Keeping the right patients Keeping the right patients away from Hospitalaway from Hospital

Park Inn Hotel Telford Park Inn Hotel Telford 16 September 201516 September 2015

Bernie BentickBernie Bentick

Topics coveredTopics covered

• InfertilityInfertility

• Ovarian Hyperstimulation Syndrome (OHSS)Ovarian Hyperstimulation Syndrome (OHSS)

• Bleeding in Early PregnancyBleeding in Early Pregnancy

• Hyperemesis GravidarumHyperemesis Gravidarum

Infertility Definition: NICEInfertility Definition: NICE

Failure to conceive after regular Failure to conceive after regular unprotected intercourse for 2 years in the unprotected intercourse for 2 years in the absence of known reproductive pathologyabsence of known reproductive pathology

BUT:BUT:

If no conception after 1 year, couples should be If no conception after 1 year, couples should be offered further investigation, including semen offered further investigation, including semen analysis and assessment of ovulationanalysis and assessment of ovulation

Infertility – NICE Guidelines Infertility – NICE Guidelines for General Practicefor General Practice

• General Pre-conception advice & folic General Pre-conception advice & folic acidacid

• Rubella antibody screening Rubella antibody screening

• Cervical screening, when appropriate Cervical screening, when appropriate

• Early referral ( at presentation ) if Early referral ( at presentation ) if history of problem which could cause history of problem which could cause subfertility subfertility

NICE: Principal Investigations in NICE: Principal Investigations in Primary CarePrimary Care• Semen analysisSemen analysis

with repeat after 3 months, if abnormal, with repeat after 3 months, if abnormal, butbut ASAP ASAP if severe abnormalityif severe abnormality

• Ovulation testsOvulation testsProgesterone mid luteal Day 21 / 28 Progesterone mid luteal Day 21 / 28

• Hormone profile if cycle irregular, Day 2 to 8Hormone profile if cycle irregular, Day 2 to 8

• Day 2 FSH Day 2 FSH

Ovulation Prediction Kits – available over the Ovulation Prediction Kits – available over the countercounter

NNICE : General Lifestyle Advice in ICE : General Lifestyle Advice in Primary CarePrimary Care

Sexual intercourse every 2-3 daysSexual intercourse every 2-3 days

1-2 units alcohol/week for women1-2 units alcohol/week for women

2-3 units alcohol /week for men2-3 units alcohol /week for men

Smoking cessation programme for Smoking cessation programme for smokerssmokers

Body mass index of 19-29Body mass index of 19-29

Information about prescribed, over the Information about prescribed, over the counter and recreational drugscounter and recreational drugs

Information about occupational hazardsInformation about occupational hazards

NICE: WHEN TO REFERNICE: WHEN TO REFER

• At presentation At presentation when history of predisposing factors when history of predisposing factors or woman age or woman age 35 years 35 years regardless of duration of subfertility regardless of duration of subfertility

• After 1 year After 1 year when investigations abnormal or woman 30 to 34 years when investigations abnormal or woman 30 to 34 years

• After 2 years After 2 years when investigations normal and woman < 30 years when investigations normal and woman < 30 years

• Discourage when woman Discourage when woman 41 years 41 years - very poor pregnancy rates / high miscarriage - very poor pregnancy rates / high miscarriage rates rates - unless considering Donor Oocyte IVF – 50% - unless considering Donor Oocyte IVF – 50% preg per cycle - minimal NHS funded treatment in this age preg per cycle - minimal NHS funded treatment in this age group group

Internet Resources for Internet Resources for GPGP’’s and patientss and patients

1. www.shropshirefertility.co.uk2. www.shropshireivf.co.uk3. www.hfea.gov.uk4. http://guidance.nice.org.uk/CG11/NICEGuidance/p

df/English5. http://guidance.nice.org.uk/CG11/PublicInfo/pdf/E

nglish

Incidence of OHSS

Some degree in all women who respond to ovulation induction (including clomiphene, gonadotrophins and GnRH analogues)

