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 !!!!