Update in obstetrics and gynecology 2012
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Transcript of Update in obstetrics and gynecology 2012
UPDATE IN UPDATE IN OBSTETRICS AND OBSTETRICS AND GYNECOLOGYGYNECOLOGY
16TH JUNE 2012
DR. ARIVENDRAN
M.D (UKM) MRCOG (UK)
MILLENIUM MILLENIUM DEVELOPMENT GOAL 4DEVELOPMENT GOAL 4REDUCE CHILD MORTALITYTarget 4A: Reduce by two-thirds,
between 1990 and 2015, the under-five mortality rate ◦Under-five mortality rate◦Infant (under 1) mortality rate◦Proportion of 1-year-old children
immunized against measles
MILLENIUM MILLENIUM DEVELOPMENT GOAL 5DEVELOPMENT GOAL 5IMPROVING MATERNAL HEALTHTarget 5A: Reduce by three quarters,
between 1990 and 2015, the maternal mortality ratio ◦ Maternal mortality ratio◦ Increase proportion of births attended by
skilled health personnelTarget 5B: Achieve, by 2015, universal
access to reproductive health ◦ Contraceptive prevalence rate◦ Adolescent birth rate◦ Antenatal care coverage◦ Unmet need for family planning
Women to the top
Life expectancy: females as a % of males, 2010 106
Adult literacy rate: females as a % of males, 2005-2010* 95
Enrolment ratios: females as a % of males, Primary GER, 2007-2010* 99
Enrolment ratios: females as a % of males, Secondary GER, 2007-2010* 107
Survival rate to last grade of primary: females as a % of males, 2006-2009* -
Contraceptive prevalence (%), 2006-2010* –
Antenatal care coverage (%), At least once, 2006-2010* 79
Antenatal care coverage (%), At least four times, 2006-2010* –
Delivery care coverage (%), Skilled attendant at birth, 2006-2010* 99
Delivery care coverage (%), Institutional delivery, 2006-2010* 98
Delivery care coverage (%), C-section, 2006-2010* –
Maternal mortality ratio† , 2006-2010*, reported
29
Maternal mortality ratio† , 2008, adjusted
31
Maternal mortality ratio† , 2008, Lifetime risk of maternal death: 1 in: 1200
OUTLINE OF OUTLINE OF PRESENTATIONPRESENTATION
HYPEREMESIS GRAVIDARUM
MISCARRIAGES
MOLAR PREGNANCY
ECTOPIC PREGNANCY
HYPEREMESIS HYPEREMESIS GRAVIDARUMGRAVIDARUMSevere persistent
vomiting in pregnancy, which causes weight loss (more than 5% of body mass) associated with ketosis and electrolyte imbalance
Affects 0.3%-1.5% of pregnant women.
NAUSEA AND VOMITING in pregnancy, which effects about 80 % pregnant women
PATHOPHYSIOLOGYPATHOPHYSIOLOGY Still poorly understood.
Various hormonal, mechanical and psychological factors have been implicated.
The temporal relationship between the level of human chorionic gonadotrophin (hCG) (peaking between 6–12 weeks) and severity of vomiting suggest hCG may have a causative role.
DIAGNOSISDIAGNOSIS Hyperemesis is a DIAGNOSIS OF EXCLUSION.
Onset is always in the first trimester, usually weeks six to eight
Other causes of vomiting, such as urinary tract infection, appendicitis, cholecystitis, hepatitis should be excluded
INVESTIGATIONSINVESTIGATIONSFULL BLOOD
COUNTRENAL PROFILELIVER FUNCTION
TESTURINE DIPSTIX /
BIOCHEMISTRYURINE C&SPELVIC
ULTRASOUND
MANAGEMENTMANAGEMENTBed restHydrationAntiemetics Small
carbohydrate meals
Carbonated drinks
Psychological support
HYDRATIONHYDRATION Intravenous
rehydration with Normal Saline (sodium chloride 0.9 % )
Potassium chloride supplement is usually required with each bag of saline
Solutions containing dextrose should be avoided (e.g. dextrose saline) because they do not contain enough sodium and may precipitate Wernicke’s encephalopathy
ANTIEMETICSANTIEMETICSMetoclopramide ( MAXOLON ) 10 mg three times a day
intravenously or orally ( BE WARY OF OCCULOGYRIC CRISIS )
ANCOLOXIN( VELOXIN ) Combination of meclozine 25mg and pyridoxine 50 mg( vit b6), 1 tab bd
Prochlorperazine ( STEMETEIL ) Oral 5mg three times a day oral or IM 12.5mg three times a day
INITIAL MANAGEMENT INITIAL MANAGEMENT (Daycare management )(Daycare management )
IV Maxolon 10 mg 6 - 8 hourly
TWO LITRES ( 4 PINTS ) of intravenous normal saline solution given over four to six hours with / without potassium chloride
Investigations taken and reviewed
If symptoms persist than for If symptoms persist than for admission….admission….