Mild 20-33% (of IVF cycles)

Moderate 3-6%

Severe 0.1 -2%

Usually Out-Patient Usually Out-Patient ManagementManagement• 1 1 Mild OHSS:- Mild OHSS:- Abdominal bloating Abdominal bloating• Mild abdominal painMild abdominal pain• Ovarian size usually ‹8 cmOvarian size usually ‹8 cm

• 2 Moderate OHSS:- 2 Moderate OHSS:- Moderate abdominal painModerate abdominal pain• Nausea ± vomitingNausea ± vomiting• Ultrasound evidence of Ultrasound evidence of

ascitesascites• Ovarian size usually 8–12 cmOvarian size usually 8–12 cm

Out-Patient Management of suspected Out-Patient Management of suspected mild/moderate OHSSmild/moderate OHSS

• Analgesia: Paracetamol (occasionally Opiates)Analgesia: Paracetamol (occasionally Opiates)

• Anti-emetic if significant vomiting (see Hyperemesis Anti-emetic if significant vomiting (see Hyperemesis drugs)drugs)

• Drink to quench thirstDrink to quench thirst

• Contact Fertility Nurse of Treatment Unit (Office Hours)Contact Fertility Nurse of Treatment Unit (Office Hours)

• Fertility Nurse will arrange clinical review, ultrasound & Fertility Nurse will arrange clinical review, ultrasound & necessary bloods then see/contact every 2-3 days until necessary bloods then see/contact every 2-3 days until resolvesresolves

In-Patient Treatment In-Patient Treatment requiredrequired• 3 Severe OHSS: 3 Severe OHSS: Clinical ascites (occasionally Clinical ascites (occasionally

hydrothorax)hydrothorax)• OliguriaOliguria• Haemoconcentration haematocrit ›45%Haemoconcentration haematocrit ›45%• HypoproteinaemiaHypoproteinaemia• Ovarian size usually ›12 cmOvarian size usually ›12 cm

• 4 Critical OHSS: 4 Critical OHSS: Tense ascites or large hydrothoraxTense ascites or large hydrothorax• Haematocrit ›55%Haematocrit ›55%• White cell count ›25 000/mlWhite cell count ›25 000/ml• Oligo/anuriaOligo/anuria• ThromboembolismThromboembolism• Acute respiratory distress syndromeAcute respiratory distress syndrome

Management of suspected severe Management of suspected severe OHSSOHSS

• Contact Gynae on-call team to arrange Contact Gynae on-call team to arrange immediate emergency admission to Gynae immediate emergency admission to Gynae WardWard

• Severe OHSS protocol will be commencedSevere OHSS protocol will be commenced

• On-call Consultant & Fertility Team involvedOn-call Consultant & Fertility Team involved

• HFEA will be informedHFEA will be informed

Bleeding in early Bleeding in early pregnancy(1)pregnancy(1)

• Positive pregnancy test & bleeding/pain Positive pregnancy test & bleeding/pain ‹ 16 ‹ 16 weeksweeks

• Occurs in at least 20% of all pregnanciesOccurs in at least 20% of all pregnancies

• Refer to EPAS for next appointment within 48hrsRefer to EPAS for next appointment within 48hrs

Bleeding in early Bleeding in early pregnancy(2)pregnancy(2)

• Only if unwell or high risk of ectopic: refer via Only if unwell or high risk of ectopic: refer via

GATU for review before 6 pm, otherwiseGATU for review before 6 pm, otherwise Gynae Gynae WardWard

• GATU & Gynae Ward are NOT a fast track to scanGATU & Gynae Ward are NOT a fast track to scan

• If <5/40 commence serial BHCGIf <5/40 commence serial BHCG’’s in the surgery – s in the surgery – ask EPAS for adviceask EPAS for advice

Hyperemesis Gravidarum Hyperemesis Gravidarum (HEG)(HEG)

• HEG refers to persistent nausea and HEG refers to persistent nausea and vomiting associated with fluid & vomiting associated with fluid & electrolyte disturbance or nutritional electrolyte disturbance or nutritional deficiency.deficiency.

weight loss >5% of prepregnancy weight.weight loss >5% of prepregnancy weight.

