induction with either Clomid or Letrozole.
- For women with primary ovarian insufficiency (POI), all ovulation induction strategies are
unsuccessful.
- The treatment of choice for anovulatory women with hyperprolactinemia is dopamine agonists
(will be discussed later).
CLOMIPHENE CITRATE (Clomid)

- Clomid has been the most widely used agent for ovulation induction for over 50 years.
- It was used as an experimental treatment option for amenorrhea caused by endometrial cancer.
- It is used most effectively in women with PCOS.
- Predictors of ovulation: younger age, lower BMI & presence of oligomenorrhea (menstruation that
occurs at intervals of ≥35 days) rather than amenorrhea.
‫ﺑﺎﻟﺘﺎﻟﻲ إﺳﺘﺠﺎﺑﺔ اﻟﺴﺘﺎت اﻟﻜﺒﯿﺮه اﻟﺘﺨﯿﻨﺔ اﻟﻠﻲ ﻣﺒﺘﺠﯿﻠﮭﺎش دورة ﺑﺎﻟﺜﻼﺛﺔ أﺷﮭﺮ ﺿﻌﯿﻔﺔ‬
- Weight loss should always be attempted before initiating ovulation induction in overweight or
obese women with PCOS.
17
‫ﻹن ﻧﻘﺺ اﻟﻮزن اﻟﺒﺴﯿﻂ ﺑﯿﻔﺮق ﺟﺎﻣﺪ ﺟﺪا ً ﻓﻲ اﻻﺳﺘﺠﺎﺑﺔ ﻟﻠﺘﺤﺮﯾﺾ ﻟﺬﻟﻚ ﻻزم ﻧﺒﺪأ ﺑﯿﮫ‬
- Of those who ovulate, 30-40% conceive.
‫ﻗﻠﻨﺎھﺎ ﻗﺒﻞ ﻛﺪا ﻓﻲ ﻣﺤﺎﺿﺮة ﺣﺴﺎب ﯾﻮم اﻟﺘﺒﻮﯾﺾ‬.
‫ﺑﺎﻟﺘﺎﻟﻲ ﻣﻤﻜﻦ ﺟﺪا اﻟﻤﺮﯾﻀﮫ ﺗﺴﺘﺠﯿﺐ ﻟﻠﺘﺤﺮﯾﺾ وﯾﺤﺼﻞ ﺗﺒﻮﯾﺾ وﻣﯿﺤﺼﻠﺶ ﺣﻤﻞ‬.
- Take care, fertility potential declines rapidly after 40 years of age.
- Clomid is considered as a first-line therapy for ovulation induction in non-obese women with
PCOS (BMI <30).
- For obese women with PCOS (BMI ≥30), Letrozole rather than Clomid is cosidered as the first-
line drug for ovulation induction because it appears to result in higher cumulative live birth rates.
Pretreatment Evaluation
- The presence of ovulatory dysfunction (amenorrhea or irregular menses) must be established.
‫ ده ﯾﺒﻘﻰ إﺳﻤﮫ‬.‫ﯾﻌﻨﻲ ﻣﯿﻨﻔﻌﺶ ﯾﻜﻮن اﻟﻤﺒﯿﺾ ﺷﻐﺎل ﺗﻤﺎم وﺑﯿﻄﻠﻊ ﺑﻮﯾﻀﺎت ﻛﻞ ﺷﮭﺮ واﻟﺪوره ﻣﻨﺘﻈﻤﮫ وآﺟﻲ أﻋﻄﻲ اﻟﻤﺮﯾﻀﮫ ﺗﺤﺮﯾﺾ‬
‫ﻋﻚ‬.
- If the diagnosis of ovulatory dysfunction is uncertain, a low value (<2 ng/mL) of midluteal serum
progesterone conc. is more definitive.
- Laboratory testing: pregnancy test, TSH & prolactin to exclude pregnancy, thyroid disease &
hyperprolactinemia because these require different treatments.
- Serum FSH should also be measured as women diagnosed with primary ovarian insufficiency are
unlikely to respond to Clomid.
‫ﯾﺒﻘﻰ ﻻزم وﻻﺑﺪ ﻧﻌﻤﻠﮫ ﻟﻮ طﻠﻊ ﻋﺎﻟﻲ ﺟﺪا ﯾﺒﻘﻰ اﻟﻤﺒﯿﺾ ﺧﻠﺺ اﻟﺒﻮﯾﻀﺎت وﻣﺶ ھﯿﺴﺘﺠﯿﺐ ﻟﻠﺘﺤﺮﯾﺾ وﻟﻮ طﻠﻊ واطﻲ ﺟﺪا ﯾﺒﻘﻰ‬
‫اﻟﻤﺸﻜﻠﮫ ﻣﻦ اﻟﮭﯿﺒﻮﺳﻼﻣﺲ وﺑﺮدو ﻣﺶ ھﯿﺴﺘﺠﯿﺐ ﻟﻠﺘﺤﺮﯾﺾ‬.
- Women with PCOS & hirsutism should have a 17-hydroxyprogesterone measured; if late-onset
congenital adrenal hyperplasia is diagnosed, glucocorticoid therapy is a potential alternative for
ovulation induction.
‫ﻻزم ﻧﺨﻠﻲ اﻟﺘﺸﺨﯿﺺ ده ﻓﻲ دﻣﺎﻏﻨﺎ وﻧﺒﺤﺚ ﻋﻨﮫ‬.
- Obese women with PCOS should be screened for diabetes & encouraged to lose weight before
considering ovulation induction.
- HSG should be performed if the women have not conceived after 3 ovulatory cycles to exclude
another tubal pathology preventing pregnancy.
- For women >35 years, do serum AMH; if <1.0 ng/mL, shift the woman for assisted reproductive
interventions instead of Clomid.
18
Regimen
- Initial course: 50 mg once daily for 5 days, begin from 5th day of cycle (can start from 2nd, 3rd or
4th day) following either spontaneous or induced bleeding. However, available data suggests that
conception rates may be lower in women after a spontaneous period or progestin-induced
withdrawal bleed compared to anovulatory cycles without progestin withdrawal.
‫ﯾﻌﻨﻲ ﻟﻮ ﻣﺮﯾﻀﮫ دورﺗﮭﺎ ﻣﻠﺨﺒﻄﮫ ﻣﻤﻜﻦ ﻧﺒﺪأ اﻟﻜﻠﻮﻣﯿﺪ ﻓﻲ أي وﻗﺖ ﺑﺪون ﻣﺎﻧﺪﯾﮭﺎ ﺣﺒﻮب ﺑﺮوﺟﺴﺘﯿﺮون ﺗﻨﺰل اﻟﺪوره وﺑﻌﺪﯾﻦ ﻧﺒﺪأ‬
‫اﻟﻜﻠﻮﻣﯿﺪ ﺑﺎﻹﺿﺎﻓﮫ إن ﻧﺘﺎﺋﺞ اﻟﺘﺒﻮﯾﺾ واﻟﺤﻤﻞ أﻋﻠﻰ ﻓﻲ اﻟﻄﺮﯾﻘﮫ اﻟﻌﺸﻮاﺋﯿﺔ دي‬.
- Dose adjustment: Subsequent doses may be increased to 100 mg once daily for 5 days only if
ovulation does not occur at the initial dose.
- Maximum dose: 100 mg once daily for 5 days for up to 6 cycles. The maximum recommended
dose in women with PCOS is 150 mg daily (ESHRE/ASRM 2008).
- Once ovulation is achieved, the same dose should be continued for 4-6 cycles.
- The couple is advised to have intercourse every other day for ONE week beginning 5 days after
the last day of Clomid.
- Discontinue if ovulation does not occur after 3 courses of treatment; or if 3 ovulatory responses
occur but pregnancy is not achieved.
Monitoring
- Determination of the ovulatory LH surge by urinary LH kits is what most clinicians recommend in
practice.
- The LH surge typically occurs 5-12 days after Clomid administration is completed.
- Ovulation almost always occur within 48 hours after the detection of the urinary LH surge.
- Therefore, the interval of highest fertility is the day of the LH surge & the following 2 days.
- A mid-luteal (1 week after ovulation) serum progesterone conc. >3 ng/mL (ideally >10 ng/mL)
provides reliable evidence that ovulation has occurred.
- Some expert groups, such as RCOG & NICE, suggest serial transvaginal U/S to monitor the
number & size of the developing follicles & to time hCG administration if necessary. Serial
transvaginal ultrasound may also provide evidence of ovulation (follicle enlargement followed by
collapse suggests ovulation). Some advocate U/S monitoring of just the first clomiphene cycle in
order to exclude hyperresponse with the dose used. The first U/S is scheduled on day 10 & then
every 2-3 days if necessary. Spontaneous ovulation can be expected when the lead follicles reach
18-20 mm.
- The management of ovarian enlargement/theca lutein cysts from ovarian stimulation is
controversial. Withholding Clomid in these cases until the cyst(s) disappear either spontaneously or
after suppression with COC is recommended.
- Induction of ovulation by Clomid increases the probability of multifetal pregnancy. The risk may
be reduced by U/S monitoring & withholding hCG, IUI, or intercourse if >2 follicles >15 mm
diameter are seen.
19
Outcomes
- 60-85% of anovulatory women dt. PCOS, ovulate in response to Clomid. Of those who ovulate,
50% do so at a dose of 50 mg daily for 5 days.
- After 6 months of treatment, the pregnancy rate per cycle falls substantially despite regular
ovulation.
- Failure to conceive despite ovulatory cycles, particularly at higher doses, may be due to Clomid
antiestrogenic effects on the cervical mucus & on the endometrium; impairing implantation.
- As noted above, HSG should be performed, if not already done, in any woman who fails to
conceive within 3-6 treatment cycles.
- Failure to conceive after a maximum of 6 ovulatory treatment cycles indicates a need to further
evaluate for factors potentially causing infertility or to change to another treatment strategy.
Modified Regimens
- Addition of ovulatory dose hCG: absent or inadequate midcycle LH surge may result in a failure
to ovulate or a short luteal phase, despite Clomid-induced follicular development. In this situation,
an exogenous hCG single dose 5000-10,000 IU, IM may be added to the regimen. It is given when
transvaginal U/S (TVS) shows that the dominant follicle has reached 18-20 mm in diameter. It
should be noted that premature administration of hCG acts like a premature LH surge & may result
in follicular atresia. Serial TVS to monitor follicle size is superior & should be used to time hCG
administration. Ovulation occurs approximately 36-44 hours after the injection.
- Progesterone supplementation may also be used for luteal phase support in women treated with
Clomid dt. the antiestrogenic effects of Clomid on the endometrium & inhibition of steroidogenesis
in granulosa & lutein cells, especially with high doses of Clomid.
- Strategies to prevent thin endometrium: giving half-dose Clomid (25 mg/day) or early
administration (starting day 1).
- Intrauterine insemination can be added if there is some sort of male factor infertility.
METFORMIN
- A consensus group has recommended against the routine use of metformin (including ovulation
induction), except in women with glucose intolerance.
To be Continued ,,,
#UpToDate_Lectures
20

AROMATASE INHIBITORS (Letrozole/Femara)
- Femara blocks the conversion of Testosterone & Androstenedione to E2 & E1, respectively
(unlike Clomid, which blocks E action), thereby reducing negative feedback at the pituitary & thus
increasing FSH secretion.
- Clomid administration from day 3 to 7 competes with E for its receptors on the pituitary &
hypothalamus>>> Decreased -ve feedback on FSH>>> Increased FSH secretion with multiple
follicular growth. By the late follicular phase (day 10), the increased E2 secretion from the ovary
will not be capable of the normal -ve feedback on FSH dt. the receptor inhibition. The result is
multiple dominant follicle growth & multiple ovulation (see image).
‫ﻋﻠﺸﺎن ﻛﺪا ﻻزم ﻣﺘﺎﺑﻌﺔ ﻣﺤﺘﺮﻣﮫ ﺑﺎﻟﺴﻮﻧﺎر ﻋﻠﺸﺎن ﻧﺸﻮف أﺣﺠﺎم اﻟﺒﻮﯾﻀﺎت ﻗﺒﻞ اﻟﺘﻔﺠﯿﺮ وإﻻ ھﺘﻌﻤﻠﮭﺎ‬
OHS$
- Femara administration from day 3 to 7 results in suppression of ovarian E2 secretion & reduction
in estrogen -ve feedback at the pituitary>>> Increased FSH secretion with multiple ovarian growth.
By the late follicular phase (day 10), the increased E2 secretion from the ovary result in the normal -
ve feedback on FSH secretion & follicles less than dominant follicle size undergo atresia, with
resultant monofollicular ovulation in most cases.
‫ﻋﻠﺸﺎن ﻛﺪا اﻟﻔﯿﻤﯿﺮا ﺑﺘﻜﺒﺮ ﺑﻮﯾﻀﺔ واﺣﺪه ﻓﻘﻂ ودي أول ﻣﯿﺰة ﻟﻠﻔﯿﻤﯿﺮا إﻧﻚ ﻣﺶ ھﺘﻠﻐﻲ اﻹﻧﺪﻛﺸﻦ ﺑﺴﺒﺐ وﺟﻮد ﺑﻮﯾﻀﺎت ﻛﺘﯿﺮ ﻛﺒﯿﺮة‬
‫وﺻﻌﺐ اﻟﻤﺮﯾﻀﺔ ﺗﺠﯿﺐ ﺗﻮاﺋﻢ‬.
- In contrast to Clomid, Femara appears to be free of the adverse effects on endometrial & cervical
mucus attributed to Clomide.
‫وده ﻹن اﻹﺳﺘﺮوﺟﯿﻦ ﻓﻲ ﺣﺎﻟﺔ اﻟﻜﻠﻮﻣﯿﺪ ﻣﺶ ﻗﺎدر ﯾﺸﺘﻐﻞ ﻋﻠﻰ اﻹﻧﺪوﻣﺘﺮﯾﻢ ﺑﺴﺒﺐ ﻗﻔﻞ اﻟﺮﺳﺒﺘﻮرز ﺑﺎﻟﺘﺎﻟﻲ ﺑﻄﺎﻧﺔ اﻟﺮﺣﻢ ﻏﯿﺮ ﺳﻤﯿﻜﺔ‬
‫ودي ﻣﯿﺰة اﻟﻔﯿﻤﯿﺮا اﻟﺘﺎﻧﯿﺔ إن اﻹﺳﺘﺮوﺟﯿﻦ اﻟﻠﻲ ﺧﺮج ﻣﻦ اﻟﻤﺒﯿﺾ ﻓﻲ ﻧﮭﺎﯾﺔ اﻹﻧﺪﻛﺸﻦ ھﯿﻘﺪر ﯾﺸﺘﻐﻞ ﻋﻠﻰ ﺑﻄﺎﻧﺔ اﻟﺮﺣﻢ‬.
- A large randomized trial & a meta-analysis of 9 trials in anovulatory women with PCOS, suggest
that Letrozole therapy results in higher live-birth & ovulation rates when compared with
Clomiphene therapy. The effect appears to be most pronounced in obese women with PCOS (BMI
>30). Therefore, some experts now suggest Letrozole as a first-line drug for obese women with
PCOS. ‫ﻗﻠﻨﺎھﺎ ﻓﻲ اﻟﻤﺤﺎﺿﺮة اﻟﺜﺎﻧﯿﺔ‬
- Of note, Letrozole is still not approved by FDA for ovulation induction. In contrast, Clomiphene is
approved.
‫إﺣﻨﺎ ﻣﻮاﻓﻘﯿﻦ ﻧﺴﺘﺨﺪﻣﮫ ﻣﻌﻨﺪﻧﺎش ﻣﺸﻜﻠﺔ‬.
- By the way, Letrozole is widely used as adjuvant therapy for postmenopausal women with breast
cancer (inhibit E2 synthesis) & have been used off-label in the treatment of patients with
anovulation.
21
Regimen
- Initial course: 2.5 mg/day for 5 days, begin from day 3 to day 7, following either spontaneous or
induced bleeding.
‫ﯾﻌﻨﻲ ﻧﻔﺲ طﺮﯾﻘﺔ إﺳﺘﺨﺪام اﻟﻜﻠﻮﻣﯿﺪ ﺑﺎﻟﻈﺒﻂ‬
- Dose adjustment: if the cycle is ovulatory but pregnancy has not occurred, the same dose should
be used in the next cycle. If ovulation doesn't occur, the dose should be increased to 5 mg/day with
a maximal dose of 7.5 mg/day. Higher doses (7.5 mg) appear to be ass. with a thinning of the
endometrium similar to that seen with Clomid.
- Femara has a shorter half-life (48 hours versus 2 weeks for Clomid), which would predict a lower
risk of teratogenicity if pregnancy occurred.
‫ودي اﻟﻤﯿﺰة اﻟﺜﺎﻟﺜﺔ وﻋﻠﺸﺎن ﻛﺪا ھﻨﺴﺘﺨﺪﻣﮫ ﺑﺎﻟﺮﻏﻢ إﻧﮫ ﻟﺴﺔ ﻣﺎإﺗﻮﻓﻘﺶ ﻋﻠﯿﺔ ﻟﻺﻧﺪﻛﺸﻦ‬.
- You must confirm that the patient is not pregnant before starting Femara as it could disrupt the
normal aromatase activity during the early fetal development & therefore be potentially teratogenic
if administered inadvertently during early pregnancy. So, do pregnancy test before therapy.
- The addition of Femara to Gn therapy appears to reduce the dose of FSH required to achieve
optimal controlled ovarian hyperstimulation.
‫ﯾﻌﻨﻲ ﻣﻤﻜﻦ ﻧﺴﺘﺨﺪم اﻟﻔﯿﻤﺎرا ﻣﻊ اﻟﺤﻘﻦ ﻋﻠﺸﺎن ﻧﻘﻠﻞ ﻛﻤﯿﺔ اﻟﺤﻘﻦ اﻟﻠﻲ ھﻨﺴﺘﺨﺪﻣﮭﺎ ﻹن ﺳﻌﺮھﺎ ﻏﺎﻟﻲ طﺒﻌﺎ ً ﺑﺲ اﻟﻤﻔﺎﺟﺌﺔ ﻟﻤﺎ ﺗﻜﺘﺸﻒ إن‬
‫اﻟﻔﯿﻤﺎرا أﻏﻠﻰ‬
- Femara may also improve response to ovarian stimulation with FSH in poor responders (defined
as < 3 follicles >18 mm in diameter on the day of LH surge or hCG administration). (See image in
comments)
i.e it lower FSH requirement & increase the number of mature follicles.
Approaches For PCO

- For women with PCOS & BMI >30: start Femara.
- For women with PCOS & BMI <30: start either Clomid or Femara, but if you started with Clomid
& the patient doesn't ovulate with Clomid 100 mg, try Femara before moving to Gn therapy.
Gn THERAPY (uFSH:Merional/Fostimon)
- The postmenopausal women don't ovulate, so they don't have E2, but they have large amounts of
Gn (FSH & LH).
‫ ھﻞ ﻧﻌﺪي اﻟﻔﺮﺻﺔ دي؟ اﻹﺟﺎﺑﺔ ﻷ‬:‫واﻟﺴﺆال ھﻨﺎ‬
.‫راح اﻟﻌﻠﻤﺎء ﺟﺎﯾﺒﯿﻦ اﻟﺒﻮل ﺑﺘﺎﻋﮭﻢ وﻣﺴﺘﺨﻠﺼﯿﻦ اﻟﺠﻮﻧﺎدوﺗﺮوﻓﯿﻦ ﻋﻠﺸﺎن ﻧﺪﯾﺔ ﻟﺴﺖ اﻟﺒﻨﺎت اﻟﻠﻲ اﻟﻤﺒﯿﺾ ﺑﺘﺎﻋﮭﺎ ﻣﺒﯿﻄﻠﻌﺶ ﺑﻮﯾﻀﺎت‬
‫وﻧﻔﺲ اﻟﺤﺮﻛﮫ ﻋﻤﻠﻮھﺎ ﻣﻊ اﻟﺤﻮاﻣﻞ اﻟﻠﻲ ﻋﻨﺪھﻢ ھﺮﻣﻮن اﻟﺤﻤﻞ ﻋﺎﻟﻲ وإﺳﺘﻐﻠﻮا اﻟﺸﺒﺔ اﻟﻠﻲ ﺑﯿﻨﮫ وﺑﯿﻦ ھﺮﻣﻮن اﻟﺘﻔﺠﯿﺮ‬
- These human Menopausal Gonadotropins (hMG) contain both LH & FSH in the same ratio, but
we need only FSH to use it for induction, so purification done with production of a purified urinary
FSH (uFSH) & a recombinant human FSH (rhFSH).
22
Indications
1. Women with PCOS who have not ovulated or conceived with weight loss, Clomid or Femara.
2. Hypogonadotropic anovulatory women (hypopituitarism or hypothalamic) amenorrhea.
- hCG (same structure as LH:Choriomon/Epifasi) is used to trigger ovulation when the ovarian
follicles are mature. A dose of 250 mcg of recombinant hCG is equivalent to the standard doses of
urinary hCG (5000-10,000 units).
Protocols
"Step-Up Protocol"
It is designed to allow the FSH threshold to be reached gradually, minimizing the excessive
stimulation & therefore the risk of development of multiple follicles. In this protocol, the initial
dose of FSH is 37.5-75 IU/day. It is recommended that the dose be increased only if, after 14 days,
no response is documented on U/S & serum E2 monitoring. Increments of 37.5 IU then are given at
weekly intervals up to a maximum of 225 IU/day. The detection of an ovarian response is an
indication to continue the current dose until hCG can be given to trigger ovulation.
The low-dose, step-Up regimen should be considered the first choice treatment.
‫ﻧﻔﻀﻞ ﻧﺰود ﻓﻲ اﻟﺠﺮﻋﮫ ﺑﺎﻟﺘﺪرﯾﺞ‬
"Step-Down Protocol"
It mimics more closely the physiology of normal cycles. The starting dose of FSH is 150 IU/day
after spontaneous or progesterone-induced bleeding & continued until a dominant follicle (>10 mm)
is seen on transvaginal U/S. The dose is then decreased to 112.5 IU/day, followed by a further
decrease to 75 IU/day after 3 days, which is continued until hCG is administered to induce
ovulation. The appropriate starting dose can be determined by using the low-dose, step-Up regimen
for the first treatment cycle.
‫ﯾﻌﻨﻲ ﺷﻮف اﻟﺠﺮﻋﮫ اﻟﻠﻲ ھﺘﺠﯿﺐ ﻧﺘﯿﺠﺔ ﻣﻊ اﻟﻤﺒﯿﺾ ﻓﻲ اﻟﺒﺮوﺗﻮﻛﻮل اﻷول وإﺑﺪأ‬
‫ﺑﯿﮭﺎ ﻓﻲ اﻟﺒﺮوﺗﻮﻛﻮل اﻟﺜﺎﻧﻲ‬
"Conventional Gn Protocol"
In which, the starting dose of FSH is 150 IU/day. However, this regimen is ass. with a multiple
pregnancy & OHS. It is used mainly for treating the majority of women with anovulatory infertility
before proceeding to more aggressive treatments such as IVF.
23
Monitoring of Gn Therapy
- The ovarian response to Gn therapy is monitored using transvaginal U/S to measure follicular
diameter.
- The scans during the late follicular phase, usually performed every 2-3 days, should be focused on
identifying follicles of intermediate size.
- hCG is given as an ovulatory trigger (single dose 5000-10,000 IU, IM) on the day that at least one
follicle appears to be mature (≥18 mm &/or a serum E2 200 pg/mL (734 pmol/L)). It should be
noted that premature administration of hCG acts like a premature LH surge & may result in
follicular atresia. Serial TVS to monitor follicle size is superior & should be used to time hCG
administration. Ovulation occurs approximately 36-44 hours after the injection.
- If ≥3 follicles >15 mm are present, stimulation should be stopped & hCG withheld with the use of
a barrier contraceptive in order to prevent multiple pregnancies & OHS.
- If both anovulatory & male factor infertility are causing the couple's infertility, then combined
ovulation induction with IUI is a useful approach.
Practical Approach
- Merional (75/150 IU) has FSH & LH activities.
(Other brands: Metrodine, Menogon, Menofactor & Pergonal).
It is not preferred in PCO as the patient has already high LH, but can be used if the anovulatory
patient has low LH.
- Fostimon (75/150 IU) has only FSH activity.
(Other brand is FSH Sedico)
It is the preferred drug in PCO as the patient has already high LH.
- Choriomon (5000 IU) has only hCG activity.
(Other brands: Profasi, Epifasi & Pregnyl)
It is used after 24 hr from the last Fostimon/Merional dose.
- A simple protocol is to start induction by Clomid as mentioned above, followed by TVS on day
11-12 to check response. A follicle ≥18 mm is considered a good response & no need to give
Choriomon (hCG).
- If no adequate response with Clomid, you can add Fostimon (in PCO) or Merional (if low LH) 75
IU injections on days 6, 8, 10 & check response on day 11 by TVS & add more injections as
indicated to reach the ≥18 mm follicle size, then it's better to give Choriomon (hCG) in that case &
better with follicle size (20-22 mm).
24
PULSATILE GnRH
- The pulsatile administration of GnRH using an infusion pump stimulates the production of
endogenous FSH & LH within the normal range, so result in a single dominant follicle.
- It is indicated for women with hypogonadotropic hypogonadism (hypothalamic amenorrhea) who
have normal pituitary function.
Pulsatile GnRH Dosing

