UPDATE IN UPDATE IN OBSTETRICS AND OBSTETRICS AND

GYNECOLOGYGYNECOLOGY

SATURDAYSATURDAY

17 NOVEMBER 2012 17 NOVEMBER 2012

REFERRAL / ISSUES REFERRAL / ISSUES ::

WHAT ? WHEN ? And HOW ?

REFERRAL SYSTEMREFERRAL SYSTEM CLINIC O&G – PAKAR 1CLINIC O&G – PAKAR 1 EXT NUMBER : 152EXT NUMBER : 152 HOSPITAL NUMBER : 07-9433333HOSPITAL NUMBER : 07-9433333 DAY AND TIME: DAY AND TIME: - MONDAY AND WEDNESDAY MONDAY AND WEDNESDAY

( 2.00PM – 5.00 PM )( 2.00PM – 5.00 PM )- FRIDAY ( 2.45 PM – 5.00 PM )FRIDAY ( 2.45 PM – 5.00 PM )

CLINIC SCHEDULE:CLINIC SCHEDULE: MONDAY ( 2.00 PM – 5.00 PM)MONDAY ( 2.00 PM – 5.00 PM)

PRE PREGNANCY CLINIC &PRE PREGNANCY CLINIC &

COMBINED CLINIC COMBINED CLINIC

TUESDAY ( 8.00 AM – 1.00 PM )TUESDAY ( 8.00 AM – 1.00 PM )

ANTENATAL CLINICANTENATAL CLINIC

THURSDAY ( 8.00 AM – 1.00 PM )THURSDAY ( 8.00 AM – 1.00 PM )

GYNAE CLINICGYNAE CLINIC

FRIDAY ( 8.00 AM – 12 NOON )FRIDAY ( 8.00 AM – 12 NOON )

POSTNATAL CLINICPOSTNATAL CLINIC

Cont.Cont. CONSULTATIONCONSULTATION WORKING HOURS: MO INCHARGEWORKING HOURS: MO INCHARGE

ACCORDING TO CLINICACCORDING TO CLINIC AFTER WORKING HOURS / PUBLIC AFTER WORKING HOURS / PUBLIC

HOLIDAY: MO ONCALL HOLIDAY: MO ONCALL SPECIALIST ONCALLSPECIALIST ONCALL

EARLY PREGNANCY EARLY PREGNANCY PROBLEMSPROBLEMS

MISSED MISCARRIAGE MISSED MISCARRIAGE INCOMPLETE MISCARRIAGE INCOMPLETE MISCARRIAGE THREATHEN MISCARRIAGE THREATHEN MISCARRIAGE TRO ECTOPIC PREGNANCY ( ASAP )TRO ECTOPIC PREGNANCY ( ASAP ) MOLAR PREGNANCY ( ASAP )MOLAR PREGNANCY ( ASAP ) MODERATE/SEVERE HYPEREMESIS MODERATE/SEVERE HYPEREMESIS

GRAVIDARUM ( ASAP )GRAVIDARUM ( ASAP ) RECURRENT MISCARRIAGE ( Clinic )RECURRENT MISCARRIAGE ( Clinic )

HYPERTENSION IN HYPERTENSION IN PREGNANCYPREGNANCY

BP > 140 / 90BP > 140 / 90 Symptoms and signs of Impending Symptoms and signs of Impending

EclampsiaEclampsia Albuminuria 2+ and moreAlbuminuria 2+ and more Whenever UNSURE, please do referWhenever UNSURE, please do refer And And REFER EARLY / IMMEDIATELYREFER EARLY / IMMEDIATELY

MEDICAL - DIABETESMEDICAL - DIABETES

All known diabetics ( as early as All known diabetics ( as early as possible )possible )

IMGTT with BSP > 7 mmol/lIMGTT with BSP > 7 mmol/l AS PER PROTOCOLAS PER PROTOCOL GDM on diet control can be managed GDM on diet control can be managed

in the health side and refered for IOL in the health side and refered for IOL at EDDat EDD

ANTENATAL CASESANTENATAL CASES Parameters in mm ( Growth Chart ) Parameters in mm ( Growth Chart ) Twins for chorionicity as early as possible ( Twins for chorionicity as early as possible (

11stst trimester, before 14 weeks ) trimester, before 14 weeks ) Dating scan ( as early as possible, 8 weeks Dating scan ( as early as possible, 8 weeks

– 13 weeks )– 13 weeks ) Symphisiofundal height measurement Symphisiofundal height measurement

(serial measurements, diff of 4cm )(serial measurements, diff of 4cm ) Low lying placenta ( PP ) – after 28 weeks Low lying placenta ( PP ) – after 28 weeks Abnormal Lie ( non cephalic presentation) Abnormal Lie ( non cephalic presentation)