• Most severe manifestation of the spectrum Most severe manifestation of the spectrum of nausea & vomiting of pregnancy.of nausea & vomiting of pregnancy.

Morning Sickness: Dotted line-nausea Solid line-vomitingMorning Sickness: Dotted line-nausea Solid line-vomiting

Anti-emetics

• No evidence that any one anti-emetic is superior to another

• Anticholinergics/Antihistamines (H1 receptor antagonists): Cyclizine & Promethazine

• Phenothiazines: Prochlorperazine & Chlorpromazine

• Dopamine receptor antagonists: Metoclopramide & Domperidone

• Selective 5-hydroxytryptamine receptor antagonists (5-HT3): Ondansetron

• or combinations of these agents

• Proton pump inhibitors & H2 receptor antagonists for dyspepsia: Omeprazole & Ranitidine

Vitamins

• Folic acid 400ug daily

• Consider Vitamin B1 & B6 in patients with protracted course

• Vitamin B1 (Thiamine) 25 - 50mg PO TDS for those with prolonged vomiting OR

• Pabrinex weekly injections.

• Vitamin B6 (Pyridoxine) 10mg TDS especially for those with nausea is the main symptom.

HYPEREMESIS FLOW CHART

Severe nausea, vomiting, dehydration, ketonuriaAdmit to GATU for rapid rehydration before 12noon or 9am* the following day

▼History

Investigations – FBC, U&E, LFT, MSUTFT& Blood sugar (1st visit only)

On subsequent visits – U&Es onlyUSS to be arranged (1st visit only if not had previous scan)

▼Rapid intravenous (IV) hydration

3 litres of Sodium Chloride 0.9% or Hartmann’s solution at 500 mls/hr (3litres in 6 hrs)If K < 3.3 mmol give Sodium chloride 0.9% + 40 mmols of KCL per bag X 2 bags at

250ml/hour▼

Anti-emeticsCyclizine 50 mgs IV

▼ ▼Good response, normal U&E’s Poor response or

Ultrasound (1st admission) K+ < 3.3mmol/l ▼ ▼

Discharge after 4 to 6 hours Do not dischargeon regular anti-emetics VTE risk assessment

Cyclizine 50 mgs tds and Promethazine 25 mgs bd

*GP to give antiemetic in the Surgery if for following day

OTHER CAUSES OF VOMITING IN OTHER CAUSES OF VOMITING IN PREGNANCYPREGNANCY

• Urinary tract infection• Gastritis• Cholecystitis• Appendicitis• Peptic ulcer• Hepatitis• Pancreatitis• Migraine• CNS disease• Labyrinthitis• Meniere’s disease• Thyrotoxicosis• Addison’s disease• Uremia• Hypercalcemia

• Eating disorders

• Iron• Opioids

SUMMARYSUMMARY

• Fertility Referrals according to NICE (adopted Fertility Referrals according to NICE (adopted by CCG)by CCG)

• OHSS usually managed as an Outpatient by OHSS usually managed as an Outpatient by Fertility UnitFertility Unit

• Bleeding/pain in early pregnancy managed Bleeding/pain in early pregnancy managed by EPAS, with admission rarely needed by EPAS, with admission rarely needed (for haemodynamically unstable patient) (for haemodynamically unstable patient)

• Hyperemesis gravidarum is managed as Day Hyperemesis gravidarum is managed as Day Case by GATU & ward admission rareCase by GATU & ward admission rare

GENERAL FERTILITY STATISTICS GENERAL FERTILITY STATISTICS -UNSELECTED -UNSELECTED POPULATIONPOPULATION

• 80% chance of pregnancy in 1st year80% chance of pregnancy in 1st year

• 86% chance of pregnancy by 2nd year86% chance of pregnancy by 2nd year

• BUT: fertility declines with a womanBUT: fertility declines with a woman’’s s ageage