Regular IV Maxolon 8 hourly,
6 pint IV drip of N/Saline with potassium supplement
Daily urine ketoneVomit chartI/O Chart
PLEASE REFER IF : PLEASE REFER IF : Evidence of dehydration ( URINE
KETONE 2+ AND MORE )Severe electrolyte imbalance
( Na+ < 130, K+ < 3.0 )Unable to maintain oral intakeClinical evidence of moderate to
severe dehydrationClinically unstable ( tachycardia,
hypotensive )
COMPLICATIONSCOMPLICATIONSMallory Weis tear Acute renal
failureCentral pontine
myelinolisisWernicke
encephalopathyKorasakoff
psychosisDepression
MISCARRIAGESMISCARRIAGESTHREATHEN
MISCARRIAGE
COMPLETE/ INCOMPLETE
MISCARRIAGE
SILENT MISCARRIAGE/ DELAYED MISCARRIAGE
DEFINITION/DEFINITION/TERMINOLOGYTERMINOLOGYThreatened miscarriage (Threatened
abortion )
Complete miscarriage (Complete abortion )
Incomplete miscarriage ( Incomplete abortion )
Missed( Silent ) miscarriage (Missed abortion )
Delayed ( Silent ) miscarriage ( Anembryonic pregnancy )
DEFINITION/DEFINITION/TERMINOLOGYTERMINOLOGYSilent miscarriage ( Blighted
ovum )
Inevitable miscarriage (Inevitable abortion)
Miscarriage with infection ( Septic abortion )
Early fetal demise
THREATHEN THREATHEN MISCARRIAGEMISCARRIAGE
Clinically : Vaginal bleeding
abdominal pain CERVIX CLOSE
Pelvic ultrasound:
Intrauterine gestation sac
Fetal pole with cardiac activity seen
MANAGEMENTMANAGEMENTREASSURANCE
/ SUPPORTIVERESTVITAMIN
SUPPLEMENTS ( FOLIC ACID )PROGESTOGENS
( ORAL / IM )PAD CHART
COMPLETE COMPLETE MISCARRIAGEMISCARRIAGEClinically: Cessation of vaginal
bleeding and abdominal pain with a
closed cervix
PELVIC ULTRASOUND :
Endometrial thickness 15 OR less
No evidence of retained products of conception
INCOMPLETE INCOMPLETE MISCARRIAGEMISCARRIAGE
Clinically :Passage of pregnancy-related
tissue,bleeding and/orabdominal pain; CERVIX OPEN
Pelvic ultrasound :Heterogenous
tissues / sac distorting midline endometrial echo
Endometrial thickening
MISSED / SILENT/ DELAYED MISSED / SILENT/ DELAYED MISCARRIAGEMISCARRIAGE
Clinically :
Minimal vaginal bleeding
or pain; loss ofpregnancy symptoms; CERVIX CLOSE
Pelvic ultrasound :
Fetal pole > 7 mm with no fetal activity.
Gestation sac diameter >25 mm with no fetal pole or yolk sac
Addendum to GTG No 25 (Oct 2011): Addendum to GTG No 25 (Oct 2011): The Management of Early The Management of Early Pregnancy Loss Pregnancy Loss Ultrasound diagnosis of
miscarriage should only be considered with a mean gestation sac diameter >/= 25mm (with no obvious yolk sac), or with a fetal pole with crown rump length >/=7mm (the latter without evidence of
fetal heart activity) A transvaginal
ultrasound scan should be performed in all cases
Addendum to GTG No 25 (Oct 2011): Addendum to GTG No 25 (Oct 2011): The Management of Early The Management of Early Pregnancy LossPregnancy LossWhere there is any
doubt about the diagnosis and/or a woman requests a repeat scan, this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken for uterine evacuation.
