Follow-up

• 3-4 \vk post treatment to confirm efficacy (confirmed by spontaneous menses or pregnancy test)

• contraception counselling +

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GV19 Gynaecology Toronto Notes 2023

Termination of Pregnancy

Indications

• patient desires an end to pregnancy

• may be for medical reasons (health of mother or fetal anomaly) or social reasons, including patient

request

Legal Considerations

• no current law in Canada concerning abortion, therefore considered legal at any GA, however GA

limits and access vary significantly by region

• CPSO:a physician must provide a referral for abortion services regardless of personal beliefs, but not

compelled to personally perform procedure

Rates

• 13.1 abortions in 1000 women 15-44 yr in Canada (2017 CIH1 data)

• worldwide: 56 million induced abortions per yr; half are unsafe (WHO data)

• maternal mortality almost zero where induced abortion issafe and legal;rises to 100 maternal deaths

in 100000 live birthsin sub-Saharan Africa and other countries where abortion is illegal and unsafe

• in Canada,91% of induced abortions occur <12 wk GA;much less common after 24 wk GA (usually

only for maternal/fetal reasons)

Methods of Induced Abortion

• medical

gold standard up to 9 wk GA

• mifepristone and misoprostol 95-98% effective up to 49 d after LMP

mifepristone (200 mg PO on 1st d) blocks the progesterone receptor (progesterone required in

early pregnancy), alters the endometrium,induces bleeding and causes the cervix to soften

misoprostol (800 mg PV/BUC on 2nd or 3rd d) is a synthetic prostaglandin thatstimulates uterine

contractions and expulsion of the products of conception

• can also use misoprostol alone or methotrexate and misoprostol (with lower success rates of 90-

95%)

• good follow-up and back-up access to D&C required if medical abortion fails

• side effects: bleeding (self-limited) and pain (while tissue passes) are expected side effects, as well

as nausea,diarrhea, and chills/fever due to prostaglandin effects

contraindications:

absolute: ectopic pregnancy, chronic adrenal failure, ambivalence

relative: unconfirmed GA,IUD in situ, long term steroid therapy, bleeding disorder/

anticoagulation, porphyria

• between 14-24 wk GA medical induction of labour (misoprostol followed by oxytocin) is an

option, whereas after 24 wk GA induction of labour is the only option

• surgical

• <14 wk GA:

manual vacuum aspiration - up to 12 wk GA with handheld aspiration device

suction dilatation + aspiration ± curettage -may involve presurgical preparation of cervix

with laminaria tents and/or misoprostol

14-24 wk GA:dilatation and evacuation; presurgical preparation of cervix required with

laminaria tents

pain or discomfort during procedure mitigated by use of appropriate analgesia/sedation/

anesthesia (including paracervical blocks)

rare complications ( l

-5%):laceration of cervix, infection/endometritis, retained products of

conception, ongoing pregnancy

very rare complications (0.1-2%): hemorrhage, perforation of uterus, Asherman’

ssyndrome

(adhesions within the endometrial cavity causing amenorrhea/infertility),future preterm birth

(controversial and likely only with repeated abortion)

• counselling

counselling options always provided including possibility of carrying pregnancy with/without

adoption

offer future contraception (most effective way to prevent unintended pregnancies) and family

planning services

ensure follow-up

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GYMGynaecology Toronto Notes 2023

Pregnancy-Related Complications

First and Second Trimester Bleeding

Approach to the Patient with Bleeding in First Trimester (T1)/ Second Trimester (T2)

History

risk factors for ectopic pregnancy (see Ectopic Pregnancy, GY21)

previous spontaneous abortion

recent trauma

characteristics of the bleeding (including any tissue passed)

characteristics of the pain (cramping pain suggests spontaneous abortion)

history of coagulopathy

gynaecological/obstetric history

fatigue, dizziness,syncopal episodes due to hypovolemia, fever (may be associated with septic

abortion)

Bleeding in Pregnancy Definitions

• First trimester bleeding:vagina!