- after 36 weeks - after 36 weeks

ANTENATAL CASESANTENATAL CASES

Breech – at term ( > 36 weeks )Breech – at term ( > 36 weeks ) Previous scar – at 36 weeksPrevious scar – at 36 weeks Teenage pregnancy / Single Parents Teenage pregnancy / Single Parents

– 36 weeks– 36 weeks Post Date - 40/52 + 6 days Post Date - 40/52 + 6 days

- AFI & CTG at EDD- AFI & CTG at EDD

MEDICAL – RHESUS MEDICAL – RHESUS NEGATIVENEGATIVE

SENSITISED MOTHERS ( Coombs test SENSITISED MOTHERS ( Coombs test positive )positive )

HISTORY OF HYDROPS FETALISHISTORY OF HYDROPS FETALIS ALL RHESUS NEGATIVE MOTHERS ALL RHESUS NEGATIVE MOTHERS

(BEFORE 28 WEEKS For IM Rhogem)(BEFORE 28 WEEKS For IM Rhogem)

MEDICAL - ANAEMIAMEDICAL - ANAEMIA

Severe anaemia – Hb < 8g/dlSevere anaemia – Hb < 8g/dl Not tolerating oral iron supplementsNot tolerating oral iron supplements Not responding to oral iron Not responding to oral iron

supplementssupplements THALASSAEMIA ( especially if both THALASSAEMIA ( especially if both

parents are carriers )parents are carriers ) Kindly pls do anaemia work out before Kindly pls do anaemia work out before

referring patient ( Ferritin, Iron, TIBC, referring patient ( Ferritin, Iron, TIBC, FBP )FBP )

MEDICAL - CARDIACMEDICAL - CARDIAC

Known cardiac diseaseKnown cardiac disease Heart murmur and symptomsHeart murmur and symptoms Symptoms and signs suggestive of Symptoms and signs suggestive of

cardiac pathology ( ECHO )cardiac pathology ( ECHO ) Kindly pls arrange for ECHO prior to Kindly pls arrange for ECHO prior to

appt in Combine Clinicappt in Combine Clinic

MEDICAL - ASTHMAMEDICAL - ASTHMA

Uncontrolled bronchial asthma Uncontrolled bronchial asthma (Combine Clinic )(Combine Clinic )

Well controlled asthma can be Well controlled asthma can be managed in health sidemanaged in health side

MEDICAL – THYROID MEDICAL – THYROID DISORDERSDISORDERS

Patients on treatment for thyroid disordersPatients on treatment for thyroid disorders Kindly pls don't do TFT in first trimester Kindly pls don't do TFT in first trimester

unless very suggestive symptoms. unless very suggestive symptoms. (Difficult to interpret )(Difficult to interpret )

If abnormal in first trimester, can repeat in If abnormal in first trimester, can repeat in second or third trimestersecond or third trimester

Patients can breast feed if on low dose Patients can breast feed if on low dose treatmenttreatment

T4 drops as pregnancy progressesT4 drops as pregnancy progresses

MEDICAL – CONNECTIVE MEDICAL – CONNECTIVE TISSUE DISEASETISSUE DISEASE

REFER ALL PATIENTS IMMEDIATELYREFER ALL PATIENTS IMMEDIATELY

( SLE / RA / NEPHROTIC SYNDROME )( SLE / RA / NEPHROTIC SYNDROME )

POSTPARTUMPOSTPARTUM Episiotomy wound breakdown – pls refer to Episiotomy wound breakdown – pls refer to

clinic ( No need admission unless clinic ( No need admission unless symptomatic )symptomatic )

LSCS wound breakdownLSCS wound breakdown Postpartum high blood pressurePostpartum high blood pressure Urinary retentionUrinary retention SECONDARY PPHSECONDARY PPH POSTPARTUM PYREXIAPOSTPARTUM PYREXIA HEART DISEASE WITH SYMPTOM OF FAILUREHEART DISEASE WITH SYMPTOM OF FAILURE POST PARTUM BLUES/ DEPRESSION/ POST PARTUM BLUES/ DEPRESSION/

PSYCHOSISPSYCHOSIS DVTDVT

MENSTRUAL DISORDERSMENSTRUAL DISORDERS

Menorrhagia ( > 40 years old, Menorrhagia ( > 40 years old, nulliparous, DM, Obesity)nulliparous, DM, Obesity)

Menorrhagia not responding to Menorrhagia not responding to treatment ( < 40 years old )treatment ( < 40 years old )

Post menopausal bleeding (ASAP)Post menopausal bleeding (ASAP) Amenorhoea ( primary and secondary )Amenorhoea ( primary and secondary ) Dysmenorhoea ( especially failed Dysmenorhoea ( especially failed

treatment like NSAIDS )treatment like NSAIDS )

GENERAL GYNAECOLOGYGENERAL GYNAECOLOGY

ABNORMAL PAP SMEARSABNORMAL PAP SMEARS INFERTILITYINFERTILITY PELVIC MASSPELVIC MASS

ANY QUESTIONS ????

THANK YOUTHANK YOU