Rubella

Pathogen: Rubella virus

This is a notifiable disease. This means that all diagnosed cases must be reported to the national Public Health services.

 

Also known as

• German measles
• Three-day-measles 

Vulvitis

Disease class: Vulvar diseases

This refers to inflammation of the vulvae (the external female genitalia). 

The vulva includes the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulval vestibule, urinary meatus, the vaginal opening, and Bartholin's and Skene's vestibular glands.

Vaginitis

Disease class: Vaginal diseases

This refers to inflammation of the vagina.

Uterine cervicitis

Disease class: Uterine cervical diseases

 

Parametritis

Disease class: Pelvic Inflammatory Disease

Oophoritis

Disease class: Ovarian diseases
Disease class: Pelvic Inflammatory Disease

This refers to inflammation of the ovaries.

Endometritis

Disease class: Pelvic Inflammatory Disease

Disease class: Uterine diseases

This refers to inflammation of the uterus.

The evolution of the placenta

An interesting hypothesis postulates that the placenta was shaped by mammalian co-evolution with mutualistic, symbiotic viruses.

Placentalia

Animals can be viviparous (bearing live young inside the parents) or oviparous (storing young inside eggs). Mammals in the group placentalia have evolved to have a placenta. The placenta is a temporary organ, which provides new capabilities to assist viviparity. It facilitates the exchange of gas, nutrients, and waste between the foetus and the mother.

The placenta arises from the blastocyst. This develops into an embryoblast (which becomes the embyro) and a trophoblast. The trophoblast burrows into the blood supply in the uterine wall of the mother, and it develops into the placenta.

Placental viviparous species, such as humans, gained unique advantages compared to oviparous species and even other viviparous species. This allowed them to evolve down new avenues, to behave differently, and to exploit new ecological niches.

Viruses

The placenta is a relatively immune-privileged zone, making it ideal for viral replication, survival and proliferation. It is also a potential bridge for viruses to pass from parent to offspring.
The placenta confers competitive advantages to the placentalial host.
Therefore the placenta could support the continued existence of both parties.

Viruses are strongly mutagenic, with strong genetic engineering capabilities. Many years of research have confirmed that retroviruses can infect germline DNA, to produce offspring with a genome containing a new endogenous retrovirus element. 5–8% of the human genome is believed to be composed of endogenous retroviruses.

The genes necessary for placental generation and development may have been implanted by viruses into the genome of placentalia animals.  Such a process would have occured gradually over the course of countless generations, with continous selection pressure and mutagenesis caused by the symbiotic viruses.

Trial and error 

There are four possible outcomes to a de novo mutation.

1. A host is born with a new mutation in their genome. Their genome produces a functional placenta. The host is able to reproduce successfully and passes the functional genotype on to future generations. 
2. A host is born with a new mutation in their genome. Their genome produces a dysfunctional placenta. The host is unable to reproduce successfully, and fails to pass the faulty genotype onto future generations.
3. A host is born with a new mutation in their genome. Their genome produces a functional placenta with a small advantageous variation. This variation could be a loss of a redundant feature, or a gain of a beneficial feature. As this genotype has an advantage compared to their peers in the gene pool, they would be more likely to reproduce successfully. This is a competitive advantage. Over many generations, their offspring will have a higher rate of survival and successful reproduction. The prevalence of the new genotype will expand and become the majority in the gene pool. 
4. A host is born with a new mutation in their genome. Their genome produces a functional placenta with a small disadvantageous variation. This variation could be a loss of a beneficial feature, or a gain of a redundant feature. As this genotype has a disadvantage compared to their peers in the gene pool, they would be less likely to reproduce successfully. This is a competitive disadvantage. Over many generations, their offspring will have a lower rate of survival and successful reproduction. The prevalence of the new genotype will remain low in the gene pool. Eventually it may cease to exist. 

You can see how over time, the placenta could develop rapidly from nothing, to become a complex and useful organ.

 

Strength in mutualism

Why didn't the virus evolve to harm the hosts? Why didn't the host kill the viruses like it normally would? Consider the three potential outcomes here:

1. The viruses caused harm to the host, so the host and viruses died out.
2. The host caused harm to the viruses, or failed to transmit them to offspring, so the viruses died out. The host lost the advantage of the symbiosis and they lost the evolutionary arms race.
3. The viruses supported the hosts, so they were replicated and continued to exist. The host nurtured the viruses, so they kept a useful tool and won the evolutionary race.

 

Remember the microbiota

If you needed further convincing of this co-evolution, consider the mutualistic relationship between humans and other organisms. The human gut contains so many bacteria that the ratio of bacterial cells to human cells is estimated to be 1:1, or even 10:1. These bacteria have been extensively proven to be a blend of harmless commensals and useful mutualists. Humans and gut microbiota have co-evolved so intimately, that there is a proven two-way interaction between the microbiome and various human systems. Mood, metabolism and immunity are examples of such systems.