bleeding within the first 12 wk

• Second trimester bleeding:12-20 wk

Differential Diagnosis

• Physiologic bleeding:spotting,due to

implantation of placenta -reassure

and check serialp-hCGs

• Abortion (threatened,Inevitable,

incomplete,complete)

• Abnormal pregnancy (ectopic,molar)

fxeHydatidiform Mole.GV53)

• Trauma (post-coital or after pelvic

exam)

• Genital lesion (e.g. cervical polyp,

neoplasms)

• Subchorionic hematoma

• NonOB'GYN related cause of

bleeding (e.g.hemorrhoids)

Physical

• vitals (including orthostatic changes)

• abdomen (symphysis fundal height, tenderness, presence of contractions)

• perineum (signs of trauma, genital lesions)

• speculum exam (cervical os open or closed, presence of active bleeding/dots/tissue)

• pelvic exam (uterine size, adnexal mass, uterine/adnexal tenderness, cervical motion tenderness)

Investigations

• (5-hCG

• U/S (confirm intrauterine pregnancy and fetal viability)

. CBC

• group and screen

Treatment

• IV resuscitation for hemorrhagic shock

• treat the underlying cause

Every

mwoman of childbearing age

presenting to ER with abdominal or

pelvic pain should have p-hCG measured

Spontaneous Abortions

• see Termination of Pregnancy,GY19 for therapeutic abortions

Table 13. Classification of Spontaneous Abortions

Management of Abortions

• Always rule out an ectopic pregnancy

. Always check Rh; if negative,give

Rhogam'

• Always ensure patient is

hemodynamically stable

Type History Clinical and Ultrasound Findings Management ( Rhogam )

live fetus on ultrasound

Cervix closed

Threatened Bleeding *

cramping Watch and wait

<5% will goon to abort

a) Watch and wail

b) Misoprostol 800 pg PV now and 800 pg

PV 24h later

c) OK

a) Watch and wait

b) Misoprostol 800 pg PV now and 800 pg

PV 24h later

c) OK

Inevitable Fetus low in uterus onultrasound

Cervix open

Bleeding and cramping

*

rupture of membranes

Incomplete Bleeding and cramps tpassage of

tissue noticed

Residual tissue inuterus on ultrasound

Cervix open Embryonic demise can be diagnosed

by ultrasound based on an intrauterine

gestational sac.embryonic crown-rump

Complete Bleeding and complete passage ol sac length il mm, and no cardiac activity

and placental tissue

No bleeding (letal death inutero)

Empty uterus on ultrasound

Cervix closed,no bleeding

No (etui heart rate on ultrasound, fetus

and sac still inuterus

Cervix closed,no bleeding

No management needed

Missed a) Watch and wail

b) Mifepristone 200 mg P0 followed by

misoprostol 800 pgPV 24 h later

c) OK

Evaluate mechanical,genetic,

environmental,and other risk factors

a) IV broad specimen antibiotics

b) DK 24 h after antibiotics

c) Misoprostol 800pg PV 24 h later

Recurrent >3 consecutive spontaneousabortions

Septic Contents of uterus infected - very rare Tissue in uterus onultrasound

Foul discharge

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GY21 Gynaecology Toronto Notes 2023

Ectopic Pregnancy

Definition

• embryo implants outside of the endometrial cavity

Ovarian artery

Fallopian

Uterine

cavity

Sitesot ectopic pregnancy and

blood supplyto the uterus,

ovary,andtallopiantube

Normal site of implantation

I

- Cervical 2

:

2 -Interstitial Vagina .5

3 - Perineal/Broad ligaments i

4 -lsthmal -

5 Tobal

- Ampullar 3

6 -Infundibullar

7 - Ovarian

_

'

•

0

Figure 10. Sites of ectopic pregnancy implantation

ampullary (70%)»isthmal (12%) > fimbrial (11%) > ovarian (3%) > interstitial (2%) > abdominal (1%)

Epidemiology

•1 /100 pregnancies

•fourth leading cause of maternal mortality, leading cause of maternal death in first trimester