- The IV route is superior to the SC route.
- In order to mimic the normal pulsatile release of GnRH, the pulse interval is 60-90 minutes. The
most physiologic dose for IV administration is 75 ng/kg.
- In practice, some clinicians use 2.5 mcg/pulse for women weighing <50 kg & 5 mcg/pulse for
women >50 kg; others use doses ranging from 2.5-10 mcg/pulse, starting with 2.5 mcg & increasing
until the minimum dose to induce ovulation is reached. A smaller infusion device has been
introduced.
- In published studies, pulsatile GnRH is continued for the entire cycle. In the clinical setting,
pulsatile GnRH administration may be discontinued after ovulation & the corpus luteum supported
by hCG of pregnancy. A potential regimen for luteal phase hCG administration that has been used
with Gn therapy is 500 units administered on days 7, 10 &13 after ovulation.
- Women being treated with IV pulsatile GnRH should be seen weekly to monitor the IV site for
swelling, pain or erythema. We monitor the patient's initial cycles with U/S until we are confident
that a dose that will induce ovulation has been reached.
- Once U/S monitoring is stopped, the patient can predict ovulation in subsequent cycles with
urinary LH kits or confirmed by measuring a luteal phase progesterone conc.
- Results: Ovulation rates 90% & pregnancy rates 80%.
Best Wishes
#UpToDate_Lectures
25
26
How to Differentiate Clinically between Abortion & Ectopic Pregnancy
@ The main presentation of abortion is bleeding & the main presentation of ectopic is pain.
@ Pain & tenderness in ectopic is more in one iliac fossa & in abortion is suprapubic (very
important sign).
@ Vaginal bleeding is fresh bright red in case of abortion & dark brown in case of ectopic dt. the
long journey of blood from tube through uterus till cx & vagina, that makes it hemolysed.
@ By P/V; if you moved cx to any side (Rt./Lt.) there will be severe pain in case of ectopic
pregnancy & not in abortion.
Live Clinical Scenario of Unruptured Ectopic

How to suspected ectopic from history & examination?
A case of primary infertility for 3 years dt. severe PID who received induction of ovulation outside
& now PG after +ve pregnancy test, 6-8 wk, come to maternity ER/clinic C/O severe lower
abdominal pain with mild brownish spotting; then by examination there is severe tenderness in one
iliac fossa more than suprapubic & P/V minimal bleeding with cervical motion tenderness to one
side. Vital signs; BP normal, pulse high normal dt. pain. Take the pt. from her hand to the U/S
room, check if there is intrauterine GS. If there is IUGS, take breath as this is most probably
threatened abortion, but still there is a very small risk of heterotropic pregnancy (one baby
intrauterine & another one ectopic); admit this pt. for good evaluation of adnexia by transvaginal
U/S & do serial B. HCG.
If the other option; there is no intrauterine GS, mostly this is ECTOPIC; do good evaluation to the
adnexia to discover the intact GS. By this, you most probably diagnosed or excluded Ectopic
pregnancy without any investigations yet.
Live Clinical Scenario of Ruptured Ectopic

A case with same or similar scenario as before but generally not well, pale, feeling faint or loss of
consciousness, much more pain, distended abdomen, tenderness elsewhere, tachycardia like pulse
120/m, hypotensive like BP 80/40, by scan empty uterus with darkness intraabdominal around the
uterus & adnexia, urgent CBC show low Hb & low Hct.
27
What Next?
- Unruptured Ectopic: admit the pt. to ward to confirm diagnosis by transvaginal U/S & serial
B.HCG every 2 days with subnormal rise (not doubling) with close observation for any symptoms
or signs of rupture till confirming diagnosis for management.
- Ruptured Ectopic: its a clinical diagnosis from the first presentation of a case with positive
pregnancy test & surgical abdomen. Prepare good a mount of blood after cross matching & take the
pt. for laparotomy.
Best Regards
#UpToDate_Lectures
Mohamed Sabry
28
Management of Pre-eclampsia
Definitions
- Pre-eclampsia (PET): HTN after 20 wk with Proteinuria ≥+1 in a previously normotensive
woman.
- Eclampsia: development of grand mal seizures in a woman with preeclampsia, in the absence of
other neurologic causes.
- HELLP $: Hemolysis, Elevated Liver enzymes, Low Platelets. It represents a severe form of
preeclampsia.
- Superimposed PET: PET on top of chronic HTN.
Risk Factors
- H/O PET.
- Chronic HTN, DM, renal disease, SLE, AP$.
- Old, Obese, PG.
- Twins.
Diagnosis
PET without severe features (mild PET)
BP ≥140/90 & Proteinuria ≥1+.
PET with severe features (severe PET)
One of the following;
- Severe HTN ≥160/110 & Proteinuria. OR
- Mild PET with either;
.. Severe headache.
.. Epigastric pain or vomiting.
.. Blurring of vision.
.. High liver enzymes (ALT or AST >70 IU/l).
.. High creatinine >1.1 mg/dL.
.. Decreased platelet count <100,000.
.. HELLP $.
Prevention for women with risk factors e.g PG ‫ﻓﻲ اﻟﻌﯿﺎده‬

- Aspirin 75 mg/day from 12 wk until birth.
- U/S for fetal growth, AFI & Umbilical Artery Doppler from 28-30 wk & repeat after 1 month.
29
Investigations for Diagnosed Cases
- Check for proteinuria by Dipstick, if +1, do 24 hours urine albumin; if > 300 mg protein, it is
significant proteinuria.
- High serum uric acid confirm diagnosis.
- CBC for platelets count.
- Renal function tests for creatinine.
- Liver function tests for ALT & AST.
- Coagulation profile only if platelets <100.
- Diagnosis of HELLP $ needs confirmation of hemolysis by high LDH.
- U/S for fetal growth, AFI & Umbilical Artery Doppler if conservative management is planned,
repeat every 2 wk.
- CTG at diagnosis & repeat weekly if conservative management is planned.
Management of Mild PET BP ≥140/90 & Proteinuria;

Conservative Management
- Neither give anti-HTN nor MgSO4.
- Start oral Labetalol only if systolic BP ≥150 OR
diastolic BP ≥100. Make target BP <150/100-80.
- Regarding use of anti-HTN drugs in PET, see the next topic.
- Check BP/6 hours.
- Repeat investigations twice weekly or 3 times weekly if under anti-HTN.
- Give Dexamethasone for lung maturity.
- Deliver at 37 wk.
Management of Severe PET BP ≥160/110 or as criteria up;

Try Conservative Management
If <34 wk, if BP is controlled & no deterioration in investigations & not symptomatic.
- Start anti-HTN.
- Check BP more than 4 times/day.
- Repeat investigations 3 times weekly.
- Deliver at 34 wk.
Immediate Delivery
If ≥ 34 wk or < 34 wk & deteriorating.
- Control BP: Labetalol is the first line even oral form; if you have only hydralazine ampules, its
30
better to give the first dose at the same time with 500 cc Saline infusion as it can cause profound
hypotension affecting the fetal perfusion.
- Start MgSO4 loading dose 4 gm IV over 5 minutes, followed by 1 gm/hr for 24 hours postpartum.
- After giving MgSO4, monitor UOP, maternal reflexes, RR & oxygen saturation.
- If eclampsia developed, give additional 2 gm IV over 5 minutes.
- IV fluids at rate of 80 ml/hr to avoid pulmonary edema. Maintain the fluid restriction until there is
a postpartum diuresis, as oliguria is common with severe PET.
- Deliver by CS if < 32 wk or by induction of labor if ≥ 34 wk dt. the high failure rate of induction
before 32 wk.
- Do not use Ergometrine or Syntometrine postpartum.
Postpartum Monitoring
- Continue anti HTN.
- Check BP/6 hours.
- Measure platelet count, LFT & serum creatinine 48–72 hours after delivery.
Adjusting_MgSO4_Dose_in_Fluids
- 1 amp. MgSo4 = 20 ml = 2 gm.
5 amps = 100 ml = 10 gm.
- The required daily fluids for NPO pt. are 3 liters average i.e. 125 ml/hr.
- In PET, we give only 80 ml/hr & not in the form of saline to avoid the increase in BP.
- MgSo4 is given mainly with D5%.
For Loading Dose: put 2 amps (4 gm) MgSo4 in 100 ml D5% & give over 5 min.
For Maintenance Dose:
1. Bring 1 bottle of D5% & drain 100 ml from it, so the remaining are 400 ml.
2. Put 5 amps of MgSo4 (100 ml) on the 400 ml D5% giving 500 ml solution containing 10 gm
MgSo4 sufficient for 10 hours (1 gm/hr).
3. So, every 50 ml solution contains 1 gm MgSo4 (500/10).
4. From this 500 ml solution, adjust infusion pump for 50 ml/hr = 1 gm MgSo4/hr =10 gm/10hr =
One bottle 500 ml/10hr.
5. So the bottle will finish by 10 hr & repeat for the remaining of 24 hr by the same way for another
10 hr, then make the solution again but infuse for the remaining 4 hr only to complete the 24 hr
infusion.
6. Pt. should receive 80 ml/hr; already we give 50 ml D5% containing MgSo4/hour, so we give 30
ml Ringer Lactate plane in the other arm.
‫ ﺳﺎﻋﺔ واﻟﻤﺤﻠﻮل اﻟﻠﻲ ﯾﺨﻠﺺ ﻧﺤﻂ ﺑﺪاﻟﮫ واﺣﺪ ﺟﺪﯾﺪ‬24 ‫ﯾﻌﻨﻲ ﻣﺤﻠﻮﻟﯿﻦ ﺑﯿﺘﺤﺮﻛﻮا ﻓﻲ ﻧﻔﺲ اﻟﻮﻗﺖ ﻟﻤﺪة‬.
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How to control BP in pregnancy for ch. HTN, preeclampsia &

superimposed preeclampsia?
Labetalol
- A combined alpha- & beta-blocker, 100 mg twice daily, increase by 100 mg twice daily every 2-3
days as needed. Usual effective dose range is 200-800 mg in 2 divided doses. Maximum total daily
dose 2400 mg. In acute situations, give labetalol 20 mg IV over 2 minutes. Repeat BP measurement
at 10-minute intervals & if still high give the following doses at the same order after every 10
minutes till controlling BP is established; give 40, 80, 80, 80 mg to achieve a cumulative maximum
dose of 300 mg & you can stop at any step once BP is controlled. If still high BP, add nifedipine as
mentioned down.
In my practice for long-term use, I start 200 mg twice daily & if overcontrolled decrease the dose
to 100 mg twice daily, but if insufficient to control BP, increase the dose to 200 mg 3 times/daily,
then 4 times/day acc. to your needs. As regard acute situations, I can give the IV dosing mentioned
up & if not available, I give oral doses instead, in the same way 200 mg once then assess BP at 30
minutes intervals instead of 10 minutes in IV dosing.
Nifedipine
- A calcium channel blocker, 30-60 mg once daily as an extended release tablet, increase at 7-14
day intervals. Usual effective dose range 30-90 mg/day. Maximum total daily dose 120 mg.
In my practice I reserve it for the resistant cases not controlled by labetalol alone i.e if pt on
labetalol 200 mg 4 times daily & still BP >145/90, I decrease the labetalol dose to 200 mg 3 times
daily & add nifedipine 20 mg 2 times daily & if still high BP, increase the nifedipine dose to 60 mg
sustained release once daily with the 3 times daily labetalol. If BP still high, increase the labetalol
dose to 200 mg 4 times daily+nifedipine 60 mg once daily & TERMINATE this case once BP is
stabilized even if she is asymptomatic or very early preterm e.g 27 wk only & don't forget to screen
for thrombophilia after delivery
Hydralazine
- A peripheral vasodilator, usually reserved only for acute shooting BP, not for long-term use.
In my practice I don't like it at all even in acute situations as it can cause profound maternal
hypotension & predispose to fetal distress & even IUFD, so eb3b 3n elshr w8nylo
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Methyldopa
- A centrally acting alpha-agonist, 250 mg 2-3 times daily, increase every 2 days as needed & take
care; the full hypotensive effect of an initial dose or adjustment of methylodopa may not occur until
after 2-3 days of continuous use. Usual effective dose is 250-1000 mg in 2-3 divided doses daily &
maximum total daily dose is 3000 mg/daily.
In my practice I don't use it dt. weak & slow effect & the extrapyramidal side effects deside it
predispose to postpartum depression.
- There is big controversy regarding the target BP & at the end they put the target should be less
than 150-130/100-80.
(In my practice, I start small doses once BP reach 145/95)
- For women with complicated or secondary hypertension (eg, target-organ damage as left
ventricular hypertrophy, microalbuminuria, retinopathy, dyslipidemia, maternal age >40 years,
history of stroke, previous perinatal loss, diabetes), we suggest treatment of HTN, even if mild
(Grade 2C). Our treatment target is systolic pressure 140-120/90-80.
If you are a small pretty junior, just smile & save only one of those drugs in your beautiful mind
for emergency situation
#UpToDate_Lectures
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Regimen of MgSO4 for Fetal Neuroprotection
MgSO4 is found to decrease the risk of stillbirth, cerebral palsy & early neonatal death in babies
delivered preterm.
Candidates for Treatment

- Women whom we believe will deliver within 24 hours.
- Recent PPROM.
- Preterm labor with intact membranes.
- Planned medically or obstetrically indicated preterm delivery.
Contraindications
- Women with myasthenia gravis since it can precipitate a severe myasthenic crisis.
- Women with known myocardial compromise or cardiac conduction defects because of its anti-
inotropic effects.
- Women with impaired renal function as it is excreted via kidney.
Gestational Age Range

- From 24 wk till 32 wk.
Dose
- 4 gm loading over 20 minutes & a maintenance dose of 1 gm/hour.
Timing
- Every effort should be made to reserve therapy for women who are at high risk of imminent
delivery rather than women who are simply diagnosed with threatened preterm labor or PPROM
without preterm labor.
- For women who will undergo scheduled CS, we administer the loading dose & then initiate
maintenance therapy 6-12 hour prior to the scheduled surgery.
- If emergency or expeditious delivery is indicated because of maternal or fetal status, it should not
be delayed to administer MgSO4.
- If induction of labor is likely to take >24 hours, it is reasonable to delay administration until
cervical ripening is achieved & delivery is more proximate since we do not administer MgSO4 for
>24 hours.
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Duration
- MgSO4 is discontinued when the infant is delivered.
- We limit the MgSO4 infusion to a maximum of 24 hours, even if delivery has not occurred.
- We do not administer more than one course of magnesium sulfate for neuroprotection.
Monitoring
- Urine output & deep tendon reflexes should be closely monitored in all patients.
- The maintenance phase of treatment should be continued only if a patellar reflex is present (loss of
reflexes being the first manifestation of symptomatic hypermagnesemia), respiratory rate
>12/minute & urine output >100 ml/4 hours.
Choice of Tocolytic for Women with Preterm Labor

- Magnesium sulfate should not be chosen for tocolysis based solely upon fetal neuroprotective
effects.
- In women <32 wk of gestation who are candidates for tocolysis, we use indomethacin for labor
inhibition in women also receiving magnesium sulfate for fetal neuroprotection.
Best Regards
#UpToDate_Lectures
35
Management of Thrombocytopenia with Pregnancy

Definition
- The normal range of platelets in non-pregnant women is 150,000-400,000/μL.
- Thrombocytopenia is defined as platelet count <150,000/μL.
- Bleeding ass. with surgery is rare unless the platelet counts are <50,000/μL.
- Spont. bleeding is rare unless the platelet counts are <10,000/μL.
The Most Common Causes of Thrombocytopenia in Pregnancy

- Gestational Thrombocytopenia (70%).
- Preeclampsia/HELLP $ (21%).
- Immune Thrombocytopenic Purpura (3%).
Gestational Thrombocytopenia (GT)

Pathophysiology may be dt. hemodilution (so, some consider GT a normal finding in 3rd▲).
Clinical Manifestations
.. Asymptomatic patient.
.. Usually develops in the 3rd▲.
.. Detected incidentally on routine prenatal screening.
.. If no pre-pregnancy history of thrombocytopenia or abnormal bleeding & counts >70,000/μL, the
condition is more likely to be GT.
- GT has no apparent risks for either the mother or infant at delivery.
- Platelet counts normalize following delivery.
Management
.. Monitor platelet count periodically.
.. No treatment for GT.
.. There is no preferred mode for delivery (do CS for obstetric indications only).
.. Epidural anesthesia is considered safe when platelet count is >50,000/μL.
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HELLP Syndrome
Diagnosis
.. Hemolysis: known by
* Presence of schistocytes on peripheral smear.
* Total bilirubin >1.2 mg/dL.
* LDH >600 U/L.
.. Elevated Liver enzymes: ALT or AST >70 U/L.
.. Low Platelets <100,000/μL.
.. Epigastric or right upper quadrant pain in 50-70%.
.. Headache in 50%.
.. Visual changes in 10-20%.
- Early HELLP $ is often misdiagnosed as heartburn, with many women prescribed antacids prior to
the correct recognition of this life-threatening condition.
- Not all patients with HELLP $ meet the strict criteria for preeclampsia.
- 15% of patients present with diastolic BP <90 mmHg & minimal or no proteinuria.
- Major complications can still occur despite normal BP & proteinuria.
- Thrombocytopenia reaches a nadir at 24-48 hr postpartum.
Management is Delivery
.. Timing: delivery can be delayed for 24-48 hr prior to 32-34 wk to administer corticosteroids if the
patient is asymptomatic & the fetus has reassuring CTG.
.. MgSO4 should be administered intrapartum & postpartum, regardless of BP levels to prevent
eclampsia.
.. Mode of delivery: CS is acceptable <32 wk with an unfavorable cervix dt. anticipated long
induction time in a clinically deteriorating patient.
Target of platelets
.. Maintain counts >20,000/μL for vaginal delivery &
>50,000/μL for cesarean delivery.
.. If platelets fall <50,000/μL prior to CS, administer platelets just prior to surgery or
intraoperatively.
.. A range of 6-10 units of platelets is usually administered at the time of skin incision & an
additional 6 units are administered if oozing is noted during the surgery.
.. If thrombocytopenia is severe (<50,000/μL), regional anesthesia & pudendal blocks are
contraindicated.
.. Thrombocytopenia & elevated liver enzymes commonly worsen postpartum, but platelets should
start to normalize by the 3rd postpartum day.
.. Dexamethasone 10 mg IV every 12 hr until delivery may be ass. with a significant rise in the
platelet count & lesser elevations in the liver enzymes & a longer interval to delivery, although
postpartum deteriorated still can happen.
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Idiopathic Thrombocytopenic Purpura
Pathophysiology
.. There are antiplatelet Ab (IgG) that attach to the platelet membrane glycoproteins & coat the
platelets, which are then destroyed by the spleen.
.. Antiplatelet Ab may cross the placenta & cause fetal thrombocytopenia (<50,000/μL) & bleeding
complications in the neonate.
.. Fortunately, most fetuses of ITP mothers (about 90%) have normal platelet counts.
.. Easy bruising, petechiae, epistaxis, gingival bleeding, purpura, ecchymosis & melena.
.. Significant hge is rare, even when counts fall to <20,000/μL.
.. Complications: APH, PPH & intracranial hge.
Investigations
.. CBC: to exclude pancytopenia.
.. Peripheral blood smear: to exclude platelet clumping that may be ass. with
pseudothrombocytopenia.
Diagnosis: ITP is a diagnosis of exclusion

.. History of pre-pregnancy thrombocytopenia or abnormal bleeding & counts <50,000/μL, the
condition is more likely to be ITP.
.. Persistent thrombocytopenia (<100,000/μL) ± accompanying megathrombocytes on the peripheral
smear.
.. Exclusion of systemic disorders (SLE) or drugs.
.. Absence of splenomegaly.
.. Most women with ITP have a history of bruising easily, petechiae, epistaxis & gingival bleeding,
which precedes their pregnancy, but some women are completely asymptomatic.
- In general, in 1st & 2nd▲ in a woman with no history of thrombocytopenia, the more likely
diagnosis is GT. If the platelet count is <70,000/μL, ITP is more likely to be present, & if the
platelet count is <50,000/μL, ITP is almost certainly present.
Management
.. Serial assessment of the maternal platelet count.
.. Pregnant women with ITP should be instructed to avoid NSAIDs, salicylates & trauma.
.. Individuals with splenectomies should be immunized against pneumococcus, H influenza &
meningococci.
.. Hematological consultation.
- If platelets >50,000/μL & pt. is asymptomatic, No treatment is necessary.
- If platelets <50,000/μL even if Asymptomatic:
Prednisone (1st line of TTT)
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1-2 mg/kg daily. Once platelet counts reach acceptable levels, the dosage can be tapered by 10–20%
per week until the lowest dosage required to maintain a platelet count >50,000/μL.
IV immune globulin (IVIG) Indications:
* Acute conditions when time is inadequate for steroids to take effect (prior to surgery or bleeding
pt.).
* Platelet counts <10,000/μL in the 3rd▲.
* For cases refractory to steroids.
Splenectomy
Usually is avoided during pregnancy for technical reasons, although it remains an option in the 1st
& 2nd▲ when ITP is severe (counts <10,000/μL) & the patient doesn’t respond to steroids or IVIG.
Platelet transfusion: should be administered for life-threatening hge & should be available prior to
surgery for patients with severe thrombocytopenia. 6-10 units of platelets are usually administered
at one time. Platelet counts normally rise by 10,000/μL for each unit of platelets transfused, but in
ITP the rise is less pronounced dt. destruction of the donor platelets.
Mode of delivery
.. Vaginal delivery never has been proven to cause intracranial hge.
.. Cesarean delivery should be reserved for obstetrical indications only.
Best Regards
#UpToDate_Lectures
39
Anticoagulation during Pregnancy

Low Molecular Weight Heparins (LMWH/Clexane)
- Most women who require anticoagulation therapy before pregnancy will need to continue Clexane
during pregnancy & the postpartum period except for the time before delivery, we can use UFH
(Unfractionated Heparin) as it has a shorter half-life (less risk of bleeding & PPH).
- Neither UFH nor LMWH crosses the placenta & both are considered safe in pregnancy &
lactation.
CCC of Clexane
** Less bleeding episodes & less side effects.
** Longer half-life (during delivery: risk of peripartum bleeding & a relative CI for spinal
anesthesia).
** UFH is preferred over Clexane in patients with severe renal insufficiency as LMWH clearance is
almost exclusively renal, while elimination of UFH is renal & hepatic.
Warfarin (Marivan)
- It is suitable for long-term anticoagulation therapy, but outside of pregnancy because of its
teratogenicity.
- Warfarin derivatives are contraindicated because they cross the placenta & may cause fetal death
& CFMF from hge.
- Warfarin embryopathy has been linked with exposure at 6-12 wk of gestation.
- Therefore, for most women receiving prolonged anticoagulation therapy who become pregnant, it
is recommended that Clexane be used instead of Marivan.
- Although rarely prescribed in pregnancy, it is still considered in pregnancy for women with
mechanical heart valves because of their high risk of thrombosis even with heparin or LMWH
anticoagulation therapy.
- The initial dose of warfarin is usually 5-10 mg for the first 2 days & subsequent doses are titrated
to achieve an INR of 2-3.
When To Start
- Women taking warfarin prior to conception should switch to another anticoagulant (eg, Clexane)
during attempted conception or upon becoming pregnant, in order to avoid teratogenic effects of the
drug during the first trimester, then can shift back to Marivan if she is a high risk patient
(mechanical heart valve) or continue with Clexane till delivery.
- For women who are not receiving chronic anticoagulation but require anticoagulation during
pregnancy (for thromboprophylaxis), Clexane is initiated when pregnancy is established rather than
before conception & generally started in the first trimester after pregnancy is confirmed by a
positive pregnancy test, as long as there is no vaginal bleeding.
40
Dosing And Methods of Administration (see Table down)
- Platelet count should be checked regularly to monitor for heparin-induced thrombocytopenia. And
also be checked if thrombosis occurs while on any form of heparin.
Treatment of Bleeding on Heparin

- Minor bleeding (spotting) does not require protamine sulfate. If bleeding persists, one option is to
stop anticoagulation, if possible, until the bleeding stops & then resume the anticoagulant. Such
decisions depend on the degree & site of bleeding & the indication for anticoagulation.
Labor & Delivery

- Women receiving either therapeutic or prophylactic anticoagulation therapy may be shifted from
LMWH to the shorter half-life UFH at 36-37 wk or sooner if delivery is imminent (preterm labor).
- The advantage of UFH is the less risk of bleeding at the time of delivery dt. the shorter half-life.
- An alternative option is to stop the therapeutic dose LMWH/UFH 24 hr before an induction of
labor or scheduled CS.
- Patients receiving once-daily Clexane can take only 50% of their normal dose on the morning of
the day before delivery.
- The American Society of Regional Anesthesia & Pain Medicine recommend delaying spinal
anesthesia for 10-12 hr after the last prophylactic dose of Clexane or for 24 hr after the last
therapeutic dose.
- Reversal of heparin effect is rarely required with protamine sulfate & is not indicated with a
prophylactic dose of heparin. However, it is best to avoid administration of protamine antepartum
unless hemorrhage cannot be controlled using routine supportive measures.
- For women in whom anticoagulation therapy is a must during surgery, pneumatic compressions
devices are recommended during the time of surgery then shift back to Clexane.
Resuming Anticoagulation Postpartum

