Post on 17-Jun-2015
JUNIOR DOCTOR TEACHING SESSION 2013WANGANUI HOSPITAL
DR BETH WINNSHO O&G
O&G for ED
Aim
To cover ED level diagnostics and management, expected at RMO level, of common obstetric and gynaecological presentations.
Topics
PV bleed in reproductive age women Menorrhagia and Dysmenorrhoea Pelvic pain Emergency Contraception Hyperemesis
PV Bleed in pre-menopausal women
PV bleed
PV bleedBHCG -veBHCG +ve
Pelvic USSPelvic swabs and PV
exam
Intrauterine Empty uterus
NormalPregnancy
Threatened miscarriage
Missed miscarriage
Ectopic pregnancy
? Intermenstrual bleed due to STI
? Irregular Period due to DUB, pill etc
? Due to cervical
pathology eg ectropion
NB if USS not available and no senior around, abdo exam plus PV exam to assess external os will help with diagnosis.
Suspected ectopics should NOT go home.
Miscarriage Terminology Refresher...
An inevitable miscarriage describes a condition in which the cervix has already dilated open,but the foetus has yet to be expelled. This usually will progress to a complete miscarriage.
A complete miscarriage is when all products of conception have been expelled.
An incomplete miscarriage occurs when some tissue has been passed, but some remains in utero.
A missed miscarriage is when the foetus has died, but a miscarriage has not yet occurred. It is also referred to as delayed miscarriage.
Threatened miscarriage refers to PV bleeding in early pregnancy.
What are you going to do...
23 yo female 2 day hx of PV bleeding Abdo pain, suprapubic Nausea, no vomitting
Other hx points? Exam? Investigations?
To do...
Is she well or not? Normal vitals? Soft abdomen? Urine dip including BHCG Bloods including BHCG, WCC, CRP, Hb, G&S,
clotting, antenatal blood screen & rhesus status
IV access Analgesia Formal pelvic USS or bedside ED with senior PV exam- check for vaginal trauma, cervical
ectropion/polyp, check os open/closed, swabs
Management
If well patient with intrauterine pregnancy: - heart beat seen, home and FU with midwife- No heart beat, d/w O&G re home +/- repeat
beta HCG/USS
- If positive pregnancy test and no intrauterine pregnancy seen d/w O&G re repeat studies/serial beta HCG to exclude ectopic. If unwell, laparotomy.
REMEMBER!
ALL post menopausal bleeding IS endometrial cancer until proven otherwise REFER
Menorrhagia & Dysmenorrhea
Menorrhagia
Most likely to occur in pre/peri menopausal women secondary to DUB
Elicit extent of bleeding (e.g. ‘Double protection’)
Establish haemodynamic status Check for anaemia and coagulopathy Take G&S sample and keep in patient slot Do PV exam for ?bulky uterus
NB if not stable/hb <8, need ABC Mx and blood transfusion. Call O&G as may attempt intrauterine tamponade. IV conjugated oestrogen (premarin) 25mg IV 4hrly.
Management of a stable menorrhagia
Things you can do: Start ibuprofen and tranexemic acid Start ferrograd Order formal USS d/w O&G and fill out blue form
• Things O&G can do: Start provera/oestrogen (high dose) See in clinic to discuss mirena/ablation/
hysterectomy
Dysmenorrhea
Crampy suprapubic pain during period is normal!!
- Check normal abdo exam and vital signs- Check normal bloods including beta HCG
Mx:- Self care (e.g. Heat pack, exercise)- NSAIDs and paracetamol- Ask GP to consider COCP on dx if continues
Pelvic Pain
Differentials...
Pelvic Pain 1
Pelvic inflammatory disease:- Secondary to STI Often no Hx of infection- >90% present with abdo pain, worse with sex
(ask!)- 33% have irregular PV bleed- Don’t be fooled by RUQ tenderness- Full, tender adenexae are indicative of tubo-
ovarian abscess
Mx: IM or IV ceftriaxone STAT, then combination doxycycline and metronidazole as per protocol
Advise re condoms and partner tracing
Pelvic Pain 2
Ovarian incident in pre-menopausal women:
If suspect ovarian torsion: ABC Mx, IV access & emergency theatre
Post menopausal women need USS and CA 125 and O&G referral
Ovarian Cyst Ovarian Torsion: DANGER complication ovarian
necrosis
Physiological Pathological
Soft abdo and normal vital signs
Tachycardia/feverTender abdo +/- palpable
mass
Normal bHCG,WCC,CRP Often normal labsDiagnosed visually at
laparoscopy!
Emergency Contraception
Emergency Contraception
Levonorgesterol or Yuzpe (levonorgesterol & estradiol) if <72hrs
Do not need to prescribe Available from pharmacies in town (open 8:00-20:00) Cannot get from our pharmacy
Check it was consensual sex If >72hrs but <120hrs can have copper IUD
inserted by gynae in Family planning centre REFER
If >120hrs, for medical abortion REFER
Hyperemesis
Hyperemesis
Hyperemesis gravidarum= >5% of pre pregnancy body weight loss
Hospitalise if +ve ketones
Need bloods including bHCG, Hb, u&e, electrolytes, LFTs
Need urine dip for ketonesNeed USS (rule out twins, molar)
o Severe: Need IV access, IV fluids and IV antiemetic, Vit B6
o Mild: PO Vitamin B6 and antiemetics
Conclusion
Pregnancy test everyone Get Hb on everyone Take a G&S if someone is bleeding- you don’t
have to send it! Don’t be afraid to do basics to help O&G team Refer patients when needed