 

Nice hypothesis, but where is the proof? Read more:

• virology.ws: Retroviruses turned egg-layers into live-bearers
• discovermagazine.com: Mammals Made By Viruses
• pbs.org: The Viruses That Made Us Human
• journals.plos.org: The placenta goes viral: Retroviruses control gene expression in pregnancy
• sciencedirect.com: Retroviruses and the Placenta

I first wrote an essay about this hypothesis in 2014. I am pleased to see that by 2019, researchers have built a mountain of evidence to support this hypothesis. I'm also sad that the field has advanced so much, whilst I still haven't finished medical school.

Hydrops fetalis

Also known as

• Foetal hydrops

 

Causes

• Foetal erythroblastosis
• alpha-Thalassaemia

[Obstetrics and gynaecology] Introduction

Gynaecologists specialise in disease of the female genitourinary system. This includes the vagina, cervix, uterus, fallopian tubes, and ovaries.

Obstetricians specialise in diseases of pregnancy.

There is great overlap between obstetrics and gynaecology, and they are impossible to separate in early training. Many senior physicians are able to eventually subspecialise.

There is significant overlap with urology, and genitourinary medicine.

 

Etymology

Latin obstētrīx, obstētrīcis = midwife

Ancient Greek γυνή (gunḗ) = woman
Ancient Greek λογία (logia) = study

 

History taking 

• Obstetrics 
• Gynaecology 

 

Physical examination

• Pelvic examination
• Speculum examination
• Bimanual vaginal examination
• Obstetric examination

 

Procedures

 

Common presentations

• Reduced fetal movements (RFM)
• Suspected miscarriage 
• Labour complications 
• Referral from midwife or GP 

• Menorrhagia 
• Dysmenorrhoea 
• Amenorrhoea
• Dysuria
• Urinary incontinence
• Dyspareunia 
• Dysorgasmia
• Infertility 

 

Female urogenital diseases and Pregnancy complications

 

Conditions 

• Gestational diabetes
• Pre-eclampsia 
• Eclampsia
• Polyhydramnios
• Oligohydramnios
• Hyperemesis gravidarum
• Placenta praevia
• Placental abruption 
• Postpartum bleeding
• Intrahepatic cholestasis of pregnancy
• Postpartum depression
• Postpartum psychosis
• Molar pregnancy 
• Ectopic pregnancy 
• Ruptured ectopic pregnancy 
• Rhesus disease
• Sheehan's syndrome
• Pelvic inflammatory disease
• Salpingitis
• Tubo-ovarian abscess 
• Pelvic organ prolapse  
• Ovarian cyst 
• Ruptured ovarian cyst   
• Polycystic ovarian syndrome (PCOS)  
• Premature ovarian failure  
• Uterine cancer 
• Ovarian cancer
• Turner syndrome 

Hypogonadism

Disease class: Gonadal disorders

Types

• Eunuchism
• Kallmann syndrome
• Klinefelter syndrome
• Sexual infantilism

Postmenopausal bleeding

Disease class: Metrorrhagia 

Postmenopausal bleeding is defined as vaginal bleeding occurring after twelve months of amenorrhoea, in women at the age where the menopause can be expected. It can, however, occur in younger women who have experienced premature ovarian failure or premature menopause. Postmenopausal bleeding is usually benign, however, endometrial malignancy should be ruled out with urgency.

Causes

• The most common cause of postmenopausal bleeding is vaginal atrophy: The thinning, drying, and inflammation of the walls of the vagina due to a reduction in oestrogen following the menopause can result in vaginal bleeding
• HRT (hormone replacement therapy) is also a common cause of postmenopausal bleeding: Periods or spotting can continue in some women taking HRT for many months with no pathological cause, or endometrial hyperplasia due to long-term oestrogen therapy may occur, which can also cause bleeding
• Endometrial hyperplasia, an abnormal thickening of the endometrium and a precursor for endometrial carcinoma: Risk factors include obesity, unopposed oestrogen use, tamoxifen use, polycystic ovary syndrome and diabetes
• Endometrial cancer: Although 10% of patients with postmenopausal bleeding have endometrial cancer, up to 90% of patients with endometrial cancer present with postmenopausal bleeding, meaning it must be ruled out urgently
• Cervical cancer: It is important to obtain a full record of prior cervical screening programme attendance
• Ovarian cancer: Can present with postmenopausal bleeding, especially oestrogen-secreting (theca cell) tumours
• Vaginal cancer: Uncommon but can present with postmenopausal bleeding
• Other uncommon causes include trauma, vulval cancer and bleeding disorders