- The UFH or LMWH can be resumed 4-6 hours after vaginal delivery or 6-12 hours after cesarean
delivery, unless there was significant bleeding. Warfarin can be started after 5-7 days after delivery
dt. the risk of PPH is high with Marivan.
- For women with acute venous thromboembolism (VTE) who are still in the active treatment
period (ie, the first 3 months) or who have other indications requiring continuous anticoagulation
(eg, high-risk thrombophilia), concurrent Clexane at therapeutic doses should be administered along
with Marivan for a minimum of 5 days & an additional 1-2 days after an appropriate INR (2-3) has
been obtained.
- RCOG stated that "all women who have had CS (he mean emergency CS) should be considered
for thromboprophylaxis with LMWH for 10 days after delivery, apart from those having an elective
caesarean section who should be considered for thromboprophylaxis with LMWH for 10 days after
delivery if they have any additional risk factors (he mean low risk elective cases not for
thromboprophylaxis). Thromboprophylaxis should be continued for 6 weeks in high-risk women
and for 10 days in intermediate-risk women.
41
- For low risk women, ACOG recommend to place pneumatic compression devices on all patients
not already receiving pharmacologic thromboprophylaxis before cesarean delivery & continue
pneumatic compression until the patient is fully ambulatory.
Breastfeeding
All warfarin, LMWH & UFH don’t accumulate in breast milk & don’t induce an anticoagulant
effect in the infant, so they are compatible with breastfeeding.
Best Regards
#UpToDate_Lectures
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45
Management of Bartholin Cyst/Abscess
Cyst
- Cysts that are disfiguring or symptomatic are treated with incision & drainage (I&D) with Word
catheter placements (in office) & if recurred after 1-2 times do marsupialization (in operating
room).
- No intervention is necessary for asymptomatic Bartholin cysts except for women >40 years, we do
I&D to take a biopsy to exclude carcinoma.
Abscess
- The mainstay of treatment is I&D with placement of a Word catheter under local anesthesia.
- Send a culture for the pus & give antibiotics if positive for gonorrhea or chlamydia or MRSA.
- Start oral antibiotic if suspected complicated infection.
- Start IV antibiotic if systemic infection.
- If abscess recur, I&D with placement of a Word catheter & antibiotics.
- If abscess recur, do marsupialization.
- If abscess recur, do gland excision & send for histopathology to exclude carcinoma.
Techniques
Incision & drainage (I&D)
A small incision (3-5 mm) is made at or superior to the hymenal ring to prevents obvious vulvar
scarring. A small, rather than large, incision ensures that the Word catheter stays in place. The fluid
then drains spontaneously or is expressed through gentle pressure. The abscess cavity may be
irrigated & suctioned.
- The Word catheter is a balloon-tipped device that is inserted into the cyst/abscess cavity
immediately after I&D (see pictures down). The bulb of the catheter is then inflated & left in place
for at least 4 weeks to promote formation of an epithelialized tract for drainage of glandular
secretions. The end of the catheter is tucked into the vagina to minimize discomfort. When the tract
appears well-epithelialized, the balloon is deflated & the catheter is removed in the office.
Marsupialization
It refers to a procedure whereby a new ductal orifice is created. This is achieved by incising the
cyst/abscess and then everting & suturing the epithelium to the skin at the edge of the incision. The
incision may be either: a single 1.5-2 cm incision, a cruciate incision or excising a 1-2 cm ellipse of
tissue that includes the epithelial surface & the roof of the cyst. The incision is made where the cyst
protrudes into the vestibule & just outside of the hymenal ring. The edge of the proximal duct wall
46
is then grasped with fine forceps and everted onto the epithelial surface where it is sutured with
interrupted absorbable sutures, thus creating a fenestration for exit of the glandular secretions (see
picture down & video in the comments). The cyst/abscess cavity is irrigated; some clinicians insert
a drain or pack for a few days, but this is probably unnecessary.
Gland excision
In contrast to other methods, excision carries a high risk of complications, particularly excessive
bleeding (2 video for gland excision will be in the comments down).
Indications for antibiotics

●Recurrent Bartholin abscess.
●High risk of complicated infection (such as sepsis), surrounding cellulitis, pregnancy,
immunocompromised, DM.
●Culture-positive methicillin-resistant Staphylococcus aureus (MRSA)
●Signs of systemic infection (eg, fever, chills).
Regimens
- Trimethoprim-sulfamethoxazole (Sutrim forte; one double-strength tablet twice daily for 7 days) is
the first-line agent for patients who are candidates for oral therapy & who are treated as outpatients.
- Alternatives; Amoxicillin-clavulanate (875 mg orally twice daily for 1 week to cover E. coli &
Streptococcus species), plus clindamycin (300 mg orally 4 times per day for 1 week to cover
Staphylococcal species including community-associated MRSA & Bacteroides).
- The regimen may have to be modified based upon culture results (eg, if chlamydia is present,
administer azithromycin 1 gm orally as a single dose.
Pregnant women
There are no data regarding management of Bartholin cyst/abscess in pregnant women. In our
practice, we treat these in the same manner as non-pregnant. One exception is that we usually do not
perform cyst excision during pregnancy or the immediate postpartum period dt. the increased risk of
excessive bleeding.
Best Regards
#UpToDate_Lectures
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48
Abdominal Hysterectomy Technique

(Important Points & Mistakes)
There are no proven medical or surgical benefits of performing subtotal hysterectomy if the cervix
can be easily removed with the corpus as retaining the cervix commits the patient to continue
cervical cancer screening & may result in persistent post-hysterectomy bleeding.
Position in the supine or lithotomy position.

- Perform an examination under anesthesia (helps to confirm pelvic findings & guide the final
choice of incision).
- Insert Foley bladder catheter.
Sterilization & surgical draping

It is not necessary to remove hair at the planned incision site. If hair is removed, it should be clipped
rather than shaved, as patients who are shaved appear to be more likely to develop surgical site
infection.
Incision
- If a prior incision exists, most surgeons prefer to use the same incision.
- The peritoneal cavity is entered & the upper abdomen & pelvis explored for unexpected pathology
& to confirm preoperative findings. Peritoneal washing may be collected for cytologic analysis if a
malignancy is suspected.
Exposure
When positioning retractors, it is important to avoid placing the lateral blades over a femoral nerve
as it emerges lateral to the psoas muscle, since this can lead to a peripheral neuropathy. Assistants
should not lean on the retractors for the same reason. Safe placement is assured by lifting the
abdominal wall as the retractor is placed, then checking to be sure no bowel has been trapped
beneath a blade and that the blade is not pressing on the side wall of the pelvis.
Adhesiolysis
Restoring normal anatomy allows for visualization of important pelvic structures (eg, ureter, blood
vessels).
49
Round ligament ligation
- Traditionally, a large Kelly clamp is placed across each uterine cornu (fallopian tube & round
ligament are included in the clamp). This allows uterine elevation & prevents back bleeding when
the round ligaments are divided.
- An alternative technique, the round ligament is clamped & divided using electrosurgery which can
then be used to open the anterior peritoneum & mobilize the bladder, and to incise the lateral
peritoneum without adding extra time to change instruments.
- A common error is to divide the round ligament too close to the uterus, which limits exposure in
the broad ligament. The round ligament is best divided at its mid portion, or more laterally, and then
the ligament can be easily lifted to facilitate peritoneal dissection and division.
Broad ligament dissection

- The incision in the round ligament is then carried inferiorly through the peritoneum of the broad
ligament to the level of the uterine artery, and then medially along the vesicouterine fold, separating
the bladder peritoneum from the lower uterine segment.
- The retroperitoneum is entered by extending the incision on the posterior leaf of the broad
ligament. The perivesical space & perirectal space can be created at this time.
- The perivesical space is lateral to the bladder & medial to the external iliac vessels. It is an
avascular space created by sharp or blunt dissection that extends down to the levator ani muscles.
The superior vesicle artery is at medial border.
- The perirectal space is between the ureter & iliac vessels, is also avascular, and extends down to
levator ani muscles.
Avoiding ureteral injury

- The ureter is left attached to the medial or posterior leaf of the broad ligament so as not to disrupt
its blood supply.
- Prophylactic ureteral stents to help identifying ureters are not recommended, but can be used with
severe endometriosis or a history pelvic irradiation (dense adhesions).
- Open the retroperitoneum & visualizing the ureter on the posterior leaf of the broad ligament
peritoneum to prevent ureteral injury is preferred & just palpation is not enough as it may be
mistaken with vessels. The visualization of ureteral peristalsis confirms its identity.
- Additionally, when the vesicouterine space is developed, the bladder is displaced inferiorly to
laterally displace the ureters. In some women, the ureter is as little as 5 mm from the uterine artery,
and reflecting the bladder downward prior to dividing the uterine artery will slide the ureter
laterally, providing more space for placement of clamps.
- If the patient has extensive pelvic adhesions, we dissect the ureter down toward the bladder until
optimal visualization is achieved.
50
If the ovaries are to be conserved
- If the ovaries are to be conserved, an opening is created in the posterior leaf of the broad ligament
under the utero-ovarian ligament & fallopian tube. The utero-ovarian ligament is clamped, cut &
ligated with a free tie followed by a suture ligature (placed just medial to the free tie). The medial
large Kelly clamp at the uterine cornu will control back bleeding.
- It is our practice to use measures to prevent the ovaries & fallopian tubes from adhering to the
vaginal apex (a possible cause of dyspareunia). Some surgeons place a suture through the stump of
the utero-ovarian ligament & then sew the stump to the psoas muscle or to the round ligament
stump using an absorbable suture.
If the ovaries are to be removed

- If the ovaries are to be removed, the broad ligament opening is extended superiorly to the
infundibulopelvic ligament. A curved clamp is placed lateral to the ovary, making certain that the
entire ovary is included in the surgical specimen. This is facilitated by elevating the
infundibulopelvic ligament & creating a generous space in the posterior pelvic peritoneum between
the ureters & ovarian vessels to avoid injury of ureters during clamping.
- Each infundibulopelvic ligament is cut and ligated with a free tie followed by a suture ligature
(placed just medial to the free tie). Tying the pedicle before suturing it prevents formation of an
expanding hematoma through inadvertent puncture of the ovarian vessels. Sutures on vascular
pedicles should not be used to elevate the pedicle, as this may compromise the knot strength &
hemostasis. ‫ﻣﺘﺸﺪش ﻋﻠﯿﮭﺎ‬
Perivesical & perirectal dissection

- The bladder is dissected off the lower uterine segment & cervix. Sharp dissection is preferred as
the use of a blunt dissection with a sponge stick may lead to a cystostomy, particularly if there has
been prior surgery (eg, cesarean delivery). In addition, an incision into the bladder is more easily
repaired than a tear from blunt dissection.
- After this dissection, a small sponge can be placed beneath the bladder retractor to tamponade any
small bleeding vessels.
- The posterior peritoneum between the uterosacral ligaments just beneath the cervix & rectum is
incised.
Uterine vessel ligation
- Sharp dissection is used to skeletonize the uterine vessels, removing any loose overlying
connective tissue. This allows visualization of the uterine vessels, thereby ensuring that clamps are
placed on these vessels & not on the ureter (as it passes below the uterine vessels). The bladder
should be reflected inferiorly with sharp dissection prior to dividing the uterine arteries.
- A curved clamp is placed perpendicular to the uterine artery at the junction of the cervix & lower
uterine segment. Care is taken to place the tip of the clamp adjacent to the uterus at this site of
anatomic narrowing. ‫ﻋﺾ ﻓﻲ اﻟﺮﺣﻢ‬
51
- The uterine artery is cut & ligated. Some surgeons place 2 curved clamps & ligate the uterine
artery twice. Given the proximity of the ureter to the uterine artery, single clamping is preferred.
The same procedure is then carried out on the opposite side.
- The cardinal ligament & any remaining broad ligament are divided by placing a straight clamp
medial to the uterine vascular pedicle & parallel to the cervix for a distance of 2-3 cm. The pedicle
is cut & ligated with a suture ligature. The number of bites needed to reach the vagina can vary
depending on the length of the cervix.
Supracervical (subtotal) hysterectomy

- If a supracervical hysterectomy is planned, the cardinal ligaments are clamped until a point is
reached midway between the level of the internal & external cervical ostia. The cervix is then
amputated with a scalpel or cautery. Care is taken to avoid injury to surrounding structures.
- To avoid continued cyclical bleeding from retained lower uterine segment endometrium, some
surgeons will cauterize or resect the endocervix. The cervical stump is then closed with a size 0
absorbable suture in a running or interrupted fashion. Some surgeons will cover the stump with
peritoneum.
Total hysterectomy
- The cardinal ligaments are clamped, cut & ligated bilaterally until the level of the external cervical
os is reached. A series of pedicles may be required depending upon the size of the uterus.
- To remove the cervix, the uterus is pulled cephalad & the tip of the cervix is palpated. Care should
be taken to avoid foreshortening the vagina.
- The cervicovaginal junction at the level of the external cervical os is palpated, and an incision is
made, entering the vaginal apex. A circumferential vaginal incision is made with the Jorgenson
scissors, amputating the cervix & uterus.
Closure of the vaginal cuff

- Kocher clamps are placed bilaterally at the cuff angles. A figure-of-eight suture of 0 or 2-0 gauge
synthetic absorbable figure of 8 stitches are used to close the vaginal cuff. The suture incorporates
the uterosacral & cardinal ligaments at the angle of the vagina.
- Some surgeons prefer to leave the cuff open to heal secondarily. If this method is used, a running
suture is used for hemostasis along the cuff edge & the peritoneal defect superior to the cuff is
sutured closed. There appears to be no difference in postoperative febrile morbidity whether the
vaginal cuff is closed or remains open.
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Final examination & closure
The pelvis is thoroughly irrigated with warm saline or Ringer's lactate solution. Meticulous
hemostasis at all pedicles is confirmed.
Best Regards
#UpToDate_Lectures
53
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55
Ureter & Bladder Injury in Gynecologic Surgery
Mechanisms of Ureteral Injury

- Crushed with a clamp.
- Kinked or ligated with a suture.
- Lacerated or transected during dissection.
- Devascularization or denervation.
This will leads to ureteral obstruction (resulting in hydronephrosis & possible irreversible injury
which, if bilateral, can lead to renal failure), genitourinary fistula & urinoma.
The most common site of ureteral injury is the distal ureter at the level of the uterine arteries.
Mechanisms of Bladder Injury

- Cystotomy.
- Laceration of the bladder wall.
- Devascularization or denervation.
- Accidental placement of an intravesical suture.
An intravesical suture may be symptomatic or asymptomatic, depending upon the location of the
suture in the bladder & coincident infection. When bladder injuries present postoperatively,
genitourinary fistulas appear to be the most common presentation.
Prevention of Causes
- The most important method for primary prevention is intraoperative identification of the bladder &
ureters & avoidance of injury through meticulous surgical techniques.
- Preoperative placement of prophylactic ureteral catheters in the operating room prior to the initial
incision, in patients with known or suspected periureteral fibrosis such as those with severe
endometriosis, large cervical fibroids or prior pelvic irradiation. Ureteral catheters allow the surgeon
to easily palpate the ureters prior to applying clamps or ligating pedicles. Ureteral catheters are
placed via a cystoscope by an experienced clinician.
Ligation of the ovarian vessels

To avoid ureteral injury during ovarian vessels ligation during oophorectomy (with or without
hysterectomy), open the retroperitoneum & visualize or palpate the ureter prior to isolating,
clamping or ligating the ovarian vessels. Visualization of peristalsis confirms that the ureter has
been identified. Take care to avoid disrupting the blood supply of the ureter, which may result in
ischemia & necrosis.
56
Ligation of the uterine arteries
Mobilizing the bladder from the anterior cervix & displacing it inferiorly will shift the ureters
inferior to the uterine arteries prior to clamping. The ureters pass below the uterine vessels, & once
these vessels are ligated, the ureter will pass just inferior & lateral to this pedicle. So, to protect the
ureter during subsequent dissection of the cardinal ligament, the clamp is placed medial to the
uterine artery pedicle.
Vaginal cuff closure
As the bladder is dissected off the surface of the vagina or cervix & displaced inferiorly, the ureters
will descend with the bladder to a level safely below the superior aspect of the cuff.
4. Avoiding bladder injury
Use sharp dissection with or without electrosurgery, whether the dissection is easy or difficult.
Blunt dissection may result in increased bleeding or tearing of the bladder. Bladder injury that
occurs with sharp, rather than blunt, dissection can often be easier to repair.
Intraoperative Evaluation
- If bladder injury is suspected, a 3-way catheter can be used, which will allow instillation of
contrast material (dye) in the bladder & check for any leak abdominally. Leakage of dye into the
operative field confirms the presence of a bladder or ureteral defect & helps to pinpoint its location.
The absence of the appearance of dye does not exclude injury as the dye may be retroperitonial or
an injury other than a laceration may have occurred (eg, thermal injury). Use 200-500 mL of
methylene blue (2-3 drops in saline). Sterile infant formula can be used. ‫ﻟﺒﻦ اﻷطﻔﺎل‬
- Intraoperative cystoscopy is performed to evaluate bladder injury (eg, perforation, bleeding or
suture) & confirm urine efflux from both ureteral orifices. Absence or abnormal flow (delayed or
sluggish) from one or both ureters warrants further evaluation for ureteral transection or obstruction.
Blood coming from a ureteral orifice can also point to ureteral injury & must be investigated.
However, cystoscopy does not detect all ureteral injuries; partial ureteral obstruction or transection
or thermal injuries may be missed.
Postoperative Presentation
- The most important principle of postoperative diagnosis of urinary tract injury is to have a high
index of suspicion, since early symptoms & signs may be subtle.
- Urinary tract injuries that are not recognized intraoperatively are most likely to present within the
first 2 weeks after surgery.
- Presentation may be one of the following:
● Leakage of urine from the vagina or abdominal incision: the time course of development of
vesicovaginal or ureteral vaginal fistula ranges from days to weeks.
● Unilateral or bilateral flank pain: complete ureteral obstruction may present with ipsilateral flank
pain within 24 hours after surgery.
● Hematuria, Oliguria or Anuria.
● Abdominal pain or distension.
● Nausea with or without vomiting.
57
● Ileus dt. irritation of the bowel by urine.
● Fever.
- Partial ureteral obstruction may be asymptomatic, but may progress over time to complete
obstruction & result in loss of function in the ipsilateral kidney. Such loss of function may remain
silent or be discovered at some point during investigations for other health conditions.
- A ureteral or bladder defect with leakage of urine into the peritoneal cavity may present as
abdominal pain & ascites.
- In the retroperitoneum, a collection may develop into a urinoma; the patient may become febrile
dt. infection. Based on the urinary tract anatomy, a retroperitoneal collection is typically due to a
ureteral, rather than bladder injury.
Postoperative Evaluation
Examination
Assess hemodynamic stability?, fever?, UOP?, hematuria?, ascites? & bowel sounds?
Lab investigations bilateral ureteral obstruction results in acute renal failure. Unilateral complete
obstruction is accompanied by a transient minimal increase in creatinine as the other kidney
compensates for the loss of function in the contralateral kidney.
- If uroperitoneum (urinary ascites) is suspected, some clinicians obtain a biochemical analysis of
the peritoneal fluid by performing paracentesis or sending fluid from an intraperitoneal drain. The
results from such testing do not provide direct evidence of urinary tract injury, and confirmation
may still be needed with more definitive testing (eg, cystoscopy with IV indigo carmine). Similar
values of creatinine in serum & ascitic fluid (or lower levels in ascitic fluid) is reassuring for the
absence of uroperitoneum. If creatinine is normal in the serum & elevated to a level similar to urine
in the ascitic fluid, urinary tract injury is likely, but the patient still requires testing with cystoscopy
&/or imaging for confirmation.
U/S can be used as an initial test to assess for hydronephrosis or to exclude a retroperitoneal
collection if ureteral injury is suspected.
CT with renal contrast or Cystoscopy with retrograde IV pyelography

Can be done depending on test availability.
‫ﯾﺤﻘﻦ ﻣﻦ ﻓﻮق أو ﯾﺤﻘﻦ ﻣﻦ ﺗﺤﺖ وﯾﺼﻮر‬
Ureteral double-J stenting
During the retrograde pyelogram as a first-line treatment may manage the injury & avoid the need
for more invasive surgery.
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Management
Antibiotic prophylaxis
If a patient in whom a urinary tract injury occurs has clinical signs suggestive of UTI (cloudy urine
output from the bladder catheter, malodorous urine or bladder mucosa that appears inflamed on
cystoscopy), send urine culture during surgery & treat empirically for UTI until the culture results
are received.
Ureteral injury
Repair of ureteral injuries often involves ureteral stenting or advanced surgical repair. If there is
ligation or kinking of a ureter with a suture, the suture is removed. Transection or other types of
extensive damage (eg, crush injury, thermal damage) may require reanastomosis.
Bladder dome or supratrigonal injuries (‫)اﻟﺠﺰء اﻟﻌﻠﻮي‬

They are usually repaired with excellent results. Very small injuries (<1 cm) may either be repaired
or managed by leaving the bladder catheter in place for 5-7 days, followed by a cystogram to
confirm closure. All other cystotomies should be repaired. The repair is a 1- or 2-layered running
closure with absorbable suture. Use 1 layer for a small cystotomy (<2 cm) or 2 layers for larger
cystotomies. When there are more than 1 cystostomy in close proximity to each other & well away
from the bladder trigone, an option is to incise the small defects to combine them into a single
defect before beginning the repair. When the repair is completed, the closure should be tested to see
if it is water-tight by instilling dye into the bladder catheter. Additionally, we evaluate the closure
with cystoscopy, taking care to not over distend the bladder nor traumatize the suture line with the
cystoscope. The bladder will reepithelialize within 3-4 days & regains its normal strength after 21
days. We usually leave the bladder catheter in for 5-14 days, depending on the size & location of the
defect.
Bladder trigone injuries (‫)اﻟﺠﺰء اﻟﺴﻔﻠﻲ‬

Injuries to the trigone or below the trigone may involve the ureters or urethra & are more difficult to
repair than dome or supratrigonal injuries. Exposure & suturing of this area are difficult. This is
because the trigone includes the ostia of the ureters & urethra and is located in the inferior &
posterior aspect of the bladder.
Prior to patient discharge

A voiding trial is performed to ensure adequate bladder function. First, we have the patient stand at
the bedside to drain the bladder catheter completely. Once empty, we then retrograde fill her
bladder with 300 mL of sterile water or saline followed by immediate catheter removal. The patient
is allowed 10 minutes to void. She must void 200 mL or more to demonstrate adequate voiding
function. Most women with unsuccessful voiding trials are discharged home with a temporary
indwelling bladder catheter.
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Neurogenic Bladder Dysfunction
- Chronic postoperative neurogenic bladder dysfunction can result from procedures that involve
extensive dissection & mobilization of the bladder. This type of complication is more likely
following extensive perivesical dissection.
- Radical hysterectomy, for example, interrupts parasympathetic & sympathetic innervation due to
resection of the uterosacral & cardinal ligaments. Operative trauma may result in edema &
hematoma formation that affects the bladder's functions of urine collection & micturition.
- Women with postoperative urinary retention are treated with bladder catheterization. In our
experience, normal bladder function will return within several days in most patients.
Best Regards
#UpToDate_Lectures
60
Management of Rh -ve Pregnant Women who Received Rh +ve Blood

OR
Rh -ve mother who didn't receive anti-D after delivery of Rh +ve baby:
- At first do ICT to check for sensitivity & if ICT is negative, give Anti-D injection as usual.
- If ICT is positive, do Anti-D antibody titer.
- Ab titer is done monthly if stable result & every 2 wk if rising titer.
- If a critical level is reached (>16 or 32), do MCA-PSV Doppler at 1-2 wk intervals.
- MCA-PSV indicate the velocity of blood flow in the MCA which increases as fetal Hb level falls
(anemia) due to the fast blood flow in the MCA due to decreased viscosity.
- If MCA-PSV ≤1.5 MoM for gestational age, this indicate the absence of moderate to severe
anemia & if it remains at this level, we begin weekly antenatal surveillance at 32 wk (CTG, BPP,
fetal movement count, AF volume & Doppler assessment), then we schedule delivery at 37-38 wk.
- If MCA-PSV >1.5 MoM, transfer her to a fetal medicine center to obtain a fetal blood for Hb
checking & a possible intrauterine transfusion if Hct <30%. Then they consider delivery at 35 wk.
- Fetal Hb/Hct should be checked before transfusion because a high MCA-PSV is not a definitive
proof of clinically significant fetal anemia; false positives occur.
- Intravascular intrauterine transfusion is generally limited to pregnancies between 18-35 wk
because before 18 wk, the small size of the relevant anatomic structures poses technical challenges,
and after 35 wk, intrauterine transfusion is considered riskier than delivery followed by postnatal
transfusion therapy.
Abbreviations
- ICT: indirect Coombs titer.
- MCA-PSV: middle cerebral artery (MCA) peak systolic velocity (PSV).
Best Regards (y)

#UpToDate_Lectures
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Management of Recurrent pregnancy loss (RPL) or Recurrent Abortion
Definition
Occurrence of 3 successive losses (spontaneous abortions) of clinically recognized pregnancies
before 20 wk.
- In our practice, we start investigating after 2 failed clinical pregnancies.
- Ectopic & molar pregnancies are not included.
History
o If there was uterine instrumentation? To rule out adhesions.
o If the menstrual cycle is normal? To rule out endocrine dysfunction.
o If there is premenstrual spotting? To rule out LPD.
o If there is menorrhagia? To rule out fibroid.
o If there is hypomenorrhia? To rule out hypoplastic uterus & Asherman $.
o If there is galactorrhea? To rule out hyperprolactinemia.
o If there is a history of congenital abnormalities or karyotypic abnormalities, which may be
heritable?
o If fetal cardiac activity ever detected? RPL before detection of cardiac activity suggests a
chromosomal abnormality.
o If there is consanguinity? To rule out genetic disorders.
o If there is exposure to environmental toxins, which may be lethal to developing embryos?
o If there is a history of venous or arterial thrombosis suggestive of AP$?
o What information is available from previous laboratory, pathology & imaging studies?
o What is the timing? 1st▲ is usually dt. CFMF, while 2nd▲ is usually dt. local cause.
o What is the order? Ascending in uterine hypoplasia & descending in incompetent cx.
o Character of abortus? Fresh in local cause, macerated in maternal disease & malformed in CFMF.
Examination
- With attention to signs of endocrinopathy (e.g. hirsutism, galactorrhea).
Uterine assessment
Anatomic causes of RPL are typically diagnosed using HSG or sonohysterography.
Sonohysterography
- More accurate than HSG & gives more information than U/S alone about uterine abnormalities.
- It delineates the internal contours of the uterine cavity & provides concomitant sonographic
visualization of the outer surface & wall of the uterus.
- See image down.
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Hysterosalpingogram (HSG)
- It provides more information about tubal anatomy & patency.
- See images down.
Hysteroscopy
- Hysteroscopy is considered the standard for diagnosis & treatment of intrauterine abnormalities.
U/S
- Useful for the diagnosis of a septate uterus & provide information about the presence and location
of uterine myomas.
- Transvaginal U/S (TVS) also provides information about the possibility of cervical insufficiency
during pregnancy.
MRI
- MRI is useful for distinguishing between a septate & bicornuate uterus suspected on U/S or HSG.
Anticardiolipin Ab_& _lupus anticoagulant