•increase in incidence over the last 3 decades

•three commonest locations for ectopic pregnancy:ampullary (70%), isthmic (12%),fimbrial (11%)

Etiology

•50% due to damage of fallopian tube cilia following HID

•intrinsic abnormality of the fertilized ovum

•conception late in cycle

•transmigration of fertilized ovum to contralateral tube

Susspooled Ectopic Pregnancy

t. Positive urine (ShCG;2.Abdominal pain;3.Vaginal bleeding

i Contraindications to Methotrexate

Therapy for Ectopic Pregnancy

• Hemodynamic instability

• Abnormalities in hematologic.

hepatic,or renal function

• Immunodeficiency

• Active pulmonary disease

• Peptic ulcer disease

• Hypersensitivity to methotrexate

• Heterotopic pregnancy with

coexisting viable intrauterine

pregnancy

• Breastfeeding

• Unwilling or unable to adhere to

methotrexate protocol

Hemodynamically unstable ur suspiciun

of impending/ongoing ruptured ectopic

( Hemodynamically stable ]

i

*

Transvaginal U/S

SerumpliCG [ Surgery )

T

j T T

Intrauterine

pregnancy

BiCG level low and declining,

AND no fetal heartbeat or

extrauterine sac suspicious

for ectopic pregnancy,

AND pabent is reliable for follow-up

<3.5 cm unruptured ectopic

AND no fetal heart rate

AND fCG<5000

AND no hepatic/renal/

hematological disease

AND compliance assured

AND able and willing to follow-up

Patient does not meet

criteria for medical

management,OR

contraindication to

methotrexate

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[Expectant management J [ Methotrexate [ Surgery ]

Figure 11. Algorithm for suspected ectopic pregnancy +

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GY22 Gynaecology Toronto Notes 2023

Risk Factors

• previous ectopic pregnancy

• gynaecologic

current 1UD use - overall risk of pregnancy very low,but increased risk of ectopic pregnancy if

pregnancy occurs

history of FID (especially infection with C. trachomatis),salpingitis

infertility

• infertility treatment (1V1

;

pregnancies following ovulation induction (7% ectopic rate))

• previous procedures

any surgery on fallopian tube (for previous ectopic pregnancy, tubal ligation, etc.)

abdominalsurgery for ruptured appendix, etc.

• smoking

. structural

uterine leiomyomas

adhesions

ODx of Lower Abdominal Pain

• Urinary tract: UTI, kidney stones

• Gl: diverticulitis, appendicitis

• Gynaecological: endometriosis. PID,

fibroid (degenerating, infarcted.

torsion), ovarian torsion,ovarian

neoplasm, ovarian cyst, pregnancyrelated

<§>

Any woman presenting with abdominal

pain, vaginal bleeding, and amenorrhea

is an ectopic pregnancy until proven

otherwise Investigations

• serial (5-hCG levels; normal doubling time with intrauterine pregnancy is every 48 h in the first 8 wk

rise in P-hCG <35% every two days across 3 measurements is consistent with a non-viable

pregnancy

prolonged doubling time, plateau, or decreasing levels before 8 wk implies nonviable gestation but

does not provide information on location of implantation

85% of ectopic pregnancies demonstrate abnormal p-hCG doubling

• ultrasound

• extra- uterine gestational sac with a yolk sac or embryo, regardless of cardiac activity, is diagnostic

• specific suggestive, but not diagnostic, finding on transvaginal U/S is a tubal ring

• suspect ectopic pregnancy in case of empty uterus by transvaginal U/S with P*hCG >2000-3000 mlU/

ft

Mote than half of patients with ectopic

pregnancy have no risk factors

Presentation of Ectopic Pregnancy

Ruptures

• Acute abdomen with increasing pain

• Abdominal distention

• Shock

mL

• laparoscopy (sometimes used for definitive diagnosis)

Treatment

. goals of treatment: conservative (preserve tube if possible), maintain hemodynamic stability

• surgical = laparoscopy

linear salpingostomy an option if tube salvageable, however, patient must be reliable to follow- up

with weekly (5-hCG

15% risk of persistent trophoblast ifsalpingostomy, must monitor P-hCG titres weekly until they

reach non-detectable levels

salpingectomy if tube damaged or ectopic isipsilateral recurrence

« consider Rhogam* if Rh-negative

patient may require laparotomy if unstable, extensive abdominalsurgical history, etc.