Investigations

• NICE guidelines state that women over the age of 55 with postmenopausal bleeding should be investigated within two weeks by ultrasound for endometrial cancer¹
• A thorough history is necessary: Enquire about timing, consistency and quantity of the bleeding, as well as a full gynaecological and obstetric history. It is especially important to ask about risk factors for endometrial cancer and to establish a menstrual timeline from menarche to menopause. A full drug history including HRT use should be sought. Red flag symptoms for gynaecological cancer should be enquired about¹
• A vaginal and a full abdominal examination should be performed: Looking for any masses or abnormalities within the abdomen or felt from within the vagina, as well as a speculum visualisation of the walls of the vagina and cervix. Blood or discharge may be seen
• Immediate testing could include a urine dipstick to look for haematuria or infection, a full blood count to look for anaemia or a bleeding disorder, as well as CA-125 levels
• For those referred on a cancer pathway within two weeks, a transvaginal ultrasound is the investigation of choice: The endometrial lining thickness is assessed, for post-menopausal women with bleeding, an acceptable depth is <5mm. However, it may miss some pathology and if clinical suspicion is high, further testing is required
• A definitive diagnosis of endometrial cancer can be achieved by an endometrial biopsy: This can either be taken during hysteroscopy or by an aspiration (pipelle) biopsy, where a thin flexible tube is inserted into the uterus via a speculum to remove cells for testing
• Imaging in secondary care could include a CT or MRI of the uterus, pelvis and abdomen
• Women on HRT with postmenopausal bleeding still need to be investigated to rule out endometrial cancer

Management

• Once a more serious diagnosis has been ruled out, the following can be used to treat the more common causes of postmenopausal bleeding
• Vaginal atrophy: Topical oestrogens and lifestyle changes such as lubrication can help reduce the symptoms of vaginal atrophy, HRT can also be used
• If a bleed is due to the type of HRT that the patient is on, different HRT preparations can be used to try to reduce this
• In the case of endometrial hyperplasia, usually dilatation and curettage is performed to remove the excess endometrial tissue

Placenta praevia

Disease class: Obstetric labor complications

Disease class: Placenta diseases

Placenta praevia describes a placenta lying wholly or partly in the lower uterine segment

Epidemiology

• 5% will have low-lying placenta when scanned at 16-20 weeks gestation
• incidence at delivery is only 0.5%, therefore most placentas rise away from cervix

Associated factors

• Multiparity
• Multiple pregnancy
• Embryos are more likely to implant on a lower segment scar from previous caesarean section

Clinical features

• Shock, consistent with visible loss
• No pain
• Uterus not tender
• Lie and presentation may be abnormal
• Foetal heart usually normal
• Coagulation problems rare
• Small bleeds before large

Investigations

• Placenta praevia is often picked up on the routine 20 week abdominal ultrasound.
• The RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe.

Classical grading

• I - placenta reaches lower segment but not the internal os
• II - placenta reaches internal os but doesn't cover it
• III - placenta covers the internal os before dilation but not when dilated
• IV - placenta completely covers the internal os

Chorioamnionitis

Disease class: Fetal diseases
Disease class: Placenta diseases

Postpartum thyroiditis

Disease class: Autoimmune thyroiditis

Disease class: Puerperal disorders

Mastitis

Disease class: Breast diseases

Disease class: Puerperal disorders

Cardiotocography

Also known as CTG.

This is an investigation used in obstetrics.

Technique 

External CTG

One probe is placed above the fetal heart.
One probe is placed above the fundus.

Internal CTG

One probe is placed on the fetal scalp.

 

Metrics

1. Fetal heartbeat
2. Indicator showing movements felt by mother (caused by pressing a button)
3. Fetal movement
4. Uterine contractions

Metrorrhagia

Disease class: Uterine haemorrhage

 
This term describes vaginal bleeding outside the menstruation phase of the menstrual cycle. 

Subtypes

• Intermenstrual bleeding
• Postmenopausal bleeding 

Premature Rupture of Fetal Membranes

Disease class: Obstetric labor complications

Also known as PROM.

Dystocia

Disease class: Obstetric labor complications

Dystocia: Slow or difficult labour

Shoulder dystocia

Initially, request senior help and ask the mother to hyperflex their legs (McRobert's manouvere) and apply suprapubic pressure. This method works in 90% of cases.

If this method fails, episiotomy is required. This allows internal manouveres including:

• Wood's screw manouvere
• Grasping and manipulation of the posterior arm. 

Final resorts

• Symphisiotomy
• The Zavanelli manouvere (leading to Caesarean section). By this point fetal damage is often irreversible.