- The minimum immunology work-up for women with RPL is measurement of anticardiolipin Ab
(IgG & IgM) & lupus anticoagulant.
- Both tests should be done twice, 6-8 wk apart, because a low to mid positive level can be due to
viral illness then revert to normal.
- The anticardiolipin Ab titer is considered elevated if medium or high titers of both IgG & IgM are
present in blood.
Thyroid function tests & thyroid peroxidase antibodies

- Should be done for women with clinical manifestations or with history of thyroid disease.
- Screening asymptomatic women for subclinical thyroid dysfunction can be offered as there is
evidence of an increased risk of abortion in women with subclinical hypothyroidism & in euthyroid
women with thyroid peroxidase Ab.
Karyotyping of couples & abortus

- This is the last test we obtain & only if the above examinations are normal.
- It is part of the evaluation of RPL, despite the low yield of abnormality, cost & limited prognostic
value.
- The purpose is to detect balanced translocations that could be passed to the fetus unbalanced.
- Chromosomal abnormalities detectable in parental peripheral blood preparations are an indirect &
limited indicator of fetal karyotype. So, many experts also recommend karyotype of the abortus or
products of conception.
Screening for DM should be limited to women with clinical manifestations.
Screening for inherited thrombophilia.
63
Management acc. To the cause
Uterine abnormalities
- If uterine septum, intrauterine adhesions or submucosal myoma, hysteroscopic metroplasty can be
done.
- Repair of bicornuate & septate uteri reduce the abortion rate from 85% (before surgery) to 10%
(after surgery).
- Prophylactic cervical cerclage in women with no history of cervical insufficiency isn’t advised.
Antiphospholipid $ Aspirin & heparin improve the pregnancy outcome.
Overt thyroid disease or DM should be treated.
Polycystic ovary $ (PCO$)

Metformin can be used to decrease the risk of abortion (which is 20-40%), but the effectiveness is
NOT proved.
Hyperprolactinemia Treatment with bromocriptine even in the absence of overt hypogonadism.
Parental karyotype abnormality

- Parental karyotyping may be indicated in couples with ≥3 clinical miscarriages.
- In <10% of couples, one partner (mostly the mother) will be diagnosed with a balanced
translocation. So, we can test the mother first followed by the father as needed.
- Couples in whom chromosomal abnormalities are discovered in one or both partners or the abortus
are generally referred for genetic counseling.
- They should be informed about the probability of having a chromosomally normal or abnormal
conception in the future.
- IVF with preimplantation genetic diagnosis (PGD) can be used to avoid transfer & implantation of
an affected embryo.
- PGD improves the pregnancy outcome of translocation carriers with a history of repeated
pregnancy loss.
- For evaluation of products of conception (POC): gestational tissue can be cultured on placenta or
blood & kept in normal saline & NOT formalin.
64
Treatment options for unexplained RPL (40%):
1. Stop smoking, alcohol, caffeine & reduction in BMI (for obese women).
2. Progesterone: We typically prescribe progesterone (200 mg 3 times/day, vaginally) as empiric
treatment of unexplained RPL. It is started 3 days after the LH surge, so as not to inhibit ovulation
& continued until 10 wk of pregnancy (when placental progesterone production is sufficient).
3. Human menopausal Gn (hMG): Ovarian stimulation via hMG is effective for treatment of
endometrial defects in women with RPL. The mechanism may be correction of a luteal phase defect
or stimulation of a thicker endometrium, so leading to a better implantation site.
4. IVF & preimplantation genetic diagnosis.
Unproven therapies
- Aspirin with or without heparin.
- Low-molecular weight heparin (LMWH).
- Human chorionic gonadotropin (hCG).
Best Regards
65
66
Important stitches in uterus against atony

Compression Sutures
Cho square sutures

- Cho described a technique in which a straight needle with #1 chromic catgut is used to place
sutures in a small rectangular array to compress the anterior & posterior uterine walls against one
another at sites of heavy bleeding.
-The through & through sutures extend from the serosa of the anterior wall to the serosa of the
posterior wall.
- After creating a square, the ends are tied down as tight as possible to compress the myometrium.
- 2-5 squares/rectangles are made, as needed.
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Pereira stitch
- Pereira described a technique in which a series of transverse & longitudinal sutures of a delayed
absorbable multifilament suture are placed around the uterus via a series of bites into the
submucosal myometrium.
- 2-3 rows of these sutures are placed in each direction to completely envelope & compress the
uterus, similar to the way one might truss a stuffedroast.
- When the transverse sutures are brought through the broad ligament, care should be taken to avoid
damaging blood vessels, ureters, and fallopian tubes.
- The longitudinal sutures begin & end at the last transverse suture nearest the cervix, and do not
enter the uterine cavity.
- The myometrium should be manually compressed prior to tying down the sutures to facilitate
maximal compression.
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Hayman stitch
- Hayman described a modification of the B-Lynch suture that is performed without a hysterotomy.
- 2-4 vertical compression sutures are placed, as needed, but in contrast to the B-Lynch technique,
these sutures pass directly from the anterior uterine wall to the posterior uterine wall.
- A transverse cervicoisthmic suture can also be placed if needed to control bleeding from the lower
uterine segment.
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B lynch suture
- A large Mayo needle with #2 chromic catgut is used to enter & exit the uterine cavity at 1 & 2.
- The suture is looped over the fundus & then reenters the uterine cavity posteriorly at 3, which is
directly below 2. The suture should be pulled very tight at this point.
- It then enters the posterior wall of the uterine cavity at 4, is looped back over the fundus, and
anchored by entering the anterior lateral lower uterine segment at 5 & crossing through the uterine
cavity to exit at 6.
- The free ends at 1 & 6 are tied down securely to compress the uterus.
- The technique has been used alone & in combination with balloon tamponade. This combination
has been called the "uterine sandwich."
70
Bhal technique
- The only modification to the B-Lynch suture.
-This entail 2 sutures instead of 1, with the knots tied in the anterior-inferior margin of the lower
uterine segment, without any difference in the compression effects compared to the original B-
Lynch suture.
#UpToDate_Lectures
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Expert Technique for Vaginal Delivery
Some doctors put their hands in their waist while delivering a cephalic pt. vaginally after scrubbing
& putting overhead & OR shoes with goggles. So, plz those secret techniques are for YOU.
Techniques to be professional in delivering the patient vaginally

1. When you press on the pelvic floor by your fingers, this stimulate uterine contraction.
So, press by 2-4 fingers (whatever the volunteer fingers you have) on the posterior vaginal wall just
at the level of occiput/ischial spine, you will see more descending of the head.
2. If you did the previous step perfectly & saw your outcome proceed for the most efficient step;
Put your fingers between the head & vaginal wall at the level of ischial spine then swab the fingers
you put inside from one side to the other side beneath the occiput i.e. make the head of baby on the
dorsum of your fingers & swab the fingers from the lt. side to the rt. side almost at the level of
ischial spine while you are pressing on the pelvic floor by the same fingers at the same time. This
will help internal rotation.
So, by this step you assisted the head descend & the internal rotation.
3. If you become professional in doing the previous steps, do this last one.
Do all I mentioned before by fingers from one hand & the other hand pressing on the fundus doing
fundal pressure by one hand in the direction of vagina or just correct the axis of uterus over vagina
during contractions (sometimes uterus is tilted to one side acc. to position of the baby inside).
#UpToDate_Lectures
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Management of Complicated Ovarian Cyst (Adnexal Torsion)
Overview
- It refers to the complete or partial rotation of the ovary with the fallopian tube on its ligamentous
supports, often resulting in impedance of its blood supply.
- An ovarian physiologic cyst (functional cyst, corpus luteum) or a neoplasm is the most likely
factor to predispose to ovarian torsion, but also ovarian torsion may also occur in patients with
normal ovaries (no mass & not enlarged).
- The right ovary appears to be more likely to torse than the left, possibly because the right utero-
ovarian ligament is longer than the left and/or that the presence of the sigmoid colon in the left side
of the colon may help to prevent torsion.
Presentation
- Acute onset of moderate to severe pelvic pain, often with nausea & possibly vomiting, in a woman
with an adnexal mass.
- Take care, torsion may occur in the absence of an adnexal mass. So, a high index of suspicion is
required to make the diagnosis as it may end by gangrene & loss of the ovarian function.
Examination
- Most patients exhibit pelvic &/or abdominal tenderness, although tenderness on examination is
absent in as many as ⅓ of patients.
- Tenderness may be localized to the side of an adnexal mass or may be diffuse.
- A palpable pelvic mass may or may not be present.
- Peritoneal signs are present in a small number of patients and should raise concern for adnexal
necrosis.
- Low grade fever may be a sign of adnexal necrosis (with leukocytosis).
- Some patients with torsion present with a slightly high HR or blood pressure, typically in
association with the severe pelvic pain.
Investigations
- Pregnancy test to exclude ectopic pregnancy dt. the acute pelvic pain.
- WBC as adnexal necrosis then infection are associated with leukocytosis which when present, it
raise concern for a severe adnexal damage.
- If an adnexal mass is present & malignancy is suspected, serum tumor markers should be drawn.
- Ultrasound is the initial imaging study of choice for patients with suspected ovarian torsion with
these findings (NOT all findings are necessary):
73
1. An enlarged ovary compared with the contralateral ovary due to edema & vascular & lymph
engorgement.
2. An ovarian mass: In torsion, the patient will have pain ipsilateral to the mass.
3. Abnormal ovarian location: in Cul de sac or anterior to uterus.
4. Decreased or absent Doppler flow within the ovary: since the ovary has a dual blood supply, flow
can be present even in the presence of torsion. Arterial flow in systole without flow in diastole is
evidence for outflow obstruction, but venous flow in the setting of torsion is associated with ovarian
viability. It is helpful when performing U/S for torsion to ensure that Doppler flow settings are set
appropriately by obtaining flow tracings in the contralateral ovary prior to examining the
symptomatic ovary (see images down).
5. Rupture of an ovarian cyst is often accompanied by hematoperitoneum or free fluid in the pelvis.
- The decision to proceed with surgery is based upon combination of presentation, examination &
U/S findings.
Laparotomy vs Laparoscopy
- The diagnosis of torsion is confirmed by direct visualization of the rotated ovary, tube or
paraovarian cyst.
- Surgeons should document the findings with laparoscopic photographs of the adnexa.
- Most torsed ovaries are considered potentially viable, unless there is a clearly necrotic
appearance.
- Ovarian conservation is the preferred approach for premenopausal women & most ovaries should
be considered viable unless there is a high degree of certainty that the ovary is not viable due to the
CLEARLY necrotic appearance.
- An ovary that is dark & enlarged likely has vascular & lymphatic congestion & may have
hemorrhagic lesions. Traditionally, ovaries with this appearance have been thought to be nonviable,
but multiple studies have found that many women (even those with a blue or black ovary) retain
ovarian function following detorsion (see images down).
- Rarely, ovarian or tubal necrosis are present at time of surgery.
- The appearance on gross inspection of a necrotic ovary or tube includes a loss of normal anatomic
structure & a gelatinous or friable consistency.
- A technique to assess whether ovarian perfusion is present is the ovarian bivalving, in which the
ovary is untwisted & the ovarian cortex incised. This method allows visualization of whether blood
flow is present at the incision. In addition, there is a potential therapeutic effect by relieving the
increased pressure exerted by the lymphatic & venous congestion.
- The key factor is to perform detorsion as quickly as possible as the risk of ovarian ischemic
damage increase with an increasing the interval between symptoms to surgery.
- There is also no evidence of an increase of adverse events with detorsion.
74
Interventions
• For most premenopausal patients with ovarian torsion, detorsion & ovarian conservation is
recommended rather than salpingo-oophorectomy.
• Patients with an ovarian mass that is suspicious for malignancy require salpingo-oophorectomy.
• After detortion, if a benign mass is present, ovarian cystectomy is often performed.
• Ovaries that are hemorrhagic &/or edematous are most likely viable, so oophorectomy should be
reserved for necrotic/gelatinous/dead-tissue.
• Salpingo-oophorectomy is also reasonable for postmenopausal women.
• Irreversible ischemic damage to the adnexa can occur & may lead to infection if a necrotic ovary
is retained, so postoperative care should include observation for signs of peritonitis or sepsis.
#UpToDate_Lectures
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77
Cesarean Scar Defect (Niche/Isthmocele)
Formation
- It forms after cesarean delivery, at the site of hysterotomy, on the anterior wall of the uterine
isthmus.
- Improper healing of the cesarean incision leads to thinning of the anterior uterine wall, which
creates an indentation & a fluid-filled pouch at the cesarean scar site.
Risk Factors
The exact reason why a niche develops has not yet been determined; however, Surgical techniques
that may increase the chance of niche development include low (cervical) hysterotomy, single-layer
uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing
technique & multiple cesarean deliveries. Patients with medical conditions that may impact wound
healing (such as diabetes & smoking) may be at increased risk for niche formation.
Complications
The presence of fibrotic tissue in the niche acts like a valve, leading to the accumulation of blood in
this reservoir-like area. A niche thus can cause delayed menstruation, resulting in abnormal
bleeding, pelvic pain, vaginal discharge, dysmenorrhea, dyspareunia & infertility. Accumulated
blood in this area can ultimately degrade cervical mucus & sperm quality, as well as inhibit sperm
transport, a proposed mechanism of infertility. Women with a niche who conceive are at potential
risk for cesarean scar ectopic pregnancy, with the embryo implanting in the pouch & subsequently
growing & developing improperly.
Evaluation
- The best time to assess for the abnormality is after the patient’s menstrual cycle, when the
endometrial lining is at its thinnest & recently menstruated blood has collected in the defect (this
can highlight the niche on imaging).
- Transvaginal U/S or saline-infusion sonohysterogram serve as a first-line test for in-office
diagnosis.
Treatment
- Treatments for cesarean scar defect vary dramatically & include hormonal therapy, hysteroscopic
resection, laparoscopic repair & hysterectomy.
- To promote fertility, the fibrotic tissue must be removed as the cesarean scar defect in a gravid
uterus represents a risk for uterine rupture. The laparoscopic approach allows the defect to be
repaired & restore the integrity of the myometrium.
78
Technique of uterine closure (Uptodate)
- Routine manual/instrumental cervical dilatation before closing the uterus is unnecessary in both
laboring and non-laboring women.
- Do not irrigate the uterus with antibiotic solution before closure.
- Choice of suture is largely based on personal preference.
- Myometrial closure: perform a 2-layer, continuous closure with delayed absorbable synthetic
suture incorporating all of the muscle to avoid bleeding from the incision edges.
- We do not use locking sutures unless arterial bleeding is evident.
- The endometrial layer should probably be included in the full thickness myometrial closure.
- Perform a 2-layer rather than a single-layer uterine closure, but use a single-layer closure when a
tubal ligation is performed concurrently. If a single-layer closure is performed to save time, we
suggest an unlocked technique. A double (or even triple)-layer closure may be necessary when the
myometrium is thick, such as with a classical incisions.
- Do not close the visceral or parietal peritoneum because it saves time and there is no convincing
evidence of harm (increased adhesion formation).
Best Regards
#UpToDate_Lectures
79
Management of Missed Implanon
- Etonogestrel implant (Implanon) is a single-rod progestin contraceptive placed subdermally in the

inner upper arm for long-acting reversible contraception (3 yr).
- The implant may migrate a short distance (<2 cm) over time.
- Women who are postabortion or postpartum (even if breastfeeding) can have the implant inserted
immediately after termination of pregnancy or delivery.
- Unscheduled bleeding is the most common side effect & reason for discontinuation.
- Back-up contraception for 7 days after insertion is important if inserted away from the LMP.
- The hormonal effects end promptly after removal & >90% of women ovulate within 3-4 wk of
removal.
- If the implant is not removed after 3 yr, the contraceptive effects persist, possibly for as long as 2
years more.
- Rods too deeply placed can't be palpated under the skin, but can be seen with imaging studies
(Implanon can be identified with high resolution U/S or MRI; Nexplanon is radio-opaque & can be
identified with just plain X-ray).
- Such "lost" rods should be located with a high frequency (10-15 mega Hz), short focus, linear U/S
transducer prior to attempting the removal. Our target here is to identify an acoustic shadow (the rod
itself is more difficult to see), measure the depth & draw a line representing the rod location on the
surface of the skin. If the rod is very deep (>1.5-2 cm), U/S should be used during the removal
procedure because movement of the patient's arm may change the location of skin marks in relation
to the underlying implant.
- Removal of contraceptive implants is never an emergency; there is no evidence that their presence
adversely affects pregnancies or other conditions.
#UpToDate_Lectures
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Management of Pregestational DM
FIRST TRIMESTER
History
• Classification: type 1 or 2
• Insulin or oral hypoglycemic?
• Complications associated in the pregnancies before?
• Idea about glycemic control: if she has self-monitoring paper.
Routine investigations
CBC, bl group & Rh, serology (HBV, rubella, syphilis) & urine (asymptomatic bacteriuria).
Hb_A1C it reflects the glycemic control over the prior 8-12 wk & thus assists in counseling her
regarding the risks of miscarriage, CFMF & preeclampsia. The American Diabetes Association
(ADA) recommends aiming for an A1c <6.5%.
Assessment of comorbidities baseline renal function, thyroid function tests (thyroid dysfunction is
common with type 1 DM), eye examination by an ophthalmologist to detect retinopathy.
US to document viability, as the rate of miscarriage is high in women with diabetes especially those
with poor glycemic control.
General Principles
• Explain to the mother the importance of self-monitoring of blood glucose, diet therapy, medication
& exercise.
• Target blood glucose values acc. to The ACOG & the American Diabetes Association (ADA):
... Fasting ≤95 mg/dL.
... Pre-prandial ≤100 mg/dl.
... 1-hr postprandial ≤140 mg/dl.
... 2-hr postprandial ≤120 mg/dl.
• Explain to the patients with a markedly elevated A1C value of the increased risk of CFMF
especially NTD & cardiac defects.
• For those with type 1 & 2 DM, begin aspirin 81 mg/day after 12 wk to decrease the risk of
preeclampsia (we can start earlier).
• The ACOG recommends preconception & 1st▲ supplementation with 4 mg of folic acid dt. the
risk of NTD.
• Refer her to endocrinologist, dietician & diabetic educator to help her control her bl. Sugar.
• Extra visits can be used to review monitored blood glucose values, results from the
ophthalmologic & laboratory examination (e.g. renal function, A1C, thyroid function).
• If a woman is both obese & diabetic, the clinician should be mindful of the potential morbidities of
both conditions.
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Type_1_DM_Dosing
• Multiple daily injection regimen (3-4) in pregnant women is preferred especially in women with
type 1 DM.
• Insulin requirements during the 1st trimester are similar to those prior to pregnancy in women with
type 1 DM.
• Dosing is continually adjusted based on self-monitoring of blood glucose & A1C values.
• The average insulin requirements in pregnant women with type 1 diabetes are:
... 1st▲ → 0.7 U/kg.
... 13-28 wk → 0.8 U/kg.
... 29-34 wk → 0.9 U/kg.
... 35 wk till term → 1 U/kg.
• Approximately 50% of the total insulin dose is administered as a rapid acting insulin (eg, Humalog
or NovoRapid) before each meal & the other 50% is administered as an intermediate insulin (NPH)
twice daily or long-acting insulin (Lantus or Levemir) once or twice daily.
• For most pregnant women, each premeal dose is approximately 0.15 times their pregnant weight in
kg & the basal dose (intermediate or long-acting insulin) is calculated as 0.45 times the patient's
weight in kg.
• As an example, an 80 kg pregnant woman with diabetes would take 12 units (80 x 0.15) of
Humalog or NovoRapid before each meal & 18 units (80 x 0.45 /2) of NPH or Levemir twice daily
or 36 unit (80 x 0.45) of Lantus once daily. The first Levemir dose is given before breakfast & the
second dose is given either before dinner with a rapid-acting insulin or at bedtime, whichever works
best for avoiding nocturnal hypoglycemia. Total dose in the example above is (12 x 3)+(18 x 2)= 36
(50%)+36 (50%)=72 Unit= average insulin dose at 3rd trimester (80 x 0.9).
Type_2_DM_Dosing
• For women with excellent glycemic control on an oral anti-hyperglycemic drug such as metformin
at conception, maintaining euglycemia during organogenesis is critical & more important than
switching to insulin.
• Metformin can be continued safely & effectively as the transition to insulin is initiated & until the
dose of injected insulin is sufficient to achieve metabolic control.
• Some women with excellent metabolic control on metformin may choose to continue this therapy
& take supplemental insulin later in pregnancy (if needed).
• We can use the same calculations above, but patient may need more insulin in type 2 DM dt. the
insulin resistance is very high in type 2.
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SECOND_TRIMESTER
General Principles
• As above.
• Visits every 2-4 wk through the 2nd▲, but more frequently if complications arise or glycemic
control is suboptimal.
Screening for CFMF full anomaly scan (U/S) is done at 18-20 wk & focus on NTD & cardiac
anatomy.
THIRD_TRIMESTER
General Principles
• Visits every 1-2 wk until 36 wk, then weekly until delivery.
• Close monitoring of maternal blood glucose levels.
• Monitoring FWB to minimize the risk of IUFD.
• Evaluation for macrosomia or IUGR: U/S at 28-32 wk to assess fetal growth & repeat at 3-4 wk
intervals.
• Evaluation for obstetrical or medical complications necessitating premature delivery.
Antepartum Monitoring the ACOG recommend using fetal movement counting, biophysical
profile &/or NST weekly starting at 32-34 wk then increase the frequency of testing to twice weekly
from 36 wk until delivery.
Umbilical artery Doppler may be required to assess for IUGR.