• medical = methotrexate

folic acid reductase inhibitor affecting rapidly dividing cells

use 50 mg/m 3>ody surface area;given as a one time IM dose

thisis 1/5 to 1/A chemotherapy dose, therefore minimal side effects (reversible hepatic

dysfunction, diarrhea, gastritis, dermatitis)

follow P-hCG levels on days 4 and 7 after injection, and then weekly until|3-hCG is non-detectable

plateaued or rising levelssuggest persistent trophoblastic tissue requiring further treatment

82-95% success rate, but up to 25% will require a second dose

« administer a second dose if P-hCG does not decrease by at least 15%

tubal patency following methotrexate treatment approaches 80%

stop prenatal vitamins as folic acid will decrease efficacy of methotrexate

• expectant management is an option for patients who are clinically stable, reliable for follow-up,

understand the risk of tubal rupture, and have P-hCG levels that are low and declining

Prognosis

• 9% of maternal deaths during pregnancy attributed to ectopic pregnancy

• 40-60% of patients will become pregnant again aftersurgery

• 10-20% will have subsequent ectopic pregnancy

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GY23 Gynaecology Toronto Notes 2023

Infertility

Epidemiology

• 10-15% of couples, must investigate both members of the couple

Female Factors

Etiology

• increasing age

• chemotherapy

• ovulatory dysfunction (15-20%)

• hypothalamic (hypothalamic amenorrhea)

stress,poor nutrition,excessive exercise (even with presence of menstruation), history of

eating disorders

pituitary (prolactinoma,hypopituitarism)

• ovarian

PCOS

primary ovarian insufficiency

luteal phase defect (poor follicle production, premature corpus luteum failure, failed uterine

linintjresponse to progesterone), poorly understood

systemic diseases (thyroid,diabetes,Cushing’

ssyndrome, renal/hepatic failure)

• congenital (Turner'

ssyndrome,gonadal dysgenesis, gonadotropin deficiency)

• outflow tract abnormality (15-20%)

tubal factors(20-30%)

FID

adhesions(previoussurgery, peritonitis, endometriosis)

ligation/occlusion (previous ectopic pregnancy')

• uterine factors(<5%)

congenital anomalies,bicornuate uterus,septate uterus, prenatal DES exposure, intrauterine

adhesions(e.g.Asherman’

ssyndrome),submucosal fibroids/polyps

infection (endometritis,pelvic tuberculosis)

» cervical factors(5%)

hostile or acidic cervical mucus, anti-sperm antibodies

structural defects (cone biopsies,laser or cryotherapy)

• endometriosis(15-30%)

• multiple factors (30%)

• unknown factors (10-15%)

Infertility:inability to conceive or cany

toterm a pregnancy after1yr of regular,

unprotected intercourse

Primary infertility:infertiity in the

context of no prior pregnancies

Secondary infertility: infertility in the

context of a prior conception

General/

.TS% of couples achieve

pregnancy within 6 mo.85% within 1yt

90% within 2 yr

When Should Investigations Begin?

• <35yr after lyr of regular

unprotected intercourse

• 35-40 yn after >6mo of regular

unprotected intercourse

• >40 yn immediately

Earlier if:

