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