- If non-reassuring fetal testing dt. a reversible problem such as hyperglycemia or DKA, it is
advisable to resuscitate the fetus in utero by treating the medical disorder (pathological FHR
patterns will often revert to normal when the mother's metabolic status is corrected).
- Do the last U/S at 38 wk to estimate the fetal weight & decide the plan of delivery.
Administration of betamethasone if preterm birth is anticipated or planned (may cause transient

hyperglycemia).
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DELIVERY
- When emergency early delivery is indicated, it is important to remember that RDS is more likely
to develop than in infants of women without diabetes delivered early.
- Woman with good glycemic control & no vascular disease (as nephropathy or retinopathy),
delivery at 39 wk is indicated if favorable cervix.
- Woman with good glycemic control, no vascular disease, normal fetal growth, reassuring fetal
surveillance & no history of IUFD, but unfavorable cervix, induction of labor can be safely delayed
until 40 wk.
- Woman with pregestational diabetes & “vascular disease”, delivery at 37-39 wk is appropriate.
- Woman with pregestational diabetes & “poor glycemic control”, delivery at 34-37 wk following
an amniocentesis for documenting fetal lung maturity can be considered.
- In cases with repeated unexplained IUFD, terminate 1-2 wk earlier.
- According to ACOG, prophylactic CS can be done to prevent brachial plexus injury dt. shoulder
dystocia if macrosomia.
- Maternal diabetes is not a contraindication to a trial of labor after a previous CS (VBAC);
however, the success rate may be lower than in women without diabetes.
- Peripartum maintenance of maternal euglycemia is essential.
- Insulin requirements: drop sharply after delivery & should be recalculated at this time based on
sliding scale.
- NICU consultation for the baby after delivery dt. the possible morbidities after delivery.
Best Regards
#UpToDate_Lectures
85
Management of GDM
Risk Factors for GDM
.. BMI >30 kg/m2.
.. Previous macrosomic baby ≥4.5 kg.
.. Family history of DM.
.. Middle Eastern (like us) ‫ﻣﻦ أﻛﻞ اﻟﻤﺤﺸﻲ‬
.. Glycosuria 2+ or ≥ 1+ on 2 occasions.
Screening
- Universal one-step 75 gm OGTT for women with risk factors at 24–28 wk.
- If previous GDM, do self-monitoring of blood glucose OR OGTT as soon as possible in the 1st or
2nd trimester, then repeat at 24-28 wk if normal.
- If GDM diagnosed, refer to Joint diabetes & antenatal clinic within 1 week.
To Diagnose Overt Diabetes

If ≥ 1 value equals or exceeds thresholds
- FBS ≥126 mg/dl.
- HbA1c ≥6.5%
- RBS ≥200 mg/dl.
To Diagnose GDM
If ≥ 1 value equals or exceeds thresholds
- FBS 5.6 mmol/l (101 mg/dl).
- 2-h PP 7.8 mmol/l (140 mg/dl).
ANC
- Refer all women with GDM to a dietitian.
- If pre-pregnancy BMI is >27, advise to restrict calorie intake to <25 kcal/kg/day & to take
moderate exercise of at least 30 min/daily.
- Folic acid 5 mg/day.
- Start oral hypoglycemic agents:
.. If diet & exercise fail to maintain bl. glucose targets during a period of 1–2 wk.
.. If U/S suggests fetal macrosomia.
.. Both glibenclamide & metformin are effective treatments for GDM.
- Insulin is needed in about 20-30% of patients who were initially started on glibenclamide &
metformin.
- Typically, regardless of body weight, a patient whose glucose elevations are mostly postprandial is
prescribed a starting dose of 30 units (20 units of intermediate acting insulin &10 units of rapid
acting insulin) in the morning prior to breakfast. If the GDM is diagnosed & therapy started before
the 3rd trimester, we generally start with half this dose, since insulin resistance has not reached its
86
maximum level yet. If the post-dinner glucose level remains elevated, then an additional injection of
rapid acting insulin is given just prior to dinner. If fasting glucose is elevated, intermediate acting
insulin can be given along with the dinner dose of rapid acting insulin, or can be administered
separately at bedtime. Sometimes an additional dose of rapid acting insulin is necessary to maintain
euglycemia after lunch, so that a total of 4 injections per day are needed (3 rapid acting before each
meal & 1 intermediate before breakfast).
Monitoring
- Diabetes team for assessment of glycemic control every 1–2 wk throughout pregnancy.
- Self-monitoring of blood glucose levels.
‫ﺗﺨﻠﯿﮭﺎ ﺗﺴﺠﻞ ﻗﺮاﺋﺎت اﻟﺴﻜﺮ ﻓﻲ اﻟﺒﯿﺖ وﺗﻮرﯾﮭﺎﻟﻚ ﻛﻞ ﻣﻮﻋﺪ ﻋﻠﺸﺎن ﺗﺸﻮف اﻟﺴﻜﺮ ﻣﻈﺒﻮط وﻻ ﻣﺤﺘﺎج ﺗﺰود اﻟﺠﺮﻋﺎت‬.
- FBS & 1 hour PP after every meal.
- Target: FBS 63-105, 1-hr <140, 2-hr 115 mg/dl.
- For women with insulin-treated diabetes, test bl. glucose levels before going to bed at night.
- Do not use HbA1c routinely.
- U/S monitoring of fetal growth & AF volume every 4 wk from 28 wk.
Timing of Delivery
- Advise women with GDM to give birth before 40+6 wk & offer IOL or CS if indicated to women
who have not given birth by this time.
- Exclude macrosomia first by U/S before IOL.
- During labor, monitor bl. glucose hourly & maintain it between 70-126 mg/dl.
- Do not use Yutopar for tocolysis in PTL (cause hyperglycemia).
Postpartum
- Discontinue hypoglycemic treatment immediately after birth. If diabetic, reduce the dose only.
- Warn women of the symptoms of hyperglycemia.
- Sliding scale.
- FBS at the 6 wk postnatal check & annually thereafter.
- Offer annual HbA1c test to women who were diagnosed with GDM who have a negative postnatal
test for DM.
- Lifestyle advice (weight control, diet & exercise).
- Discuss contraception.
- Baby: Feed as soon as possible after birth within 30 minutes & then every 2–3 hours until feeding
maintains pre-feed blood glucose levels at a minimum of 36 mg/dl.
- Test bl. glucose routinely at 2-4 hours after birth.
You can see the link for the management of pregestational DM in the first comment.
Best Regards
87
Management of Oligohydramnious
Diagnosis
- Clinical diagnosis is based on the finding of decreased amniotic fluid on U/S examination.
- There are both objective & subjective U/S criteria for diagnosing oligohydramnios:
1. Objective criterion is generally preferable (AFI ≤5 or single deepest pocket (SDP) <2 cm).
2. Subjective suspicion of AF volume by experienced examiners has similar sensitivity for
diagnosing Oligohydramnious.
- Borderline/low normal AF means AFI >5.0 & ≤8.0 cm.
- Anhydramnios is the lack of a measurable AFI or SDP, although a thin echolucent rim may be
imaged on the inner aspect of the uterus.
- Multiple gestation: measurement of AFI for each sac of a multiple gestation is difficult so single
deepest vertical pocket is used for diagnosis as before.
Evaluation
- Exclude maternal diseases as pre-eclampsia, ch. HTN, SLE & thrombophilia.
- Exclude use of drugs as anti-PG & ACE inhibitors.
- If twins, exclude TTTT ( one oligo & other poly).
- Exclude IUFD, IUGR, kidney anomalies.
- Exclude ROM & postdate.
- Do a comprehensive U/S evaluation with fetal biometry & search for fetal anomalies (especially
renal), markers suggestive of aneuploidy (eg, increased nuchal translucency), IUGR or placental
abnormalities.
- If PROM is suspected, do speculum examination for vaginal pooling, Nitrazine & fern tests or
Amnisure, whatever available.
- If there are fetal anomalies, amniocentesis (if available) may reveal an abnormal karyotype mostly
triploidy.
Methods of increasing AFV

- Oral hydration with 1-2 liters of water or hypotonic solutions can transiently increase AF volume
particularly in patients with dehydration. This approach is easier & safer than IV fluid
administration or amnioinfusion. Hydration with water appears to reduce maternal plasma
osmolality & Na concentration, resulting in osmotically driven maternal to fetal water flux; it also
improves uteroplacental perfusion.
- Amnioinfusion: still investigational especially for 2nd trimester oligohydramnios.
- Fetal membrane sealants: 7ashish
- Sildenafil: attached a recent study down for its effect with the fluids on oligohydramnious.
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Management
First Trimester
... Oligohydramnious at this time is an ominous finding; the pregnancy usually aborts.
... We counsel these patients regarding the poor prognosis & inform them of the signs of
miscarriage.
... Serial U/S is helpful for follow up (eg, worsening oligohydramnios, embryonic/fetal demise, or
rarely resolution).
Second Trimester
... Borderline/low normal AF volume: generally have a good prognosis. Serial U/S is helpful for
follow up, which may remain stable, resolve or progress to development of oligohydramnios &/or
IUGR.
... Oligohydramnious often ends in fetal or neonatal death.
... Infants may have abnormalities, such as skeletal deformations, contractures & pulmonary
hypoplasia.
... Do a fetal anatomic survey to look for CFMF.
... Administer oral maternal hydration.
... Serial U/S to monitor AF volume, fetal growth & fetal well-being.
Third Trimester
... There is an inverse relationship between AF volume in the third trimester & the incidence of
adverse pregnancy outcomes.
... Adverse outcomes are related to meconium aspiration, umbilical cord compression &
uteroplacental insufficiency which will lead to abnormalities in fetal heart then CS with low Apgar
scores.
... Idiopathic isolated oligohydramnios at term appears to have a better prognosis.
... The duration of oligohydramnios is also a prognostic factor. Patients who present with idiopathic
oligohydramnios at an earlier GA are at risk for adverse perinatal outcomes compared with those
presenting at later GA.
... Patients with oligohydramnios early in the third trimester may be hospitalized to undergo
evaluation of possible causes, daily CTG & maternal hydration.
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Timing of Delivery
... Manage acc. to the ass. problem as preeclampsia, PPROM, IUGR, CFMF & postterm pregnancy.
... For idiopathic oligohydramnios indications for delivery include, but are not limited to,
nonreassuring CTG or reaching 37-38 wk.
... Alternatively, the patient can be followed with serial CTG & BPP until term gestation is reached;
the risks & benefits of various management plans should be discussed with the patient.
... Obtaining a short CTG recording upon admission of patients in labor to help determine whether
the FHR should be monitored continuously or whether intermittent monitoring is likely to be
sufficient.
Best Regards
#UpToDate_Lectures
90
Management of PPROM
Definition
- PROM: rupture membrane after 37 wk & before the onset of uterine contractions.
- PPROM: rupture membrane before 37 wk. It is the single most common identifiable factor
associated with preterm delivery.
Diagnosis
1. History of a sudden gush of clear or pale yellow fluid from the vagina, PLUS
2. Sterile Speculum showing pooling of fluid in the posterior vaginal fornix. If amniotic fluid is not
visible, ask the woman to push on her fundus, do Valsalva or cough to provoke leakage of AF from
the cervical os.
- Laboratory tests can be used to confirm the diagnosis when you are uncertain. Nitrazine test which
detect the pH of liquor or vaginal fluid is the most widely used (AF is alkaline, pH 7.0-7.3). See
image down.
- Commercial tests like ROM Plus: it can diagnose ROM by detection of 2 protein markers found in
AF: placental protein 12 & alpha-fetoprotein (AFP). ‫اﻟﺤﻤﺪ إﺳﺘﺨﺪﻣﺘﮫ ﻗﺒﻞ ﻣﺎ أﻣﻮت‬
- Don't do V/E, only do if patient is highly suspicious to be in labor to avoid the risk of infection
that can accelerate the preterm labor.
- U/S may confirm the diagnosis if there is oligohydramnios.
Course
- The majority of pregnancies with PPROM deliver within 1 wk of membrane rupture.
- The 3 causes of neonatal death are prematurity, sepsis & lung hypoplasia.
- The incidence of chorioamnionitis is higher at earlier GA.
Managament_From_23 wk_Till_37 wk
Hospitalization
- Hospitalization of women with PPROM who have a viable fetus from the time of diagnosis until
delivery is recommended with few exceptions.
- Activity should be limited to using the bathroom & sitting up in a bedside chair with
thromboprophylaxis.
- Further studies are needed to determine the safety of outpatient management.
Maternal Monitoring
- For signs of infection: monitor maternal temperature, pulse, & FHR every 4-8 hours.
- Periodically monitoring of WBCs & CRP has not proven to be useful.
91
Fetal Monitoring
- kick counts, CTG & biophysical profile (BPP): all have limited value in diagnosing infection.
Corticosteroids for pregnancies between 23-34 wk.

- It decrease neonatal death, RDS, intraventricular hemorrhage (IVH) & necrotizing enterocolitis
(NEC).
- A single rescue course (2 doses of 12 mg betamethasone or 4 doses of 6 mg dexamethasone) may
be considered with caution in pregnancies where the initial course was given at <26 wk & there is
another obstetric indication arises later in pregnancy.
- Multiple courses of steroids are not recommended as it may lead to possible harmful effects
including growth delay & brain developmental delay.
Prophylactic Antibiotic
- Reduces maternal & neonatal morbidity, delays delivery, allowing sufficient time for
corticosteroids to take effect.
- Amoxicillin-clavulanate (Augmentin) is ass. with increased risk of neonatal necrotizing
enterocolitis.
- RCOG recommends Erythromycin for 10 days following the diagnosis of PPROM. If group B
streptococcus is isolated, give penicillin or clindamycin in women who are allergic to penicillin.
- NICHD & MFMU recommend:
... Azithromycin 1 gm oral upon admission, PLUS
... Ampicillin 2 gm IV every 6 hr for 2 days, FOLLOWED BY
... Amoxicillin 500 mg oral 3 times daily for an additional 5 days.
This regimen cover Ureaplasmas, Chlamydia & GBS.
Chemoprophylaxis for GBS

- Group B streptococcus (Streptococcus agalactiae) is recognised as the most frequent cause of
severe early onset (<7 days of age) infection in newborn infants.
- Chemoprophylaxis for GBS is indicated if GBS test is positive or unknown & delivery is
imminent, but not given to women with recent (within 5 wk) negative GBS test.
- The NICHD regimen described above cover GBS already. After completion of this regimen,
antibiotics should be discontinued if patient is not in labor. If the patient's GBS culture is positive,
specific prophylaxis for GBS should be resumed when the patient subsequently goes into labor.
- RCOG recommend benzylpenicillin 3 gm IV as soon as possible after the onset of labour &1.5 gm
4-hourly until delivery. If patient is allergic to penicillin, give clindamycin 900 mg IV 8-hourly.
Tocolysis
- As a general rule, tocolytics shouldn't be administered for >48 hours, advanced labor (>4 cm) or
any findings suggestive of subclinical or overt chorioamnionitis.
- It is given for women with PPROM & uterine activity who require antenatal steroids.
- Do not offer prophylactic tocolysis if there is no uterine activity.
92
Special Situations
- Women with HSV, HIV or cerclage: expectant management is controversial ???
- Meconium stained liquor: meconium release predisposes to infection by enhancing the growth of
bacteria. So, these women should be evaluated for signs of chorioamnionitis. In the absence of these
signs, meconium alone is not an indication for intervention.
- Tissue sealants: ‫درب ﻣﻦ دروب اﻟﺨﯿﺎل‬
(See comment down)
- Amnioinfusion: still under research evaluation.
Overt Chorioamnionitis
- Diagnosed clinically by maternal fever especially when ass. with leukocytosis, maternal & fetal
tachycardia, uterine tenderness +/- malodorous AF.
- They should receive targeted antibiotics rather than the prophylactic antibiotics used above.
Delivery
- For PPROM <34 wk, RCOG recommend conservative management & delivery at 34 wk.
- For PPROM between 34-37 wk, ACOG & RCOG suggest delivery dt. the high risk of infection.
- According to ACOG, in pregnancies ≥34 wk, discuss the advantages & disadvantages of delivery
versus expectant management with the patient.
- Expeditious delivery of women with PPROM is appropriate in the case of intrauterine infection,
abruptio placentae or non-reassuring CTG particularly after 32 wk.
- MgSO4 is administered prior to delivery for fetal neuroprotection for pregnancies between 24-32
wk, for women at risk of imminent delivery.
(See comment down)
- CS is performed for standard indications; otherwise, labor is induced.
Best Regards
93
Management of Infected Cesarean section Wound
(Surgical Site Infection; SSI)
Diagnosis
- The diagnosis of wound infection is clinical.
- See the levels of SSI in image down.
- Localized erythema, induration, warmth & pain at the incision site +/- purulent discharge &
separation of the wound.
- Fever & leukocytosis in advanced cases.
- Necrotizing fasciitis: the most serious wound infection, can be lethal & is a surgical emergency. It
is ccc by a copious dishwater-like drainage, dusky & friable subcutaneous tissue & devitalized
fascia (see 2 images down).
Treatment
Incision Drainage
- A syringe filled with saline solution can be used to apply irrigation under pressure to remove loose
dead tissue & exudate.
- Saline is favored because it is an isotonic solution & doesn't interfere with the normal healing
process.
- The addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine & hydrogen peroxide)
is generally unnecessary as they have minimal action against bacteria & could potentially prevent
wound healing through toxic effects on normal tissue.
- Mechanical debridement is performed with forceps & scalpel or scissors.
- All foreign bodies & devitalized tissue are excised because they can delay healing & promote
infection.
‫ﻋﺎوزﯾﻦ ﻗﻠﺐ ﺟﺎﻣﺪ ﯾﺎﺷﺒﺎب‬
- Debridement is discontinued once necrotic tissue has been removed & granulation tissue is
present.
- Enzymatic debridement involves applying exogenous enzymatic agents to the wound like
Collagenase.
- Maggot therapy (‫ )اﻟﻌﻼج ﺑﺎﻟﯿﺮﻗﺎت‬can be used as a bridge between debridement procedures or for
debridement of chronic wounds when surgical debridement is not available or cannot be performed
(see image down).
See video in comments down.
- Iodine-based antiseptics reduces the bacterial load within the wound & stimulates healing by
providing a moist wound environment.
- Honey has been used since ancient times for the management of wounds. It has broad spectrum
antimicrobial activity due to its high osmolarity & high conc. of hydrogen peroxide.
‫ﻧﺘﺎﺋﺠﺔ ﺧﺮاﻓﯿﮫ وده طﺒﻌﺎ ً ﻋﺴﻞ اﻟﻨﺤﻞ ﻣﺶ ﻋﺴﻞ ﻗﺼﺐ اﻟﺴﻜﺮ ﻟﺪرﺟﺔ إن ﺑﻌﺾ ﺷﺮﻛﺎت اﻷدوﯾﮫ ﺑﺘﻌﺒﯿﺔ ﻋﻠﻰ أﺷﻜﺎل ﻣﺮاھﻢ وﺗﺒﯿﻌﮫ‬
‫ﻟﻠﻐﺮض ده‬.
94
- If fascial disruption is suspected, drainage should be performed in the operating room.
- Deep wounds may require packing. Gauze is moistened with normal saline & placed into the
wound & covered with dry layers of gauze. When the gauze is removed (preferably before it dries
out), necrotic tissue is removed with it, which provides a form of debridement.
- Once debridement is no longer necessary, the packing material should be changed from gauze to
one that is less traumatic to the developing granulation tissue & new epithelial cells.
- Dressing changes may be required up to 3 times daily & are continued until the wound surface is
mostly covered by granulation tissue.
Dressing
- Dressings that maintain moisture & warmth facilitate healing.
- Retention of moisture is important because wound fluids contain tissue growth factors that
facilitate reepithelialization & promote autolytic debridement.
- Once necrotic tissue has been removed & the wound is granulating, these dressings can be
changed once a day or every other day in order to avoid disturbing the healing process.
#Antibiotics
- All wounds are colonized with microbes; however, not all wounds are infected. Thus, antibiotic
therapy is not indicated for all wounds & should be reserved for wounds that appear clinically
infected.
- Wound infections associated with cellulitis alone (ie, no fluctuance) can be treated with a course
of antibiotics without open drainage.
- Definitive antimicrobial treatment is guided by the clinical response of the patient & the results of
gram stain & wound culture & sensitivity.
- Clinical signs of infection that warrant antibiotic therapy include local signs (cellulitis,
lymphangitic streaking, purulence, malodor, wet gangrene) & systemic signs (fever, chills, nausea,
hypotension, leukocytosis).
Delayed Closure
- Traditionally, wounds that have been opened due to infection are left to heal by secondary
intention.
- Closure significantly shortens the healing time.
Best Regards
#UpToDate_Lectures
95
96
Management of Intrahepatic Cholestasis of Pregnancy (IHC)
Pathogenesis
- There is defect in the excretion of bile salts, increase serum bile acids which increase deposition in
the skin causing intense pruritus.
- The cause of this defect in excretion is unknown or may be genetic.
Presentation
- Pruritus
... Occur without rash (exclude dermatological diseases).
... May affect all areas of the body but characteristically starts in palms & soles. ً ‫ﻋﻼﻣﺔ ﻣﻤﯿﺰة ﺟﺪا‬
‫ﻟﻠﺘﺸﺨﯿﺺ‬
... Often worse at night.
- Jaundice present in 10% only.
- Laboratory
... The most specific & sensitive marker of IHC is total serum bile acid >10 μmol/L.
... Mild elevation in liver enzymes: some used ALT & AST values >40 IU/L as partial criteria for
the diagnosis of IHC.
So, diagnosis of IHC can be made in the presence of pruritus without rash in the absence of liver
disease in pregnant pt. >25 wk with high serum bile acids &/or liver enzymes.
Follow Up
- Coagulation profile & liver enzymes should be monitored to measure progression of the disease.
- Total bile acid levels can be followed every 2-3 wk to guide therapy & timing of delivery.
Pregnancy Outcomes
- Perinatal mortality rate is increased when the mothers have severe disease with total bile acid
levels ≥40 μmol/L.
- Bile acids may cause fetal cardiac arrest after entering cardiomyocytes in high amounts.
Management
Antenatal Care
- Umbilical artery Doppler, BPP & NST to reduce the risk of stillbirth.
- Delivery is recommended at 37 wk dt. high risk of fetal mortality.
97
Drugs
- Antihistamines & topical emollients.
- Ursodeoxycholic acid: (y) (y) (y)
... It decrease pruritus, bile acids, liver enzymes, bilirubin & neonatal complications & allow
delivery closer to term.
... Mechanism of action: it inserts a transporter protein, improving bile salt export from the liver.
... Dose: 600-2000 mg/day. We usually use 300 mg, 3 times/day till delivery.
... It has no significant maternal adverse effects.
- Cholestyramine: XXX
- Vitamin K: 10 mg oral or IM & can be repeated in 12-48 hr.
Best Regards
#UpToDate_Lectures
98
Management of Small for Gestational Age (SGA) & IUGR