INEVITABLE INEVITABLE MISCARRIAGEMISCARRIAGE
Bleeding without passage of tissue but with an open cervix
Product of conception at the cervical os
MANAGEMENTMANAGEMENTEXPECTANT
MEDICAL (PROSTAGLCANDINS )
SURGICAL ( ERPOC/ D&C )
MOLAR MOLAR PREGNANCYPREGNANCY
MOLAR PREGNANCYMOLAR PREGNANCY1 for every 700 live births
The time of diagnosis is usually very difficult for women: they have to cope with the loss of a pregnancy, the details of follow-up, potential chemotherapy and the increased risks in future pregnancies.
RISK FACTORSRISK FACTORS
AGE
Extremes of the reproductive age,
Girls under the age of 15 years have a risk approximately 20 times higher than women aged 20–40
Aged over 45 have a several hundred-fold higher risk than those aged 20–40.1
RISK FACTORSRISK FACTORSHistory of
molar pregnancy
In this group, the risk appears to be approximately 1 in 55 for those with one previous molar pregnancy and 1 in 10 for those with two.
CLINCAL FEATURESCLINCAL FEATURESExaggerated symptoms of early
pregnancyHyperemesis gravidarumUterus larger than datesPer vaginal bleedingSymptoms of hyperthyroidismPre-eclampsia ( Hypertension )
DIAGNOSISDIAGNOSISUltrasound
characteristically shows an absent gestational sac and a complex echogenic intrauterine mass with cystic spaces.
( SNOW STORM APPEARANCE )
SUSPECT MOLAR SUSPECT MOLAR PREGNANCY !PREGNANCY !
PLEASE SEND IMMEDIATELY AS AN URGENT REFERRAL
MANAGEMENTMANAGEMENTSUCTION CURRETAGE
CLOSE FOLLOW UP WITH BETA HCG MONITORING
AVOID PREGNANCY WITH BARRIER CONTRACEPTION FOR AT LEAST 6 MONTHS
ECTOPIC ECTOPIC PREGNANCYPREGNANCY
RISK FACTORSRISK FACTORSPrevious history
of ectopic Pelvic
Inflammatory Disease
EndometrosisPrevious tubal
surgery
CLINICAL CLINICAL PRESENTATIONPRESENTATIONPeriod of
amenorrhoea (POA)
Positive urine pregnancy test
Abdominal PainMinimal per
vaginal bleedingShoulder tip painFainting / Black
out episodes
SITES OF ECTOPIC SITES OF ECTOPIC PREGNANCYPREGNANCY
Clinical diagnosis of early unruptured ectopic pregnancy remains a great challenge to the clinician.
High Index of Suspicion combined with the application of technological advances(TVS) has made it possible to diagnose ectopic pregnancy earlier.
FEMALE, ABDOMINAL PAIN , UPT POSITIVE = TRO ECTOPIC PREGNANCY
MANAGEMENTMANAGEMENT
GENERAL
SURGICAL
MEDICAL
EXPECTANT
GENERALGENERALRESUSCITATION
– 2 large bore branulas and run fluids
Cross match blood
Blood grouping and rhesus ( Anti D Ig if patient is Rh negative )
SURGICAL SURGICAL MANAGEMENTMANAGEMENTLAPARASCOPY –
method of choiceSalpingectomy/
Salpingostomy
SURGICAL SURGICAL MANAGEMENTMANAGEMENTLAPARATOMY-
Large haemoperitoneum, patient clinically unstable or dense pelvic adhesions
MEDICALMEDICALClinically stableBeta hcg < 3000 iu/lPatient is able to
return for frequent close monitoring
Fetak Heart activity is absent
Ectopic sixe < 3.5cm
No contraindication to MTX
EXPECTANT EXPECTANT MANGEMENTMANGEMENTONLY IF :
Patient stable and asymptomatic
Initial beta hcg < 1000 iu/l and falling serially
Able to comply with close follow up with serial beta hcg and TVS
THANK YOU !!!!