• History of PID

• History of infertility in previous

relationship

• Prior pelvic surgery

• Chemotherapy/radiation in either

partner

• Recurrent pregnancy loss

• Moderate-severe endometriosis Investigations

• ovarian factors

day 3:ESH,LH, estradiol,TSH, prolactin,free and total testosterone, androstenedione, DHEAS,

free testosterone

• day 21-23:high serum progesterone levels confirm ovulation

• general health:CBC. Fe, HbA1c

• tubal factors Ethical Considerationsin Infertility

Treatment

• Infertility demands non-judgmental

discussion

• Ethical issuessurrounding surrogacy,

donor gametes,and other advanced

reproductive technologies are still

evolving and remain controversial

• If the physician findsthat certain

treatment options tie outside of

their moral boundaries,the infertile

couple should be referred to another

physician

hysterosalpingogram (HSG) - dye insufflated into uterus and x-ray taken

• shows uterine cavity shape and if tubes are patent

• can be therapeutic - opensfallopian tube

• sonohysterogram (SHG)

-saline insufflated into uterus and ultrasound done

• shows uterine cavity shape and if tubes are patent

• can be therapeutic and opens the tubes

laparoscopy with dye insufflation (or tubal dye test) rarely done as diagnostic

• peritoneal/uterine factors

• HSG/SHG, hysteroscopy

• other

• karyotype

anti-mullerian hormone (AMH)-a test of ovarian reserve,the higher the number the better

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GYM Gynaecology Toronto Notes 2023

Treatment

• lifestyle modifications (quit smoking/cannabis, reduce caffeine/alcohol intake, healthy diet, exercise,

etc.)

education:time intercourse relative to ovulation (have sex every other day from 2 d prior to 3 d

following presumed ovulation)

• medical

ovulation induction

• domiphene citrate (Clomid’): estrogen antagonist used in anovulatory patients

- blocks brain'

s perception of circulating estrogen, resulting in increased release of

I SH and LH which can help to induce ovulation (better results if anovulatory)

- followed by p-hCG forstimulation of ovum release

letrozole: aromatase inhibitor; may be associated with a higher rate of live birthsin patients

with PCOS

• may add:

bromocriptine (dopamine agonist) or carbamazepine (anticonvulsant) if elevated prolactin

metformin (for PCOS)

luteal phase progesterone supplementation for luteal phase defect (mechanism not completely

understood)

anticoagulation and ASA (81 mg PO once daily) for women with a history of recurrent

spontaneous abortions (for antiphospholipid antibody syndrome)

thyroid replacement to keep I SH <2.5

• surgical/procedural

tubuloplasty

lysis of adhesions

artificial insemination:intracervical insemination (1C1), intrauterine insemination (1U1),

intrauterine tuboperitoneal insemination (1UTPI),intratubal insemination (ITT)

sperm washing

IVF

intrafallopian transfer (il l )

GIFT* : immediate transfer with sperm after oocyte retrieval

ZIFF": transfer alter 2-1 h culture of oocyte and sperm

TET":transfer after >24 h culture

• 1CSJ

. 1VM

± oocyte orsperm donors

± pre-genetic screening for single gene defects in karyotype of zygote

•not performed in Canada

Male Factors

• see Urology. U37

Normal Semen Analysis (WHO lower

reference limits)

• Must be obtained after 2-7d of

abstinence

• Volume1.5 cc

• Count 15 million/cc

• Vitality 58% live

• Motility 32% progressive. 40% total

(progressive non-progressive)

• Morphology 4.0% normal

Etiology

• varicocele (>40%)

• idiopathic (>20%)

• obstruction (

-15%)

• cryptorchidism (

-8%)

• immunologic (

-3%)

• exogenous androgens

Investigations

• semen analysis and culture

Polycystic Ovarian Syndrome

Etiology

Insulin

I Polycystic Ovarian Syndrome - HAIRt estrogen 4 FSH secretion 11LH secretion Anovulation AN

Hirsutism. Hyper Androgcnism, Infertility.

t I i Insulin Resistance. Acanthosis Nigricans

t peripheral conversion to estrogen t ovarian secretion ol androgens Oligomenorrhea

t

I I

Obesity

Figure 12. Pathophysiology of polycystic ovarian syndrome

Hirsutism Infertility

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GY25 Gynaecology Toronto Notes 2023

Diagnosis

• Rotterdam diagnostic criteria: 2 of 3 required

oligomenorrhea/irregular menses for 6 mo

• hyperandrogenism

clinical evidence - hirsutism or acne

biochemical evidence -raised free testosterone

• polycystic ovaries on U/S (not appropriate in adolescents)