Definition
- A weight below the 10th percentile for GA.
- It may be constitutionally small
‫طﺎﻟﻊ ﻷﻣﮫ ﺟﺴﻤﮫ ﺻﻐﯿﺮ وﻟﻜﻦ ﻣﺶ ﺻﻐﯿﺮ ﺑﺴﺒﺐ ﻧﻘﺺ اﻟﺪم اﻟﻠﻲ راﯾﺢ إﻟﯿﺔ‬
- It may be symmetrical or asymmetrical.
- Symmetrical mean reductions in both body & head growth. This mostly has a very poor prognosis
dt restricted growth of all organs including CNS.
- Asymmetrical mean reduction in body weight with relatively normal head growth (brain sparing
effect).
‫ﯾﻌﻨﻲ ﺟﺴﻢ اﻟﺠﻨﯿﻦ ﺑﯿﻌﯿﺪ ﺗﻮزﯾﻊ اﻟﺪم ﻟﺼﺎﻟﺢ اﻟﺠﮭﺎز اﻟﻌﺼﺒﻲ ﻋﻠﻰ ﺣﺴﺎب ﻧﻤﻮ ﺑﺎﻗﻲ أﻋﻀﺎء اﻟﺠﺴﻢ ﻹن اﻟﺠﮭﺎز اﻟﻌﺼﺒﻲ إذا ﻟﻢ ﯾﺘﻜﻮن‬
‫ﻓﻲ ھﺬا اﻟﻤﺮﺣﻠﺔ ﻣﻦ ﺣﯿﺎة اﻟﺠﻨﯿﻦ ﻣﺶ ھﯿﺘﻜﻮن ﺗﺎﻧﻲ ﺣﺘﻰ ﺑﻌﺪ وﻻدة اﻟﻄﻔﻞ وھﯿﻨﺰل طﻔﻞ ﻣﻌﺎق ذھﻨﯿﺎ ً ﺑﯿﻨﻤﺎ ﺑﺎﻗﻲ أﻋﻀﺎء اﻟﺠﺴﻢ ﯾﻤﻜﻨﮭﺎ‬
‫اﻟﻨﻤﻮ ﻻﺣﻘﺎ ً ﺑﻌﺪ اﻟﻮﻻده ﺑﺎﻟﺘﺎﻟﻲ ﻧﻀﺤﻲ ﺑﮭﺎ ﻓﻲ ھﺬه اﻟﻔﺘﺮه اﻟﺤﺮﺟﮫ ﻣﻦ ﻧﻘﺺ اﻟﻐﺬاء‬.
- So, IUGR refers to a weight <10th percentile for GA due to a pathological process, while SGA
infant may be IUGR or constitutionally small.
Causes
- Any maternal or fetal or placental cause leading to decreased bl. supply to the baby or hypoxia.
Diagnosis
- The most common criteria for diagnosing IUGR is a fundal height that is at least 3 cm below the
GA in wk (e.g. fundal height 32 cm at 36 wk).
- Risk factors that raise the suspicion of IUGR:
... Significant lag of the fundal height on physical exam.
... Suboptimal growth on a prior U/S.
... History of a prior birth of a SGA infant.
... Poor maternal weight gain.
... Maternal conditions e.g. SLE, preeclampsia or HTN.
- Once the suspicion of IUGR has arisen because of risk factors or physical examination, U/S
should be used to confirm or exclude the diagnosis.
99
What We Will Look For in Scan
- The optimal time to screen for IUGR is at 34 wk.
- Abdominal circumference (AC): U/S estimation of fetal weight is the single best test to screen for
& diagnose IUGR. However, it is NOT as predictive of IUGR as U/S estimation of EFW. In IUGR,
the fetal AC is smaller than expected because of depletion of abdominal adipose tissue & decreased
hepatic size due to reduced glycogen storage in the liver.
- Estimated fetal weight (EFW): Fetal weight estimation is one of the most common methods of
identifying the IUGR fetus since pediatricians use birth weight as their primary variable for defining
growth restriction in the infant. Equations that incorporate AC, BPD & FL provide the most
accurate estimates of fetal weight.
- Growth velocity: If GA is unknown, serial U/S examinations at 2-wk intervals should be
performed to evaluate the rate of interval growth (i.e. growth velocity).
- Amniotic fluid volume: Oligohydramnios is one of the sequelae of IUGR due to hypoxia-induced
redistribution of blood flow to CNS at the expense of less vital organs such as the kidney leading to
decreased fetal urine production & oligohydramnios. So, presence of oligohydrmnios, suggest the
IUGR.
Umbilical Artery Doppler (differentiate bet. IUGR & SGA):
The Doppler has higher specificity & higher positive predictive value to diagnose IUGR compared
to measurement of the EFW by U/S.
‫ ﺷﺮﯾﺎن ﯾﺤﻤﻞ دم ﻣﻦ اﻟﺠﻨﯿﻦ ﻟﻠﻤﺸﯿﻤﮫ وورﯾﺪ واﺣﺪ ﯾﺤﻤﻞ دم ﻣﻦ اﻟﻤﺸﯿﻤﮫ ﻟﻠﺠﻨﯿﻦ‬2 ‫ﻣﺒﺪأﯾﺎ ً اﻟﺤﺒﻞ اﻟﺴﺮي ﯾﺘﻜﻮن ﻣﻦ‬
‫ﻟﻮ ﺷﺎﻛﻚ ﻓﻲ ﺣﺎﻟﺔ وﺑﻌﺘﮭﺎ ﺗﻌﻤﻞ ﺳﻮﻧﺎر ورﺟﻌﺘﻠﻚ ﺑﺪون ﻣﺎ ﺗﻌﻤﻞ اﻟﺪوﺑﻠﺮ رﺟﻌﮭﺎ ﺗﺎﻧﻲ ﺗﻌﻤﻞ اﻟﺪوﺑﻠﺮ ﻋﻠﺸﺎن ھﻮ ده اﻟﻠﻲ ھﺘﻌﺘﻤﺪ ﻋﻠﯿﺔ‬
‫ ﻓﻲ اﻟﻄﺒﯿﻌﻲ اﻟﺪم‬.‫ ﺑﺒﺴﺎطﮫ اﻟﺪوﺑﻠﺮ ﺑﯿﻈﮭﺮﻟﻚ ﺻﻮرة ﺗﺨﯿﻠﯿﺔ ﻟﺤﺮﻛﺔ اﻟﺪم داﺧﻞ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي‬.‫ﻓﻲ اﻟﺘﺸﺨﯿﺺ وطﺮﯾﻘﺔ اﻟﻌﻼج‬
‫ ﻣﻦ اﻟﻄﺒﯿﻌﻲ أﯾﻀﺎ ً أن ﯾﺘﺤﺮك اﻟﺪم‬.‫ﺑﯿﺘﺤﺮك ﻣﻦ اﻟﻄﻔﻞ وﯾﺮﺟﻊ ﻟﻠﻤﺸﯿﻤﮫ ﻋﻠﺸﺎن ﯾﺪﺧﻞ دم ﻏﯿﺮه ﻣﻦ اﻟﻤﺸﯿﻤﮫ ﻟﻮرﯾﺪ اﻟﺤﺒﻞ اﻟﺴﺮي ﻟﻠﻄﻔﻞ‬
.‫ﻓﻲ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي أﺛﻨﺎء اﻟﺴﯿﺴﺘﻮل واﻟﺪﯾﺴﺘﻮل ﻓﻲ إﺗﺠﺎة واﺣﺪ وھﻮ ﻣﻦ اﻟﻄﻔﻞ ﻓﻲ إﺗﺠﺎه اﻟﻤﺸﯿﻤﮫ ﺑﺪون ﺗﻮﻗﻒ‬.
- As the duration of pregnancy increases, the amount of blood flowing in the umbilical artery
increases during diastole. This means that the placenta is less resistant to blood flow, so providing
more blood to flow from the fetus to the placenta.
‫ﯾﻌﻨﻲ ﻣﻊ ﺗﻘﺪم اﻟﺤﻤﻞ ﺗﺘﻜﻮن أوﻋﯿﺔ دﻣﻮﯾﮫ واﺳﻌﮫ ﻓﻲ اﻟﻤﺸﯿﻤﮫ ﺗﺴﻤﺢ ﺑﺈﺳﺘﻘﺒﺎل ﻛﻤﯿﺎت ﻛﺒﯿﺮة ﻣﻦ اﻟﺪم اﻟﻠﻲ ﺟﺎي ﻣﻦ اﻟﺠﻨﯿﻦ وﺑﺎﻟﺘﺎﻟﻲ‬
‫ ﺑﺎﻟﺘﺎﻟﻲ ﻧﻤﻮ اﻟﻄﻔﻞ أﺳﺮع ﻓﻲ أواﺧﺮ اﻟﺤﻤﻞ ﻣﻘﺎرﻧﺔ ﺑﺒﺪاﯾﺔ‬،‫ﺗﻌﻄﻲ أﯾﻀﺎ ً ﻛﻤﯿﺎت ﻛﺒﯿﺮه ﻣﻦ اﻟﺪم ﻓﻲ ورﯾﺪ اﻟﺤﺒﻞ اﻟﺴﺮي ﻓﻲ إﺗﺠﺎه اﻟﺠﻨﯿﻦ‬
.‫اﻟﺤﻤﻞ ﺑﺴﺒﺐ ﻣﻀﺎﻋﻔﺔ ﻛﻤﯿﺎت اﻟﺪم اﻟﺘﻲ ﺗﺬھﺐ ﻟﻠﺠﻨﯿﻦ‬
- Reduced end diastolic flow due to increased umbilical artery resistance is seen when 30% of the
villous vasculature stop to function.
IUGR ‫ﯾﻌﻨﻲ ﻓﻲ ﺣﺎﻟﺔ‬
‫ ﺑﺎﻟﺘﺎﻟﻲ ﯾﺘﺤﺮك اﻟﺪم‬،ً ‫ﺗﻜﻮن اﻟﻤﺸﯿﻤﺔ ﺑﮭﺎ ﻣﺸﻜﻠﮫ ﺗﻤﻨﻊ إﺳﺘﻘﺒﺎل اﻟﺪم وﺗﻜﻮن ﻣﻘﺎوﻣﺘﮭﺎ ﻹﺳﺘﻘﺒﺎل اﻟﺪم ﻣﻦ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي ﻋﺎﻟﯿﺔ ﺟﺪا‬
‫ﻣﻦ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي ﻟﻠﻤﺸﯿﻤﮫ أﺛﻨﺎء اﻟﺴﯿﺴﺘﻮل ﻓﻘﻂ ﺑﺴﺒﺐ ﻗﻮة دﻓﻊ اﻟﺴﯿﺴﺘﻮل وﻟﻜﻦ أﺛﻨﺎء اﻟﺪﯾﺴﺘﻮل ﻻ ﯾﺴﺘﻄﯿﻊ اﻟﺪم إﺧﺘﺮاق‬
‫ ﻓﻔﻲ ﺑﺪاﯾﺔ اﻟﻤﻘﺎوﻣﺔ ﯾﻤﺮ اﻟﺪم أﺛﻨﺎء‬،(‫ﺗﺠﺎوﯾﻒ اﻟﻤﺸﯿﻤﮫ ﺑﺴﺒﺐ اﻟﻤﻘﺎوﻣﺔ اﻟﻌﺎﻟﯿﺔ ﺟﺪا ً ﻓﻲ اﻟﻤﺸﯿﻤﮫ )اﻟﻤﺸﯿﻤﮫ ﻧﺎﺷﻔﮫ ﯾﻌﻨﻲ ﻣﺶ زي اﻟﺴﻔﻨﺠﮫ‬
‫اﻟﺴﯿﺴﺘﻮل وﻛﻤﯿﺔ ﻗﻠﯿﻠﺔ ﻣﻦ اﻟﺪم أﺛﻨﺎء اﻟﺪاﯾﺴﺘﻮل وﯾﻈﮭﺮ ﻓﻲ اﻟﺪوﺑﻠﺮ ﻋﻠﻰ ﺷﻜﻞ ﻧﻘﺺ اﻟﺪم أﺛﻨﺎء ﻧﮭﺎﯾﺔ اﻟﺪﯾﺴﺘﻮل ﻗﺒﻞ ﺑﺪاﯾﺔ ﺳﯿﺴﺘﻮل ﺟﺪﯾﺪ‬
،‫وﻣﻊ زﯾﺎدة اﻟﻤﻘﺎوﻣﺔ ﻓﻲ اﻟﻤﺸﯿﻤﮫ ﯾﻨﻌﺪم ﻣﺮور اﻟﺪم ﺗﻤﺎﻣﺎ أﺛﻨﺎء اﻟﺪﯾﺴﺘﻮل وﯾﺨﺘﻔﻲ اﻟﺪم ﺗﻤﺎﻣﺎ ﻓﻲ اﻟﺪوﺑﻠﺮ أﺛﻨﺎء اﻟﺪﯾﺴﺘﻮل ﻛﻤﺎ ﺳﻨﺮى‬
‫ھﺬا ﯾﻌﻨﻲ إﻧﮫ ﻓﻲ ﺣﺎﻟﺔ إﺧﺘﻔﺎء دم اﻟﺪﯾﺴﺘﻮل ﻣﻦ اﻟﺪوﺑﻠﺮ أي إﻧﻌﺪام ﺣﺮﻛﺔ اﻟﺪم ﻣﻦ اﻟﻤﺮور ﻣﻦ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي إﻟﻰ اﻟﻤﺸﯿﻤﮫ أﺛﻨﺎء‬
‫اﻟﺪﯾﺴﺘﻮل ﻓﺈن اﻟﻤﺸﯿﻤﮫ ﺳﺘﻌﻄﻲ دم ﻟﻠﺠﻨﯿﻦ ﻋﻦ طﺮﯾﻖ ورﯾﺪ اﻟﺤﺒﻞ اﻟﺴﺮي أﺛﻨﺎء اﻟﺴﯿﺴﺘﻮل ﻓﻘﻂ ﯾﻌﻨﻲ اﻟﻄﻔﻞ ﻟﻦ ﯾﺴﺘﻘﺒﻞ أي دم ﻓﻲ ﺣﺎﻟﺔ‬
.‫اﻟﺪﯾﺴﺘﻮل وﺳﯿﻨﺘﻈﺮ اﻟﺴﯿﺴﺘﻮل ﻟﻜﻲ ﯾﺴﺘﻘﺒﻞ اﻟﺪم ﺛﻢ ﺗﺘﻮﻗﻒ ﺣﺮﻛﺔ اﻟﺪم ﻣﺮة اﺧﺮى أﺛﻨﺎء اﻟﺪﯾﺴﺘﻮل وھﻜﺬا‬
100
- Absent or reversed end-diastolic flow in the umbilical artery occurs when 60-70% of the villous
vasculature is obliterated & indicates poor fetal condition. Reversed diastolic flow is associated with
poorer neonatal outcomes than absent diastolic flow. These fetuses eventually show worsening
hypoxia, acidosis, loss of FHR variability & loss of fetal movement, breathing & tone.
‫ده ﺑﻘﻰ اﻟﺠﺰء اﻷﺻﻌﺐ وھﻮ إن اﻟﺪم اﻟﻠﻲ ﺑﯿﻌﺪي ﻣﻦ اﻟﺠﻨﯿﻦ ﻟﻠﻤﺸﯿﻤﺔ أﺛﻨﺎء اﻟﺴﯿﺴﺘﻮل ﻋﺒﺮ ﺷﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي ﺑﯿﺮﺟﻊ ﺗﺎﻧﻲ ﻟﻠﺠﻨﯿﻦ‬
‫ ﯾﻌﻨﻲ ﺑﺎﻟﺼﻼة ﻋﻠﻰ اﻟﻨﺒﻲ اﻟﺠﻨﯿﻦ ﻻ ﯾﺴﺘﻘﺒﻞ أي دم ﻣﻦ اﻟﻤﺸﯿﻤﺔ واﻟﺪم اﻷزرق اﻟﻠﻲ ﺑﯿﺮﺟﻌﮫ‬.‫أﺛﻨﺎء اﻟﺪﯾﺴﺘﻮل ﻋﺒﺮ ﻧﻔﺲ اﻟﺸﺮاﯾﯿﻦ‬
‫ﻟﻠﻤﺸﯿﻤﺔ ﻋﻠﺸﺎن اﻟﻤﺸﯿﻤﮫ ﺗﺪﺧﻞ دم أﺣﻤﺮ ﺑﺪاﻟﺔ ﻋﻦ طﺮﯾﻖ ورﯾﺪ اﻟﺤﺒﻞ اﻟﺴﺮي ﺑﯿﺮﺟﻊ ﺗﺎﻧﻲ زي ﻣﺎھﻮ أزرق ﻟﺸﺮاﯾﯿﻦ اﻟﺤﺒﻞ اﻟﺴﺮي‬
.‫وﻣﻔﯿﺶ دم ﺑﯿﺘﺤﺮك ﻣﻦ اﻟﻮرﯾﺪ ﻟﻠﺠﻨﯿﯿﻦ ﯾﻌﻨﻲ ﻟﻠﻲ ﻟﺴﺔ ﻣﺎ إﺳﺘﻮﻋﺒﺶ اﻟﺠﻨﯿﻦ ده ﺑﯿﺠﺎزب أو ﺑﯿﻄﻠﻊ ﻓﻲ اﻟﺮوح‬
.‫ﻓﯿﺔ أﻧﻮاع ﺗﺎﻧﯿﺔ ﻣﻦ اﻟﺪوﺑﻠﺮ ﺑﺘﺘﻌﻤﻞ وﻟﻜﻦ ﻣﺶ ھﺨﻮض ﻓﯿﮭﺎ ﻋﻠﺸﺎن ﻣﺤﺪش ﯾﺘﻠﺨﺒﻂ ﻣﻦ اﻟﻨﺎس اﻟﻠﻲ ﺑﺘﺴﻤﻊ اﻟﻜﻼم ﻷول ﻣﺮه‬
.
Antepartum Management
- Serial U/S at 2-4 wk intervals.
- Persistent growth deficiency in multiple examinations over many weeks strengthens the likelihood
of IUGR, while normal growth velocity in a small fetus suggests a constitutionally small but normal
fetus.
- Biophysical profile (BPP): It is a reliable test of FWB (fetal death within 1 wk of a normal test
score is rare). BPP is typically obtained 1-2 times/wk.
- Umbilical artery Doppler studies every 1-2 wk initially; if end diastolic flow is present & stable, it
can be repeated weekly to determine the pattern of progression.
- Daily BPP & Doppler are recommended if there is absent or reversed end diastolic flow in the
umbilical artery (impending cardiovascular & metabolic deterioration) & the fetus is not
immediately delivered because of extreme prematurity.
- One course of steroids is given between 24-34 wk in the week before delivery is expected.
- Maternal medical interventions:
... Bed rest in lateral position as it increases the uteroplacental flow.
... Treatment of the cause: e.g. preeclampsia.
... Stop smoking if she is smoker.
... Nutritional supplementation, oxygen therapy & interventions to improve blood flow to the
placenta such as bed rest, plasma volume expansion, low dose aspirin, heparin, β2-mimetics,
calcium channel blockers or sildenafil (all under trials).
... MgSo4: is given for fetuses <32 wk before delivery for neuroprotection.
... Aspirin: 81 mg/d can be used as prophylaxis as it improves the placental circulation.
Timing of Delivery
- If just high Doppler indices (RI, PI, S/D ratio) with normal or decreased umbilical artery end-
diastolic flow: deliver at ≥37 wk.
- If absent diastolic flow: immediately deliver at ≥34 wk.
- If reversed diastolic flow: immediately deliver at ≥32 wk.
- Try to delay delivery in those <32 wk with reversed flow & those <34 wk with absent flow unless
fetal surveillance is non-reassuring.
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102
A Look at Postcoital Bleeding
Cancer Cervix: the most serious cause of postcoital bleeding.

.. Colposcopy is indicated in women with abnormal cervical cancer screening tests or persistent
postcoital bleeding.
.. Once suspecting malignancy, refer to a gynecologic oncologist.
Cervical Ectropion (Ectopy/Erosion): see image down.

.. It occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu.
.. Vaginal discharge is the major complaint of women with symptomatic cervical ectropion;
postcoital bleeding is uncommon.
.. Ectropion is common in adolescents.
.. After adolescence, it may be observed in women who are pregnant or taking COC or who had a
cervical laceration during labor & delivery.
.. Cervical ectropion is common in pregnancy & may cause postcoital bleeding in pregnant women.
.. Ectropion should not be treated except in the rare occurrence of excessive mucous discharge or
spotting that is very bothersome to the woman.
.. In such cases, malignancy should be excluded before undertaking any treatment.
.. An ablative procedure using cryocautery or electrocautery is effective, but is invasive and will
result in copious vaginal discharge until healing is completed, which may take weeks.
.. Ablative treatment can also result in cervical stenosis, which can adversely affect future fertility
and, if pregnancy is achieved, labor and delivery.
.. As an alternative, we suggest a 2-week trial of an acidifying agent, such as boric acid
suppositories 600 mg vaginally at bedtime, which may be effective
(Read comment down for more details).
Cervical Polyps: see image down.

.. Cervical polypectomy is performed for polyps that are symptomatic, large ≥3 cm or appear
atypical.
.. Removal can usually be accomplished by grasping the base of the polyp with forceps and twisting
it off.
.. Cauterizing the base prevents bleeding and reduces the chance of recurrence.
Cervicitis
.. Cervicitis is associated with purulent or mucopurulent discharge, but postcoital bleeding may also
occur.
.. The most common etiology is chlamydial infection (image down).
#UpToDate_Lectures
103
104
Understanding Menopause (Lesson 1)
Late Reproductive Years

- It is the period before the onset of the menopausal transition.
- Serum FSH increases slightly, E2 is preserved, but luteal phase progesterone decrease as fertility
potential begins to decline.
- Menstrual cycles are ovulatory, but the follicular phase (the first half of the menstrual cycle before
ovulation occurs) begins to shorten (eg, 10 versus 14 days). ‫اﻟﺪوره ﺑﺘﯿﺠﻲ ﻛﺘﯿﺮ‬
- The cycles begin to shorten typically in 40s.
Perimenopause (Menopausal Transition)

- Occur dt. continuation of the process of ovarian follicular depletion.
- Occurs on average at age 47 years.
- Begins on average 4 years before the final menstrual period (FMP) & includes a number of
physiologic changes that may affect a woman's quality of life.
- Women typically first notice a lengthening in the intermenstrual interval (in contrast to the
shortening that occurs in the late reproductive years). Beside, the transition is characterized by a
gradual decrease in menstrual bleeding
‫ﯾﻌﻨﻲ اﻟﺪوره ﺑﺘﺘﺄﺧﺮ وﺗﻨﺰل ﻛﻤﯿﺎت دم ﻗﻠﯿﻠﺔ‬
- Normal intermenstrual interval during the reproductive years is 25-35 days; during the menopausal
transition, this may increase to 40-50 days.
- After the initial lengthening of intermenstrual interval, women then develop skipped cycles,
episodes of amenorrhea & increasing frequency of anovulatory cycles.
- A random serum sample may demonstrate high FSH & low E2 consistent with menopause, but
soon thereafter, FSH & E2 may return to the normal premenopausal range.
- One study reported that a random serum FSH >25 IU/L is characteristic of the late menopausal
transition.
- Other endocrine changes across the menopausal transition include a progressive decrease in serum
inhibin B, AMH & the ovarian antral follicle count (follicles measuring 2-10 mm in diameter on
transvaginal U/S). All of them are used to assess the ovarian reserve.
Menopause
- After the years of menstrual irregularity, women eventually experience permanent cessation of
menses.
- 12 months of amenorrhea is considered to represent the clinical menopause & is termed
"Postmenopause".
105
- Although the median age at natural menopause is 51.4 years, the timing of menopause is affected
by a number of factors including genetics.
- Menopause before age 40 years is considered to be abnormal and is referred to as primary ovarian
insufficiency (premature ovarian failure).
- The increase in serum FSH becomes sustained near the final menstrual period (FMP).
- The hallmark symptom of the menopausal transition/perimenopause & early postmenopausal years
is the hot flash.
- Up to 80% develop hot flashes (the most common menopausal symptom), but only 20-30% seek
medical treatment.
- Hot flashes typically begin as the sudden sensation of heat centered on the upper chest & face that
rapidly becomes generalized. The sensation of heat lasts from 2-4 minutes, is often ass. with profuse
sweating & occasionally palpitations & feeling of anxiety. Hot flashes usually occur several times
per day & common at night.
- Women may experience other symptoms including vaginal dryness, sleep disturbances, new-onset
depression, joint pain & breast pain.
- Long-term consequences of estrogen deficiency include bone loss, cardiovascular disease,
dementia & osteoarthritis.
To be Continued....
#UpToDate_Lectures
106
Evaluation & Diagnosis of Menopause (Lesson 2)
Evaluation
- The Stages of Reproductive Aging Workshop (STRAW) staging system: used primarily for
women's health research.
Women_Over_45_Years
- For women >45 yr who present with irregular menstrual cycles with menopausal symptoms such
as hot flashes, mood changes or sleep disturbance, DON'T do FSH, as they are highly likely to be in
the menopausal transition (perimenopause).
- We diagnose menopause as 12 months of amenorrhea in the absence of other causes. A high serum
FSH is not required to make the diagnosis.
- Although serum FSH is often measured, it is not necessary to make the diagnosis, & if normal, it
may be misleading.
- Occasionally, woman >45 yr will have irregular cycles & no other symptoms suggestive of the
menopausal transition. For these asymptomatic women with irregular periods, a serum FSH >15-25
IU/L would be reassuring that this is simply the menopausal transition & nothing else.
- The possibility of pregnancy must always be considered in amenorrhea.
Women_Between_40_45_Years
- For women between 40-45 yr who present with irregular menstrual cycles +/- menopausal
symptoms, endocrine evaluation is suggested as for any woman with oligo/amenorrhea.
- Although the presence of hot flashes with irregular menses strongly suggests the menopausal
transition, looking for other possible causes of oligo/amenorrhea is suggested in this age group.
- Do Pregnancy Test, TSH & Prolactine.
- Hyperthyroidism should always be considered in the differential diagnosis, as irregular menses,
sweats & mood changes are all potential clinical manifestations of hyperthyroidism.
Women_Under_40_Years
- Complete evaluation for irregular menses is necessary to exclude the primary ovarian
insufficiency (POI).
- In POI, the presence of amenorrhea is not required to make the diagnosis, as women frequently
have intermittent ovarian function & spontaneous menses.
- Measurement of serum FSH can be misleading in women with POI who still have intermittent
ovarian function, as it can be in the normal range during ovulatory cycles but in the postmenopausal
range when experiencing oligo/amenorrhea.
107
- If one suspects occult POI, measure FSH on cycle day 3 in women with menstrual cycles, & for
women with amenorrhea, the sample can be drawn on a random day.
- The presence of hot flashes &/or vaginal dryness is suggestive of POI.
Atypical Hot Flashes
- For women of any age with atypical hot flashes or night sweats, evaluation for other disorders
such as carcinoid & pheochromocytoma is indicated.
Women Taking COC

- Oral estrogen-progestin contraceptives are considered to be safe in nonsmokers up to the age of
menopause (50-51 yr).
- We typically stop the pill by age 50-51 years, when the chance of conceiving is extremely low.
- Women taking them want reassurance that they are postmenopausal before stopping. However, it
is difficult to determine if menopause has occurred because these women don't develop the irregular
bleeding or vasomotor symptoms that are typical of the menopausal transition.
- In addition, because their hypothalamic-pituitary axis is suppressed by the high dose of exogenous
estrogen, measurement of the serum FSH level is unreliable.
- Stopping the pill & measuring serum FSH 2-4 wk later is suggested. A level ≥25 IU/L indicates
that the patient has likely entered the menopausal transition.
Posthysterectomy or Endometrial Ablation

- Menopause in women who have undergone hysterectomy or endometrial ablation cannot be
determined using menstrual bleeding criteria.
- A serum FSH >25 IU/L with hot flashes, is suggestive of the late menopausal transition. For a
postmenopausal woman, FSH would be higher (70-100 IU/L).
To be continued....
#UpToDate_Lectures
108
Management of Menopausal Hot Flashes (Lesson 3)

(Feeling of Warmth)
General Knowledge
- It occur in approximately 75-80% of menopausal women.
- It often begin in the perimenopausal period, although, in some women, they do not begin until
after menopause.
- Hot flashes are mediated by thermoregulatory dysfunction at the level of the hypothalamus & are
induced by estrogen withdrawal.
- The feeling of warmth results from inappropriate peripheral vasodilatation with increased digital
& cutaneous blood flow.
- Acc. to SWAN study, the median total vasomotor symptoms duration is 7.4 years.
- Risk factors: Obesity & Reduced physical activity. ‫اﻟﻤﺮأة اﻟﻌﺮﺑﯿﮫ‬
Symptoms
- Sudden sensation of heat centered on the upper chest & face that rapidly becomes generalized.
- It lasts from 2-4 minutes & often associated with profuse sweating & occasionally palpitations.
- Sometimes followed by chills, shivering & a feeling of anxiety.
- This can cause significant sleep disturbances in many women.
Management
Simple Measures ‫ﺧﻠﯿﮭﺎ ﺗﺮطﺐ اﻟﺠﻮ‬
- Lower room temperature, use fans, dressings that can be easily shed & avoiding triggers such as
spicy foods & stressful situations. For some women, this is enough.
‫وﺧﻠﯿﮭﺎ ﺗﺨﺲ ﺑﺮدو ﻋﻠﺸﺎن طﺒﻘﺎت اﻟﺪھﻮن ﺑﺘﺤﺮر‬
Menopausal Hormone Therapy (MHT)

- It describe unopposed Estrogen Therapy (ET) for women who have undergone hysterectomy OR
Combined Estrogen-Progestin Therapy (EPT) for women with an intact uterus who need a progestin
to prevent estrogen-associated endometrial hyperplasia.
The goal of MHT

- Goal is to relieve menopausal symptoms, most importantly hot flashes (vasomotor symptoms).
Other symptoms that respond to ET include depression, vaginal atrophy & in some cases, joint
aches & pains.
- Women being treated for menopausal symptoms such as hot flashes require systemic estrogen;
women being treated only for vulvovaginal atrophy should be treated with low-dose vaginal
estrogen.
109
Contraindications to MHT:
- CI are history of breast cancer, CHD, a previous VTE or stroke, history of thrombophilias, active
liver or gallbladder disease, unexplained vaginal bleeding, high-risk endometrial cancer or transient
ischemic attack.
- The MHT is considered to be a safe option for healthy, symptomatic women who are within 10
years of menopause or <60 years & who do not have contraindications to MHT.
- Although there are alternative therapies for vasomotor symptoms, none are as effective as
estrogen.
- Although Estrogen was previously recommended as a first-line choice for prevention & treatment
of osteoporosis, now bisphosphonates is the recommended one.
Dose: Premarin tab 0.625/1.25 mg (conjugated estrogen)

Start with oral conjugated estrogen 0.625 mg/day. This regimen will relieve symptoms for most
women. Estrogen should be administered continuously without off days.
Common side effects of Estrogen include breast tenderness which can often be minimized by using
lower doses. ‫ﻧﺼﻒ أو رﺑﻊ ﻗﺮص‬
Vaginal bleeding occurs in almost all women receiving cyclic Estrogen-Progestin regimens & is
common in the early months of use.
- If Estrogen patch is available, use it dt. less side effects.
Adding Progestin
.. All women with an intact uterus need a progestin in addition to estrogen to prevent endometrial
hyperplasia, which can occur after 6 months of unopposed ET. Women who have undergone
hysterectomy should not receive progestin (No Benefit).
.. The first choice of progestin is the natural micronized progesterone (Progest or Prometrium) 200
mg/day for 12 days/month or 100 mg daily.
.. For women who are perimenopausal or newly menopausal, start with cyclic administration of oral
Prometrium 200 mg/day for 12 days of each calendar month. Continuous administration in this
population is associated with irregular, unscheduled bleeding dt. the exogenous hormones & the
continued endogenous ovarian function.
‫ ﯾﻮم ﺑﺲ آﺧﺮ اﻟﺸﮭﺮ ﻋﻠﺸﺎن ﯾﺤﺼﻠﮭﻢ دورة زي اﻟﻠﻲ ﻛﺎﻧﺖ ﺑﺘﺤﺼﻞ زﻣﺎن‬12 ‫ﻛﻔﺎﯾﺎ ﻋﻠﯿﮭﻢ‬.
.. For women who are ≥2-3 years postmenopause (No more ovarian function), use a continuous
regimen Prometrium. While there is often early breakthrough bleeding even after menopause, most
women do eventually develop amenorrhea (a desired goal of continuous administration). This
continuous regimen is also recommended for those who don't like to experience any synthetic
cycles.
‫ واﻟﺒﺪﯾﻞ‬.‫ﻟﻮ اﻟﺴﺖ دي ﺑﺘﻜﺮه اﻟﺪوره وﻣﺶ ﻋﺎوزه ﺗﺸﻮف دم أو ﺑﺪأت ﻋﻠﯿﮭﺎ أﻋﺮاض اﻹﻛﺘﺌﺎب ﺧﻠﯿﮭﺎ ﺗﺴﺘﻤﺮ ﻋﻠﻰ اﻟﺤﺒﻮب ﺑﺪون إﻧﻘﻄﺎع‬
‫ﻣﻔﯿﺶ دراﺳﺎت ﻛﺎﻓﯿﺔ( وﺗﻤﺸﻲ ﻋﻠﻰ ﺣﺒﻮب‬-‫ ﺳﻨﮫ‬55 ‫ﻟﺤﺒﻮب اﻟﺒﺮوﺟﺴﺘﯿﺮون ھﻨﺎ ھﻮ اﻟﻤﯿﺮﯾﻨﺎ )أﯾﻮه ﻧﺮﻛﺐ ﻟﻮﻟﺐ ﻟﺴﺖ ﻋﻨﺪھﺎ‬
‫اﻟﺒﺮﯾﻤﺎرﯾﻦ ﺑﺲ ﻣﻊ اﻟﻠﻮﻟﺐ‬.
110
.. One of the commercial products is Climen tablets that contain 2 active ingredients: Estradiol
Valerate 2 mg & Cyproterone Acetate 1mg (progestogen & anti-androgen) that are used for 2-phase
sequential HRT. The calendar pack of Climen tablets contains:
* 11 tablets of Estradiol Valerate 2 mg.
* 10 tablets of Estradiol Valerate 2 mg + Cyproterone Acetate 1 mg.
It is taken once daily, at the same time each day. When you have finished the pack take 1 week off,
then start over. It shouldn't be used as a COC because it does't prevent ovulation.
Duration of therapy by Estrogen or combined EPT is generally not more than 5 years or not
beyond age 60 years. For women who experience recurrent, bothersome hot flashes after stopping
estrogen, non-hormonal options are suggested.
- Routine mammograms & breast exams are recommended during therapy.
- Use of COC during the menopausal transition: when women taking a low-dose COC during
perimenopause reach age 50-51 years, we discuss stopping the pill or change it to a postmenopausal
MHT if necessary for symptoms. Because women at this age are apt to have hot flushes when
estrogen is stopped abruptly, taper the COC by one pill per week.
Primary Ovarian Insufficiency (menopause <40 years)

Hormone therapy is started at a younger age in these women & therapy should be continued until
the average age of menopause (50-51 years) to prevent premature bone loss, coronary heart disease
& stroke. At that point, if hormone therapy is stopped & menopausal symptoms are moderate to
severe, the same discussion of MHT should take place.
SSRI
- Paroxetine 10-20 mg/day tablet.
- For women who have contraindications for MHT or don't like to use it.
- Rapid response.
- Effective & can be used in women with breast cancer.
- Paroxetine is the only agent that has received approval by the FDA for the treatment of hot flashes
(still it is week for hot flashes )
- Another option is Citalopram.
- Women should be instructed to taper SSRIs to avoid drug withdrawal symptoms.
- In women whose hot flashes occur primarily at night, it was found that a single dose of
Gabapentin (Antiepileptic drug) given at bedtime often relieves the hot flashes that awaken patients
from sleep. Starting with 100 mg 1 hour before bedtime & increasing by 100 mg every 3 nights
until relief of hot flashes, side effects or a maximum of 900 mg (300 mg TID). At much higher
doses, Gabapentin may be as effective as estrogen but it is limited by its side effects.
111
Tibolone (Livial)
- Tibolone is a synthetic steroid whose metabolites have estrogenic, androgenic, and progestogenic
properties.
- It has a beneficial effect on bone mineral density.
- It is more effective than Estrogen/Progestin Therapy for treatment of sexual dysfunction in
postmenopausal women.
- However, tibolone has been associated with an increased risk of stroke & possibly breast cancer,
so it is not recommended for routine use for hot flashes.
Norethindrone Acetate (Primulot-N)

Primulot-N at an oral dose of 10 mg daily also appears to be effective for hot flushes.
Placebo Effect
It can reduce hot flashes by approximately 20-50%.
‫إﻛﺘﺒﻠﮭﺎ ﻋﻠﻰ ﺳﻮداﻧﻲ ﻣﺘﻌﺒﻲ ﻓﻲ إﻛﯿﺎس ﻣﻐﻠﻔﮫ وﻗﻮﻟﮭﺎ إﺑﻠﻌﻲ واﺣﺪه ع اﻟﺮﯾﻖ ھﺘﺨﻒ ﻣﻦ اﻟﺼﮭﺪ وﺗﺮﺟﻌﻠﻚ ﺑﺈﻧﺘﻔﺎخ‬.
Finally
- For perimenopausal women who have hot flashes while still having menstrual cycles ie, during the
late menopausal transition, give them low dose COC as described above.
- Coexisting depression in women with significant hot flashes often require treatment with both
MHT & antidepressants (usually SSRIs).
- Review comments for important discussions.
Best Regards
#UpToDate_Lectures
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Management of Atrophic Vaginitis
Symptoms
- Vulvovaginal symptoms: vaginal dryness, burning, pruritus, dyspareunia, vaginal discharge,
bleeding or spotting.
- Urinary tract symptoms: dysuria, urinary frequency, infrequently, hematuria.
Lubricants (K-Y gel)

- Symptoms of vaginal dryness can be managed by regular use of vaginal lubricants for sexual
intercourse, but they do not reverse the atrophic vaginal changes.
Estrogen Therapy
- Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy.
- Adequate estrogen therapy leads to restoration of the normal vaginal acidic pH & microflora,
thickening of the epithelium, increased vaginal secretions, decreased vaginal dryness, reduction in
the incidence of UTI & overactive bladder symptoms.
- Estriol suppository or cream is available in most of our countries in Middle East. Also, there is
Premarin cream.
- In our practice, we use cream for women who have symptomatic vulvar atrophy (eg, fissures), so
that cream may also be applied to areas of the vulva affected by atrophy. We start with daily dosing
for 2 weeks, then change to twice weekly.
- The dose & duration of treatment needed to improve symptoms vary across patients & should be
individualized according to the woman's degree of vaginal atrophy symptoms. Low dose vaginal
estrogen therapy may be used indefinitely, based upon the low risk of adverse effects, although
clinical trials to date have not followed women beyond 1 year.
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Assessment of the Ovarian Reserve

Background
- Diminished ovarian reserve refer to diminished oocyte quality, oocyte quantity or reproductive
potential.
- However, there is no ideal test for assessing ovarian reserve. A number of screening tests are
utilized, but no single test is highly reliable for predicting pregnancy potential. So, coordination of
tests provides the best assessment.
Woman Age
- A woman’s fertility starts decreasing in her late twenties, and decreases further after age 35.
- By age 45, the chance of pregnancy is very low, especially in a woman who has not conceived
after 6-12 months of attempts.
- The most important lesson from all this is that once a woman is in a place in life where she is
ready to have children, she should not delay the process.
Serum FSH
- A “good quality” egg releases certain substances (inhibin-B & estrogen) that suppress the FSH
level (negative feedback).
- When the egg quality is poor, these negative feedback signals are weak & there is a resultant
increase in FSH levels.
- An elevated FSH level therefore is an indirect indicator of compromised egg quality.
- Generally, an FSH level <8 mIU/mL is considered to be normal. The upper threshold for a normal
FSH level is laboratory dependent; cutoff values of 10-25 mIU/mL have been reported because of
use of different FSH assay reference standards & assay methodologies.
- Pregnancy rates drop when FSH levels >10 mIU/mL & are further reduced when FSH levels >15
mIU/mL.
- It is important to realize that FSH levels have low sensitivity i.e an abnormal high level signify
“diminished ovarian reserve”. However, a normal level doesn't signify that everything is okay. For
example, a 45 year old woman may have an FSH level of 7 mIU/mL but is NOT as fertile as a 25
year old with the same FSH level. So, it is important to evaluate the FSH level in the context of the
full fertility evaluation.
- When FSH levels are measured repeatedly, they can vary significantly from cycle-to-cycle. For
example, a patient with an FSH level of 12 mIU/mL one cycle may have a normal FSH level in the
next cycle. The ovarian reserve has to be significantly compromised for the FSH levels to be
persistently elevated.
- Some women with elevated FSH levels can conceive naturally. A high FSH level simply indicates
that this is less likely to get pregnant. However, women who conceive despite an elevated FSH level
have an increased risk of miscarriage.
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- An elevated FSH mean that achieving a successful pregnancy with any type of fertility treatment
including IVF will be compromised. At the same time, a mild elevation in the FSH level may be a
reason to pursue infertility treatment more aggressively & proceed directly to IVF.
Clomiphene Citrate Challenge Test (CCCT)

- This is a “stress test” for the ovary.
- It involves giving the patient 2 tablets 50 mg of Clomid or daily from days 5 to 9 of the menstrual
cycle. FSH & Estradiol levels are measured on day 3 & FSH alone on day 10.
- In women with good ovarian reserve, there will be sufficient production of ovarian hormones (E2)
from the small follicles early in the menstrual cycle to maintain FSH at a low level. In contrast,
women with a reduced pool of follicles & oocytes will have insufficient production of ovarian
hormones to provide normal inhibition of pituitary secretion of FSH, so FSH rises.
- E2 value <80 pg/mL is suggestive of adequate ovarian reserve, but other cut-offs are also utilized.
In one prospective study of women undergoing IVF, day 3 E2 levels >80 pg/mL resulted in higher
cycle cancellation rates & lower pregnancy rates. Also, estradiol levels >100 pg/mL were associated
with a 0% pregnancy rate.
- Elevated basal E2 levels are due to advanced premature follicle recruitment with early ovulation
that occurs in women with poor ovarian reserve dt. decreased inhibin B secretion which is
responsible to inhibit FSH.
So, poor ovarian reserve> decrease inhibin B level> increase FSH level> premature follicle
recruitment> increase estrogen more than 80 pg/mL> inhibit FSH & mask its high level. So,
measurement of both FSH & E2 levels helps to avoid the false-negative FSH testing. ‫ﯾﻌﻨﻲ ﻟﻮ واﺣﺪ ﻓﯿﮭﻢ‬
‫ﻋﺎﻟﻲ ﺟﺪا ﯾﺒﻘﻰ اﻟﻤﺒﯿﺾ ﺗﻌﺒﺎن‬
- Finally, a high day 10 FSH levels >10-15 mIU/mL are strongly predictive of decreased IVF
success even when day 3 FSH levels are normal.
- If the day 3 FSH or CCCT is abnormal, the patient should be referred to a reproductive
endocrinologist to discuss further diagnostic & treatment options.
‫ﯾﻌﻨﻲ اﻟﺠﻮﻧﺎدوﺗﺮوﻓﯿﻦ ﻋﺎﻟﻲ ﻣﻦ اﻟﯿﻮم اﻟﺜﺎﻟﺚ ﻣﻦ ﻗﺒﻞ ﻣﺎ ﻧﺤﻂ اﻟﻤﺒﯿﺾ ﺗﺤﺖ ﺿﻐﻂ إﻧﻨﺎ ﻧﻤﻨﻊ اﻹﺳﺘﺮوﺟﯿﻦ ﺑﺎﻟﻜﻠﻮﻣﯿﺪ وﻧﺰود‬
‫ ﺑﺮدو‬10 ‫اﻟﺠﻮﻧﺎدوﺗﺮوﻓﯿﻦ اﻟﻠﻲ ﻣﻔﺮوض ﻣﺎ ﺗﺰﯾﺪش ﻋﻦ‬
- Once again, a normal CCCT does not necessarily mean that the ovarian reserve is normal. A 45
year old with a normal CCCT will not be as fertile as a 25 year old.
Antral Follicle Count (AFC)

- A normal ovary should have a volume of at least 3 cc with at least 8-12 antral follicles.
- The counts:
Count <4 indicate poor reserve.
Count 4-7 is low, so high dosage of FSH required.
Count 8-12 indicate a slightly reduced reserve.
Count >12 is normal.
- Antral follicles are small (2-10 mm in diameter on transvaginal U/S before Gn stimulation.), fluid
filled cysts that are normally found in the ovaries.
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- The higher the antral follicle count, the better the fertility potential.
- Small ovaries may indicate compromised fertility potential, as there may be less follicles &
therefore less eggs available within the ovaries.
- Generally, when the baseline U/S at the start of an IVF cycle shows reduced ovarian volume or
AFC, increase the dose of the stimulation medications to achieve an optimal response. Also, if there
are plenty of AFC (>15-20), the dose of stimulation medications is reduced to minimize the risk of
ovarian hyperstimulation syndrome.
Anti-Müllerian Hormone (AMH)
- AMH levels decrease over time even in fertile women who have regular menstrual cycles. So,
AMH is undetectable at menopause.
- Recent data suggest that AMH levels may reflect fertility potential more accurately than
conventional markers like FSH, inhibin-B or estradiol levels.
- AMH levels correlate well with the ovarian AFC & were the only levels that decreased
longitudinally over time compared with FSH, estradiol & inhibin-B levels.
- With ovarian aging, the first change is a decrease in AMH levels, followed by a decline in inhibin-
B & finally by an increase in FSH levels.
- AMH levels do not vary significantly during the menstrual cycle. So, can be measured on any day
of the cycle.
- Women who are overweight have 65% lower AMH levels than thin women, indicating that obesity
may be associated with decreased ovarian reserve +/- ovarian dysfunction.
- Factors that increase AMH include Polycystic Ovarian Syndrome.
- AMH levels <0.5 ng/mL are associated with increased IVF cycle cancellation rates & fewer eggs
retrieved from the ovaries.
- AMH levels >1.0 & < 3.5 ng/mL suggests a good response to stimulation ng/mL are associated
with greater number of eggs retrieved &a better fertility potential.
- A high AMH level >3.5 ng/mL may predict that a woman is at increased risk for ovarian
hyperstimulation syndrome. In such women, the dose of medications with IVF can be reduced to
avoid this side effect of fertility treatments.
- It is important to note that no one test can predict with 100% certainty whether a woman will
succeed in achieving a pregnancy. All of these tests, when taken together, allow reproductive
specialists to counsel patients appropriately, and to fine tune a treatment plan that is specific to a
woman’s particular fertility potential.
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Management of Uterine Fibroid (Lecture 1)

PRESENTATIONS (History)
• The majority of myomas are small & asymptomatic, but many women with fibroids have
significant problems that need therapy.
Heavy Prolonged Menses
• The most common symptom.
• Intermenstrual bleeding or postmenopausal bleeding should prompt investigation to exclude
endometrial pathology.
• It is important to keep in mind that a woman may have fibroids & may also have endometrial
neoplasia.
• Submucosal fibroid that protrude into the uterine cavity (eg, types 0 & 1) are most frequently
related to significant heavy menstrual bleeding.
Bulk Related Symptoms

• Chronic, intermittent, dull aching pelvic pain.
• Urinary tract or bowel compression acc. to the site & size of fibroid.
Infertility
• Fibroids that distort the uterine cavity (submucosal or intramural with an intracavitary component)
result in difficulty conceiving a pregnancy & an increased risk of miscarriage.
EXAMINATION
• Anemic patient dt. bleeding.
• The abdominal examination should include palpation for a pelvic-abdominal mass.
• The level of the uterine fundus should be noted e.g fundal level is 20 wk if at umbilicus & 12 wk if
at symphysis pubis & at 16 wk if in between.
• An enlarged, mobile uterus with an irregular contour is consistent with a leiomyomatous uterus.
• Infrequently, on speculum examination, a prolapsed submucosal fibroid is visible at the external
cervical os. Prolapsed fibroid is distinguished from a large endocervical or endometrial polyp by the
firm consistency of the tissue & by pathology evaluation.
IMAGING
The indication for pelvic imaging typically includes symptoms of AUB, pelvic pain, pelvic
pressure, infertility or women who have an enlarged uterus on examination.
Ultrasound
• Pelvic U/S is the first-line study used to evaluate for uterine fibroids.
‫أول ﺧﻄﻮة ﻟﻠﺘﺸﺨﯿﺺ ﺑﻌﺪ ﺷﻜﻮى اﻟﺪم‬.
118
• Fibroids usually seen as hypoechoic, well-circumscribed round masses, frequently with
shadowing.
• The calcifications may appear as clumps or rim-like calcifications within a mass. In general, if
compared with an old picture for the fibroid, the fibroid size will be smaller once it calcifies.
• If there is an intracavitary fibroid (submucosal or intramural that protrudes into the uterine cavity)
or if you are not sure about how much the fibroid is protruding into the uterine cavity, then saline
infusion sonography (sonohysterography) or hysteroscopy may be used to evaluate the uterine
cavity.
‫اﻟﺨﻄﻮة اﻟﺜﺎﻧﯿﺔ وھﻲ ﺗﻘﯿﯿﻢ ﺗﺠﻮﯾﻒ اﻟﺮﺣﻢ ﻟﺘﺤﺪﯾﺪ ﻧﻮع اﻟﻌﻤﻠﯿﺔ‬
Saline Infusion Sonography (Sonohysterography)
• It is an imaging study in which pelvic U/S is performed while saline is infused into the uterine
cavity. It allows identification of submucosal lesions (some of which may not be seen on routine
U/S) & intramural myomas that protrude into the cavity & determine the extent of protrusion into
the endometrial cavity. It is helpful when planning a hysteroscopic resection of a fibroid.
Diagnostic Hysteroscopy
• It is useful for visualizing the endometrial cavity. Similar to saline infusion sonography, it
determine the extent of protrusion into the endometrial cavity. When the entire fibroid is visualized
arising from a pedicle or has a broad base, the lesion is hysteroscopically classified as intracavitary.
Hysteroscopy less accurately predicts the size of the myoma compared with U/S &
sonohysterography.
‫ﻛﺎﻣﯿﺮا اﻟﻤﻨﻈﺎر ھﺘﺰﻧﻘﻚ ﺑﻤﺠﺎل ﺿﯿﻖ ﻟﻠﺮؤﯾﺔ وﻣﻦ زاوﯾﺔ واﺣﺪه ﺑﺎﻟﺘﺎﻟﻲ ﻣﺶ ھﺘﻌﺮف ﺗﻘﯿﯿﻢ اﻟﺤﺠﻢ اﻟﺤﻘﯿﻘﻲ ﻟﻠﱡﻮﻓﮫ‬.
• Hysteroscopy can help in the planning of a hysteroscopic resection of a submucosal fibroid if U/S
has already confirmed the size & the relation to the cavity & rule out of small polyps not seen on
U/S.
MRI
• It is the most effective modality for visualizing the size & location of all uterine myomas & can
distinguish among leiomyomas, adenomyosis & adenomyomas.
• Due to the expense of MRI, its use is best reserved for procedural planning for complicated
procedures. For example, for women with type 3 through 6 uterine fibroids, MRI can help the
surgeon planing laparoscopic myomectomy to know the expected depth into the myometrium.
To be continued....
#UpToDate_Lectures
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- After diagnosis of uterine fibroids by U/S alone or together with saline infusion sonography
(sonohysterography) or hysteroscopy, we have to manage.
EXPECTANT_MANAGEMENT
- Asymptomatic women in accidentally discovered cases can be managed only by reassurance
without any interventions.
- Fibroids shrink & regress substantially during the postpartum period & during menopause, so
expectant management is a reasonable option for those women.
- Perform annual pelvic U/S to check progress of the size.
If symptoms appear or uterine size increase, we counsel the patient regarding the treatment options.
‫ﻟﻮ‬, ‫ﯾﺒﻘﻰ ﻟﻮ إﻛﺘﺸﻔﺖ اﻟﻠﻮﻓﮫ ﺑﺎﻟﺼﺪﻓﮫ أطﻤﻦ اﻟﻤﺮﯾﻀﮫ وأﻗﻮﻟﮭﺎ ﺣﺠﻤﮫ ﻛﺬا وﻧﻌﻤﻞ ﻋﻠﯿﺔ ﺳﻮﻧﺎر ﺗﺎﻧﻲ ﺑﻌﺪ ﺳﻨﮫ وﻧﺸﻮف ﺣﺠﻤﮫ ﺑﯿﻜﺒﺮ وﻻ ﻷ‬
‫ﺣﺴﯿﺘﻲ ﺑﺄﻟﻢ أوﻧﺰﯾﻒ ﺷﺪﯾﺪ ﻣﻊ اﻟﺪورة ﺗﻌﺎﻟﻲ ﻗﺒﻞ ﻣﺎ اﻟﺴﻨﮫ ﺗﺨﻠﺺ‬.
- We also screen women with heavy menstrual bleeding for hypothyroidism which is common in
the reproductive age women.
MEDICAL_THERAPY
Mirena
- Observational studies & systematic reviews have shown a reduction in both uterine volume &
bleeding, and an increase in hematocrit after placement of a levonorgestrel-releasing IUD.
- FDA approved for this indication.
‫ﺑﺎﻟﺘﺎﻟﻲ اﻟﻤﯿﺮﯾﻨﺎ ھﻲ اﻟﺨﯿﺎر اﻷول ﻟﻠﻤﺮﺿﻰ اﻟﻠﻲ ﺑﯿﺠﻮﻟﻚ اﻟﻌﯿﺎده ﺑﺴﺒﺐ ﻧﺰﯾﻒ ﺳﺒﺒﮫ اﻷورام اﻟﻠﯿﻔﯿﺔ وﻟﻮ ﻣﺶ ﻣﺘﺎح ﻋﻨﺪك ﺗﻘﺪر ﺗﻜﺘﺐ‬
‫ﺣﺒﻮب ﻣﻨﻊ اﻟﺤﻤﻞ‬
Combined Oral Contraceptives

- Some texts continue to suggest that COC are CI in women with uterine fibroids.
- These drugs can be useful in women with heavy menstrual bleeding, particularly those with
dysmenorrhea, but they do not appear to be effective in decreasing bulk symptoms.
- The high levels of both estrogen & progesterone during pregnancy and also COC use, decrease the
risk of developing new leiomyomas but may lead to leiomyoma growth.
‫ﯾﻌﻨﻲ ﺣﺒﻮب ﻣﻨﻊ اﻟﺤﻤﻞ ھﺘﻌﺎﻟﺞ اﻟﻨﺰﯾﻒ وﻟﺨﺒﻄﺔ اﻟﺪورة وھﺘﻤﻨﻊ ظﮭﻮر أورام ﻟﯿﻔﯿﺔ ﺟﺪﯾﺪه وﻟﻜﻦ ھﺘﻜﺒﺮ اﻟﻠﻮﻓﺎت اﻟﻠﻲ ﻣﻮﺟﻮده ﺑﺎﻟﻔﻌﻞ‬
‫ ﺑﺎﻟﺘﺎﻟﻲ ﻟﻮ اﻟﻤﺮﯾﻀﺔ ﻛﺎﻧﺖ ﻣﺎﺷﯿﮫ ﻋﻠﻰ‬.‫وأﻋﺮاض اﻟﺜﻘﻞ اﻟﻠﻲ ﻓﻲ اﻟﺤﻮض اﻟﻠﻲ ﻣﻮﺟﻮده ﺑﺴﺒﺐ ﺣﺠﻢ اﻟﻠﻮﻓﮫ إﺣﺘﻤﺎل ﺗﺴﺘﻤﺮ أو ﺗﺰﯾﺪ‬
‫ أﺷﮭﺮ ورﺟﻌﺘﻠﻚ ﺑﺘﺸﺘﻜﻲ ﻣﻦ ﺛﻘﻞ ﻓﻲ اﻟﺤﻮض وﺑﻄﻨﮭﺎ ﻛﺒﺮت ﺑﺎﻟﺮﻏﻢ ان اﻟﻨﺰﯾﻒ ﺑﻘﻰ أﻗﻞ ﻣﺎ ﺗﻐﯿﺮش اﻟﺠﻨﯿﺮا ﺑﺴﯿﻠﺴﺖ‬6-3 ‫ﺟﻨﯿﺮا ﻟﻤﺪة‬
‫وﻟﻜﻦ ﺷﻮﻓﻠﮭﺎ طﺮﯾﻘﺔ ﺗﺎﻧﯿﺔ ﻟﻠﻌﻼج زي ﻣﺎ ھﻨﺸﻮف ﺗﺤﺖ‬.
Tranexamic Acid
- It is widely used worldwide & FDA-approved for the treatment of heavy menstrual bleeding.
- Dose: 1-1.5 gm, 3-4 times daily.
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Ulipristal Acetate "Esmya 5 mg tablets"
- It is a progesterone receptor modulator that is increasingly used as a first line medical treatment of
fibroids.
- Dose: 5 mg once daily for 3 months followed by withdrawal menstrual flow, then can be repeated
for 4 times (3 months each time).
- Repeated 3-month courses effectively control bleeding & shrink fibroids in patients with
symptomatic fibroids. It can be used both for 3 months of preoperative therapy or as a short
intermittent courses interrupted by menstruation.
ً ‫ﻟﺬا ﯾﻌﺘﺒﺮه اﻟﺒﻌﺾ اﻹﺧﺘﯿﺎر اﻷول ﻷﻧﮫ ﯾﻘﻠﻞ اﻟﻨﺰﯾﻒ وﺣﺠﻢ اﻟﻮرم ﻣﻌﺎ‬.
- By the way, Uripristal can be used as an emergency contraception as an oral 30 mg tab as soon as
possible, but within 120 hours (5 days) of unprotected intercourse. Don't use it as a cyclic
contraception as it is not effective & it is a pregnancy category X, so you should exclude pregnancy
before its use & you should initiate another contraceptive measure during its use. A non-hormonal
method of contraception is recommended as Uripristal decrease the efficacy of hormonal
contraceptions.
GnRH Agonists "Zoladex"