PCOS may be confused with

• Late onset CAH (21-hydroxylase

deficiency)

• Cushing's syndrome

• Ovarian and adrenal neoplasms

• Hyperprolactinemia

• Hypothyroidism

Clinical Features

• average age 15-35 yr at presentation

• in adolescents, wait at least I -2 yr to make diagnosis as adolescence resembles PCOS

• abnormal/irregular uterine bleeding, hirsutism, infertility,obesity, virilization

• acanthosis nigricans:darkening of skin folds in intertriginous zones (indicative of insulin resistance)

• insulin resistance occurs in both lean and obese patients

• FMHxofDM

Clinical Signs of Endocrine Imbalance

• Menstrual disorder/amenorrhea

(80%)

,

Infertility (74%)

• Hirsutism (69%)

. Obesity (49%)

• Impaired glucose tolerance (35%)

. DM (10%)

Investigations

• assess BMI, BP, and fasting lipid profile at presentation

goal:identify hyperandrogenism or chronic anovulation and rule out specific pituitary or adrenal

disease as the cause

• laboratory

prolactin, TSH, free '

14

17-hydroxyprogesterone, LH:1

'

SH >2:1 (LH is chronically high with l-

'

SH mid-range or low (low

sensitivity and specificity))

• increased DHEAS, androstenedione, and free testosterone (most sensitive)

• transvagina] or transabdominal U/S: polycystic-appearing ovaries

“string of pearls” - 12 small follicles 2-9 mm or increased ovarian volume (>10 cc)

• tests for insulin resistance or glucose tolerance

75 g OGTT yearly (particularly if obese)

• consider endometrial biopsy if long-standing abnormal uterine bleeding to rule out hyperplasia

• rule out other causes of abnormal bleeding

Long-Term Health Consequences

• Hyperlipidemia

• Adult onset DM

• Endometrial hyperplasia

• Subfertility

• Obesity

• Sleep apnea

Diagnostic Ctiterii for Polycystic Ovary

Syndrome Pitfalls «nd Controversies

JOCC 2008:8:671-679 Treatment

• cycle control

• lifestyle modification (decrease BMI, increase exercise) to decrease peripheral estrone formation

• hormonal 1US, combined hormonal contraception or cyclic Provera" to prevent endometrial

hyperplasia due to unopposed estrogen

oral hypoglycemic (e.g.metformin) if T2DM or if trying to become pregnant

tranexamic acid (Cyklokapron*) for menorrhagia only

• infertility

medical induction of ovulation: letrozole, clomiphene citrate, human menopausal gonadotropins

(HMG (Pergonal*)), LHRH, recombinant l-

'

SH, and metformin

metformin may be used in conjunction with clomiphene citrate for ovulation induction

ovarian drilling ( perforate the stroma), wedge resection of the ovary • rarely done

• bromocriptine (ifhyperprolactinemia)

• hirsutism

any OCP can be used

Diane 35* (cyproterone acetate): antiandrogenic

Yasmin* (drospirenone and ethinyl estradiol):spironolactone analogue (inhibitssteroid

receptors)

• mechanical removal of hair

• finasteride (5-a reductase inhibitor)

• flutamide (androgen reuptake inhibitor)

spironolactone (androgen receptor inhibitor)

tt prevent, there is no deaa-ent definition of

biochemical hyperandrogenernia, parbcularly since

there is dependence on poor laboratory standards

for measuring androgens in women.Clinical signs

of hyperandrogenism are iB-defir.ed in women wrtti

PCOS.eoddagnoss of bob) hirsutism and polycystic

ovarian morphology remainssubjective.There is

aisothe inappropriate tendencyto assign ovulatory

statussolely on the basis of menstrual cycle history or

poorly timed endocrine measurements, therefore it is

important as clinicians to recognize the multifactorial

and complet nature ol PCOS and place thisin the

conteit of oor present diagnostic limitations.

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