- They are the most effective medical therapy for uterine myomas.
‫ﺑﻨﺴﺘﺨﺪﻣﮫ ﻟﻮ ﻗﺮرﻧﺎ ﻧﻌﻤﻞ ﻋﻤﻠﯿﺔ وﻧﺪي ﻣﻌﺎه ﺣﺪﯾﺪ ﯾﺼﻠﺢ اﻷﻧﯿﻤﺎ طﻮل ﻓﺘﺮة اﻹﺳﺘﺨﺪام ﻗﺒﻞ ﻣﻮﻋﺪ اﻟﻌﻤﻠﯿﺔ‬.
‫ﻟﻜﻦ ﺧﻠﻲ ﺑﺎﻟﻚ ﻟﯿﮫ ﻋﯿﺐ ﺧﻄﯿﺮ ﺟﺪا ً ﻏﯿﺮ إﻧﮫ ﺑﯿﺪﺧﻞ اﻟﻤﺮﯾﻀﺔ ﻓﻲ ﺳﻦ اﻟﯿﺄس ھﻨﻘﻮﻟﮫ ﺗﺤﺖ‬.
- These drugs work initially by increasing the release of gonadotropins, followed by desensitization
& downregulation to a hypogonadotropic, hypogonadal state that clinically resembles menopause
(Low FSH, LH, E, P).
- Most women will develop amenorrhea, improvement in anemia (if present) & a significant
reduction in uterine size within 3 months of initiating therapy.
- However, there is rapid resumption of menses & pretreatment uterine volume after discontinuation
of therapy.
- Bone loss leading to osteoporosis after long-term use (>12 months) is the most serious
complication & most often limits therapy.
- Because of the rapid rebound in symptoms & side effects, Zoladex is primarily used as a 3-6
months preoperative therapy in conjunction with iron supplementation to facilitate the procedure &
enable correction of anemia. It reduce the uterine size & the intraoperative blood loss.
- Continuing Zoladex for 6 months prior to abdominal myomectomy to effect volume reduction is
not optimal treatment if there is no volume reduction by 2-3 months.
‫ﯾﻌﻨﻲ ﻟﻮ إﺳﺘﺨﺪﻣﺘﮫ ﺷﮭﺮﯾﻦ ﻗﺒﻞ اﻟﻌﻤﻠﯿﮫ واﻟﺤﺠﻢ ﻟﻢ ﯾﻘﻞ ﻛﻔﺎﯾﺎ ﻛﺪا وﻣﺘﺴﺘﻨﺰﻓﺶ اﻟﻤﺮﯾﻀﮫ ﻋﻠﻰ اﻣﻞ ﻣﺶ ھﯿﺘﺤﻘﻖ‬.
- Dose: 3.6 mg/month subcut. injection.
- The main disadvantage of preoperative Zoladex use: many surgeons report that these medications
result in increased difficulty enucleating fibroids i.e you will find difficulty in reaching the cleavage
line to do enucleation during surgery & you may remove the myometrium including the fibroid
inside.
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‫‪Dr Mohamed Sabry- UpToDate in Obstetrics & Gynecology‬‬
‫ﻟﻸﺳﻒ دي ﻣﺸﻜﻠﮫ ﻛﺒﯿﺮه ﺟﺪا ً ﺟﺪا ً ﺟﺪا ً وھﻘﻮل ﻋﻠﯿﮭﺎ ﻗﺼﺔ ﺻﻐﯿﺮة‬
‫ﻣﺮﯾﻀﺔ ﻋﻤﺮھﺎ ‪ 40‬ﺳﻨﮫ وﻣﺘﺰوﺟﮫ ﻣﻦ ﺳﻨﮫ وﺗُﻌﺎﻧﻲ ﻣﻦ ﺗﺄﺧﺮ اﻹﻧﺠﺎب ﺑﺴﺒﺐ أورام ﻟﯿﻔﯿﺔ ﻛﺒﯿﺮه وطﺒﻌﺎ ً أﺧﺪت زوﻻدﻛﺲ ‪ 6‬أﺷﮭﺮ‬
‫ﻋﻠﺸﺎن ﯾﻘﻠﻞ ﺣﺠﻢ اﻷورام اﻟﻜﺒﯿﺮة اﻟﻤﻮﺟﻮده وأﺛﻨﺎء اﻟﻌﻤﻠﯿﺔ اﻟﺠﺮاح ﻛﺎن ﻣﺶ ﻋﺎرف ﯾﻮﺻﻞ ﻟﻠﺨﻂ اﻟﻔﺎﺻﻞ ﺑﯿﻦ اﻟﻮرم واﻟﻤﺎﯾﻮﻣﺘﺮﯾﻢ‬
‫وﻟﻸﺳﻒ ﺗﻢ إﺳﺘﺌﺼﺎل ﺟﺰء ﻛﺒﯿﺮ ﻣﻦ اﻟﺮﺣﻢ ﻣﻊ اﻟﻮرم اﻟﻠﯿﻔﻲ واﻟﻤﺮﯾﻀﮫ دﺧﻠﺖ ﻓﻲ ﻧﺰﯾﻒ ﺷﺪﯾﺪ إﻧﺘﮭﻲ ﺑﺎﻹﺳﺘﺌﺼﺎل‪ .‬ھﺬا اﻟﺴﯿﻨﺎرﯾﻮ‬
‫ﯾﺠﺐ أن ﺗﺘﻮﻗﻊ ﺣﺪوﺛﺔ ﻗﺒﻞ ﻣﺎ ﺗﺪي زوﻻدﻛﺲ ﻟﮭﺆﻻء اﻟﻤﺮﺿﻰ‬
‫‪To be continued...‬‬
‫‪#UpToDate_Lectures‬‬
‫‪125‬‬

Indications for Surgical Therapy
- Bulk-related symptoms as pelvic pressure & pain.
- Infertility.
- Recurrent pregnancy loss.
MYOMECTOMY
- Myomectomy is an option for women who have not completed childbearing.
- Although myomectomy is an effective therapy for heavy menstrual bleeding & pelvic pressure, the
disadvantage of this procedure is the risk that more leiomyomas will develop from new clones of
abnormal myocytes.
- The classic approach to removing subserosal or intramural myomas is through a
laparotomy/laparoscopy.
- Hysteroscopic myomectomy is the procedure of choice for removing intracavitary myomas
(submucosal & intramural myomas that protrude into the uterine cavity).
- When a fibroid prolapses through the cervix, myomectomy can be performed vaginally.
- The location of a fibroid & not its size, is the key factor regarding fibroid impact on fertility.
Fibroid that distort the uterine cavity (submucosal or intramural with an intracavitary component)
result in difficult conceiving & increased risk of miscarriage. The role of myomectomy in women
with infertility still uncertain
Preoperative Evaluation And Preparation

- MRI is typically not necessary prior to open myomectomy except for women in whom fibroid
must be differentiated from uterine sarcoma or adenomyosis.
- Preoperative correction of anemia.
- A baseline CBC & cross matching blood for all patients before myomectomy.
- D&C: as abnormal bleeding is also a symptom of uterine cancer. So, before myomectomy,
endometrial sampling should be performed in all women with bleeding symptoms especially
intermenstrual bleeding, who are >35 years or who have risk factors for endometrial cancer.
- Reducing uterine size with GnRH agonists (Zoladex): many surgeons report that preoperative
Zoladex result in increased difficulty in the enucleation of the fibroids i.e you will find difficulty in
reaching the cleavage line to do enucleation during surgery & you may remove the myometrium
including the fibroid inside. Beside, Zoladex may increases the risk of persistent myomas. So,
preoperative Zoladex is not recommended by many.
‫ﯾﻌﻨﻲ ھﯿﺼﻐﺮ اﻷورام اﻟﻠﯿﻔﯿﺔ ووﻗﺖ اﻟﻌﻤﻠﯿﺔ ﻣﺶ ھﺘﺸﻮﻓﮭﺎ ﻹﻧﮭﺎ ﺻﻐﯿﺮة وﺑﻌﺪ اﻟﻌﻤﻠﯿﺔ اﻷورام اﻟﻠﻲ ﺳﺒﺘﮭﺎ ھﺘﻜﺒﺮ ﺗﺎﻧﻲ وھﻜﺬا‬.
126
Measures to Reduce Blood Loss
Intramyometrial Vasopressin
.. It is injected into the planned uterine incision site for each fibroid. It acts by causing vaso-
constriction of the bl. vessels.
.. It is contraindicated in women with medical comorbidities (cardiovascular, vascular or renal
disease).
.. Complications may include bradycardia, cardiovascular collapse or death.
.. Care should be taken to avoid intravascular injection; before injecting, the surgeon should pull
back on the plunger of the syringe to check for blood.
.. The upper limit of a cumulative total vasopressin dose per procedure of 4-6 units has been
proposed. In our practice, we dilute 20 units of vasopressin in 100 ml saline; 4-6 units of
vasopressin equals 20-30 ml of this solution.
Tranexamic Acid "Kapron amp"

.. In our practice, we use tranexamic acid 10 mg/kg infused over 10 minutes starting at the
beginning of surgery.
Tourniquets & Clamps

.. In our practice, we use vasopressin in all patients & reserve the use of tourniquets & clamps for
women with large fibroids.
.. Palpate the broad ligament just above the level of the internal cervical os to identify a space that is
free of vessels & the ureter. Make a 1 cm incision in this clear space bilaterally. Pass the tourniquet
(eg, a Penrose drain) through the incisions with the ends protruding anteriorly. Pull the tourniquet
tight & secure by securing the ends with a Kelley clamp. Take care to avoid enlarging the broad
ligament incisions or damaging surrounding structures.
.. Occlusion of the ovarian arteries is accomplished by placing a tourniquet or atraumatic vascular
clamp (eg, bulldog clamp) bilaterally across the infundibulopelvic ligaments. Care must be taken to
avoid lacerating the ovarian vessels or compressing the ureter.
.. Some studies refer to releasing the tourniquet every 20 minutes.
Uterine Artery Ligation or Embolization or Internal Iliac Artery Ligation

May also be used to avoid hysterectomy when heavy bleeding is anticipated or occurs during
myomectomy. We reserve these techniques for situations in which other measures have failed &
additional hemostasis is needed to avoid hysterectomy.
Procedure
- Give prophylactic antibiotics since avoidance of pelvic infection with regard to fertility
preservation is important.
127
- Thromboprophylaxis: patients undergoing abdominal myomectomy (major surgery, defined as
>30 minutes duration) are at risk for venous thromboembolism & require thromboprophylaxis,
whether mechanical or pharmacologic.
- Anesthesia: typically GA.
- A transverse incision (eg, Pfannenstiel) is used whenever possible. For large uterine size, making
the transverse incision slightly higher than usual, extending the incision to the lateral borders of the
rectus muscles & then curving it cephalad to avoid the ilioinguinal nerves will make myomectomy
feasible.
For some women with large fibroids, a vertical incision may be required.
- Measures to Reduce Blood Loss: as before.
- Uterine Incision
Careful placement of uterine incisions can avoid inadvertent extension of the incision to the cornua
or ascending uterine vessels. Anterior uterine incisions are ass. with fewer adnexal adhesions than
posterior incisions. However, if the fibroids are in the posterior uterine wall, it is usually preferable
to make a posterior incision to remove them rather than to go through the uterine cavity to remove
them via an anterior incision. Many surgeons make a uterine incision at a location through which all
or most of the myomas can be removed. Vertical or transverse incisions in relation to the vascular
supply of uterus is not so important as myomas distort the normal vascular architecture.
- Removal of Myomas
The uterine incision is extended down through the myometrium & entire fibroid pseudocapsule. The
least vascular plane can be reached by extending this incision a thin layer deeper than the capsule,
after the myoma is initially visualized. The myoma will then clearly be visible and may bulge
slightly. Myomas are surrounded completely by a dense vascular layer supplying the myoma & no
"vascular pedicle" exists at the base of the myoma. The myomas are then enucleated by grasping
them with a towel clamp. The plane between the myometrium & myoma is typically dissected
bluntly using a sponge or the back end of an empty knife handle.
- Closure of Uterine Defects
The uterine defects are closed with sutures in layers. If the myometrial defect is deep (>2 cm), 2
layers may be needed to reapproximate the tissue & achieve hemostasis. In our practice, we use a
size 0 Vicryl suture for the myometrium. The serosa is closed with a running suture
Operative Challenges
- Submucosal Myomas
Hysteroscopic myomectomy is the procedure of choice for women with primarily intracavitary
leiomyomas. For those with myomas in multiple locations including submucosal, abdominal
myomectomy is preferred. Removal of submucosal myomas during abdominal myomectomy
requires deep myometrial dissection. Often, the uterine cavity is entered during this process. In our
practice, we repair the myometrium at the interface with the cavity, taking care to avoid entry of
suture into the cavity, since this may cause a foreign body reaction & adhesions.
- Cervical or Broad Ligament Myomas
Uterine leiomyomas originate within the myometrium, but, as they grow, may extend near or
128
displace adjacent structures. The first step in removing a cervical or broad ligament lesion is careful
inspection of the peritoneum overlying the fibroid to identify a clear area where the peritoneum can
be incised. With careful attention to stay in the proper surgical plane, the fibroid can be removed
with traction & blunt dissection in a direction away from vital structures (ureter & pelvic vessels).
Sharp dissection, especially where the tips of the blade cannot be seen, should be avoided.
Recurrence
- 30-60% of women will have myomas detected by U/S, 5-10 years after myomectomy.
- Preoperative use of GnRH agonists is associated with an increase in the risk of postoperative
myomas.
Pregnancy After Myomectomy

- Women who undergo myomectomy with significant uterine disruption should wait several months
before attempting to conceive; recommendations for this interval range from 3-6 months.
- If a woman is having difficulty conceiving following a myomectomy, early assessment of the
uterine cavity & fallopian tubes with HSG is advisable.
- Uterine rupture during pregnancy following myomectomy: many experts advise cesarean delivery
as a conservative approach.
- Myomectomy is rarely performed during pregnancy & usually for the indication of intractable
fibroid pain. In addition, in rare cases, myomectomy is required at the time of CS to provide access
to the uterine incision site.
ENDOMETRIAL ABLATION
- In women who have completed childbearing, endometrial ablation, either alone or in combination
with hysteroscopic myomectomy, is an alternative option to hysterectomy.
- When a submucous leiomyoma is present, microwave ablation is possible if the leiomyoma is < 3
cm, but if >3 cm, do resection of the fibroid then ablation.
UTERINE_ARTERY_EMBOLIZATION (UAE) or
UTERINE_FIBROID_EMBOLIZATION (UFE)
- It is an effective option for women who wish to preserve their uterus & are not interested in
optimizing future fertility.
- UFE results in shrinkage of myomas by approximately 30-45%.
- UAE & UFE are effective option for women who wish to preserve their uterus and are not
interested in optimizing future fertility.
- When UAE was introduced as a treatment for fibroids, a desire for future pregnancy was
considered an absolute contraindication because there was concern that poor uterine perfusion
following UAE would negatively impact fertility and result in obstetric complications or adverse
fetal effects. So, we recommend not performing UAE in women who desire future pregnancy.
129
HYSTERECTOMY
Indications
1. Acute hge that doesn't respond to other therapies.
2. Women who have completed childbearing & have other abnormality (CIN, endometriosis,
adenomyosis, endometrial hyperplasia) that would be eliminated or decreased by hysterectomy.
3. Women who have completed childbearing & have significant symptoms or multiple fibroids &
desire a definitive treatment.
4. Women who have failed prior minimally invasive therapy.
- Leiomyomas are the most common indication for hysterectomy.
- The morbidity associated with hysterectomy may outweigh the benefits when the myoma is a
solitary subserous, pedunculated or submucosal that can be excised via laparoscopy or
hysteroscopy.
- Avoiding hysterectomy should be considered by women whose only symptom is bleeding or who
are in the menopausal transition. These women are often effectively treated with either Mirena or
endometrial ablation.
- It is generally possible to remove a uterus that is ≤16 wk-size (fundus midway between the pubic
symphysis & the umbilicus) through a transverse incision (Pfannenstiel or Maylard).
- Many surgeons prefer to use a midline vertical incision. In addition, the incision may need to be
extended above the umbilicus if a uterus is >20 wks-size (fundus at the umbilicus) or larger.
- Removal of a very large uterus is ass. with concealed blood loss (volume of bl. contained within
the uterus). Awareness of this facilitates fluid & blood replacement, and can help with resuscitation
in the immediate postoperative period.
Vaginal Myomectomy
- Prolapsed leiomyomas are removed, typically via vaginal myomectomy.
The prolapsed fibroid is grasped with a towel clamp or tenaculum and pulled down into the vagina
and away from the cervix. Excessive traction on the fibroid should be avoided to prevent avulsion
of the lesion or uterine inversion.
- If the entire pedicle of the fibroid can be palpated, the entire pedicle can often be clamped across
the base. It is then cut and suture ligated using a delayed absorbable suture material.
SUMMARY
Treatment depends on the presentation:
- If abnormal uterine bleeding: women should be treated initially with medical therapy (eg, COC &
tranexamic acid). If medical therapy is not sufficiently effective or tolerated, options include
interventional radiology procedures (uterine artery embolization, magnetic resonance guided
focused ultrasound), endometrial ablation, myomectomy & hysterectomy.
- If bulk-related symptoms: treatment options include hysterectomy, myomectomy or interventional
radiology procedures (uterine artery embolization or magnetic resonance guided focused
ultrasound). The choice of treatment for bulk-related symptoms depends upon the patient’s desire
for future fertility &/or uterine conservation. Size & location of myomas & access to clinicians with
expertise in minimally invasive procedures are also important factors in this decision.
130
131
132
133
The Most Important 35 points you should know before practice

1. Don’t Do CS, unless vaginal delivery cannot be conducted.
2. Don’t do hysterotomy, unless you have a very clear indication.
3. Don’t open the uterus on top of IUFD baby or baby with major CFMF, unless you don’t have
another option.
4. Patient with placenta previa can deliver normally if the head below the lower edge of placenta &
hemodynamically stable.
5. You can do V/E for patient with APH if she has labor pain.
6. In preeclampsia, MgSO4 alone doesn’t control bl. pressure.
7. Face presentation can deliver vaginally if mento-anterior (shin is anterior).
9. Don’t give Clomid to ovulatory patient.
10. Labor pain in previous CS doesn’t mean rupture uterus & urgent delivery by repeated CS.
11. Dexamethasone dose for twins is the same dose for singleton & not the double dose.
12. Any hypotonic baby is considered birth asphyxia by NICU doctors, so save your back by
knowing the neonatal signs consistent with acute hypoxic-ischemic events which are any of those:
Apgar score <5 at 5 & 10 minutes, Fetal umbilical artery pH <7 or base deficit ≥12 mmol/L, Acute
brain injury seen on brain MRI or Presence of multisystem organ failure consistent with hypoxic-
ischemic encephalopathy (HIE).
14. Pregnant diabetic patient can receive dexa if indicated in the presence of bl. glucose monitoring
& not CI.
15. Any early pregnancy before 8 wk with lower abd. pain, please exclude tubal ectopic pregnancy.
16. Abortion in a previous 5 LSCS is not a clear indication for hysterotomy.
17. When we send the contents of abortion for histopathology, this is done to exclude gestational
trophoplastic diseases & doesn’t mean karyotyping for the embryo.
18. Don’t open the uterus on top of IUFD baby or baby with major CFMF, unless you don’t have
another option.
19. Increased vaginal secretions in early pregnancy is a normal physiological process & not
infection.
20. PABAL is indicated for the prevention of uterine atony following delivery by CS & neither after
vaginal deliver nor therapeutic for PPH.
21. In Hyperemesis Gravidarum, it’s better to avoid glucose.
22. If pregnant patient Hb >11 gm, don’t give her ferrous routinely.
(‫)اﻟﺤﺪﯾﺪ ﻣﻊ اﻟﺒﺮوﺟﺴﺘﯿﺮون ﺑﺘﺎع اﻟﺤﻤﻞ ھﯿﺴﺪھﺎ ﻣﻦ اﻹﻣﺴﺎك‬
134
23. Brow presentation can deliver vaginally when it is transient position between the occipito-
posterior & face.
25. When Clexan is indicated, it is taken daily not every other day & not once weekly.
26. If Monochorionic twins complicated by single fetal demise, don’t rush to deliver the other baby,
just counsel the mother for the possible bad outcome in the alive baby.
27. The only parameter that time delivery in IUGR baby is the Doppler findings & not delivery once
diagnosed.
28. Any patient for elective delivery don’t try to deliver before 39 wk, unless there is clear
recommendation as in intrahepatic cholestasis at 37 wk.
29. Don’t deliver patient with PPROM before 34 wk, unless there is chorioamnionitis.
30. When you have patient with severe oligohydrmnious in labor, you should expect cord
compression & atypical variable decelerations with pathological CTG & you can do CS according
to the severity of oligohydramnious or once you see changes in the CTG & don't wait for the baby
to be compromised then take him for CS.
31. Any patient with shortness of breath after CS, you should check oxygen saturation & exclude
pulmonary embolism.
32. If patient with bad CTG remote from delivery, don't strain to deliver her vaginally & save your
back by doing CS.
33. During examination of a breech in labor, take care & don't rupture the scrotum instead of the
membrane.
35. Enough
#UpToDate_Lectures
135
Thank You
Dr Sabry
136

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Dr Mohamed Sabry- UpToDate in Obstetrics & Gynecology

A Simple Gift for

Iron Deficiency Anemia during Pregnancy 6

Iron Deficiency Anemia during Pregnancy

Iron sucrose (Venofer®)

Methotrexate (MTX) Therapy in Ectopic Pregnancy (EP)

Methotrexate (MTX) Protocol in Ectopic Pregnancy (EP)

Single Dose Protocol (the preferred for tubal EP)

Multiple Dose Protocol

Precautions during Therapy

Pain After Treatment

3 Parameters predicted hemoperitoneum ≥300 ml in women with EP

Practical Method for Applying Oral Misoprostol

Induction of Ovulation in Practice (Lesson 1)

Polycystic ovary syndrome (PCO)

Induction of Ovulation in Practice (Lesson 2)

CLOMIPHENE CITRATE (Clomid)

Induction of Ovulation in Practice (Lesson 3)

Approaches For PCO

Pulsatile GnRH Dosing

How to Differentiate Clinically between Abortion & Ectopic Pregnancy

Live Clinical Scenario of Unruptured Ectopic

Live Clinical Scenario of Ruptured Ectopic

Prevention for women with risk factors e.g PG ‫ﻓﻲ اﻟﻌﯿﺎده‬

Management of Mild PET BP ≥140/90 & Proteinuria;

Management of Severe PET BP ≥160/110 or as criteria up;

How to control BP in pregnancy for ch. HTN, preeclampsia &

Regimen of MgSO4 for Fetal Neuroprotection

Candidates for Treatment

Gestational Age Range

Choice of Tocolytic for Women with Preterm Labor

Management of Thrombocytopenia with Pregnancy

The Most Common Causes of Thrombocytopenia in Pregnancy

Gestational Thrombocytopenia (GT)

Diagnosis: ITP is a diagnosis of exclusion

Anticoagulation during Pregnancy

Treatment of Bleeding on Heparin

Labor & Delivery

Resuming Anticoagulation Postpartum

Management of Bartholin Cyst/Abscess

Indications for antibiotics

Abdominal Hysterectomy Technique

Position in the supine or lithotomy position.

Sterilization & surgical draping

Broad ligament dissection

Avoiding ureteral injury

If the ovaries are to be removed

Perivesical & perirectal dissection

Supracervical (subtotal) hysterectomy

Closure of the vaginal cuff

Ureter & Bladder Injury in Gynecologic Surgery

Mechanisms of Ureteral Injury

Mechanisms of Bladder Injury

Ligation of the ovarian vessels

CT with renal contrast or Cystoscopy with retrograde IV pyelography

Bladder dome or supratrigonal injuries (‫)اﻟﺠﺰء اﻟﻌﻠﻮي‬

Bladder trigone injuries (‫)اﻟﺠﺰء اﻟﺴﻔﻠﻲ‬

Prior to patient discharge

Management of Rh -ve Pregnant Women who Received Rh +ve Blood

Best Regards (y)