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Obstetrics and Gynaecology Forum Pradnya Pisal Jyoti Shah Annie Fowler.

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Presentation on theme: "Obstetrics and Gynaecology Forum Pradnya Pisal Jyoti Shah Annie Fowler."— Presentation transcript:

1 Obstetrics and Gynaecology Forum Pradnya Pisal Jyoti Shah Annie Fowler

2 Early Pregnancy Unit Lead Consultant: Pradnya Pisal , 1267, 1979 Lead Sister: Annie Fowler , 1958 Lead Sonographer: Jyoti Shah

3 EPU Pregnant women with pain and/or bleeding from 6-14 weeks amenorrhoea (positive UPT) Pregnant women with <6 weeks amenorrhoea who have an abnormally light last period where there is a suspicion of or who have a high risk factor for ectopic pregnancy Appointment system accessible only to GPs and midwives and hospital doctors

4 EPU Routine scanning in very early pregnancy is not advised as it will generate unnecessary anxiety if the pregnancy is not visualised on scan Patients should be given a realistic idea about the scan appointment and only genuine cases should be referred to EPU as there are only fixed slots available (not for routine dating)

5 Early pregnancy scans Earliest gestational sac on TA scan: 6 weeks Earliest viable pregnancy on TA scan:7 weeks Earliest gestational sac on TV scan: 5 weeks Earliest viable pregnancy on TV scan: 6 weeks At 1000 IU, an intrauterine gestational sac on TV scan 85% of viable intrauterine pregnancies show doubling of HCG in 48 hrs Suboptimal increase in HCG over 48 hrs without intrauterine gestational sac seen on TV scan is s/o ectopic pregnancy

6 Value of USS post-miscarriage 1 in every 5 clinically known pregnancies will miscarry in the first trimester Post miscarriage or post TOP bleeding: scans are unreliable to confirm or exclude retained products of conception USS cannot differentiate between blood, clots or POC in the uterine cavity Surgical evacuation: complications in 2% cases: uterine perforation, cervical tears, intra- abdominal trauma, intrauterine adhesions, haemorrhage, mortality 0.5/100,000

7 Management of post-miscarriage or post- TOP bleeding will depend on clinical findings If the bleeding is heavy and worrying, refer to A&E If cervical os closed even with moderate bleeding with/without uterine tenderness, treat with augmentin or combination of cephelexin and metronidazole for 7 days. Screen for PID, especially chlamydia Post - miscarriage or post - TOP

8 If bleeding not settled after course of antibiotics, refer as urgent case to a consultant to be seen in the next consultant clinic If bleeding is >6 weeks post miscarriage, and bimanual examination is unremarkable, treat with a short course of hormones: COC or progestogens Counsel women to expect moderate bleeding for postnatally, (at any gestation) Next period may be delayed to 6 weeks

9 Screening for ovarian cancer Not recommended in low risk population Screening can be considered in women with: 2 first degree relatives with ovarian cancer 2 first degree relatives with ovarian cancer 1 first degree relative with ovarian cancer and 1 first degree relative with breast cancer diagnosed under the age of 50 1 first degree relative with ovarian cancer and 1 first degree relative with breast cancer diagnosed under the age of 50 One first degree relative with ovarian cancer and 2 first or second degree relatives with breast cancer, diagnosed under the age of 60 One first degree relative with ovarian cancer and 2 first or second degree relatives with breast cancer, diagnosed under the age of 60 Presence of faulty ovarian cancer causing gene in the family Presence of faulty ovarian cancer causing gene in the family 3 first or second degree relatives with bowel cancer and one case of ovarian cancer in the family 3 first or second degree relatives with bowel cancer and one case of ovarian cancer in the family

10 Screening for ovarian cancer Women with a significant family history can be referred to a genetics clinic from where they can either be referred for the UKFOCSS or for BRCA1 gene testing if appropriate Yearly CA125 and ovarian scan from years age Prophylactic oophorectomy and mastectomy does not prevent primary peritoneal cancer

11 Suspected gynaecology pathology Incidental finding in asymptomatic women with -uterine size 8-10 weeks: reassure -uterine size >10 weeks: pelvic scan, refer if appropriate Symptomatic women < 40 yrs old: pelvic scan if uterus is bulky, refer if appropriate Asymptomatic women < 40 yrs old with adnexal mass: pelvic scan and refer if appropriate All women =/> 40 yrs old with adnexal mass: request pelvic scan + refer Pelvic pain without menstrual problems in young women with satisfactory & normal bimanual examination: pelvic scan not needed, refer if appropriate

12 Endometrial assessment on pelvic scan Asymptomatic postmenopausal women: endometrial scan thickness of >/= 4mm, or fluid in the uterine cavity, should have endometrial assessment with pipelle or hysteroscopy In symptomatic women, endometrial assessment is recommended even is endometrium <4mm For symptomatic women on HRT, investigate at same level (4mm) of endometrial thickness

13 PID Lower abdo pain & tenderness Deep dyspareunia Abnormal vaginal discharge Cervical excitation & adnexal tenderness Fever (>38deg C) Diagnosis: endocervical swab for chlamydia and gonorrhoea and HVS, urine HCG USS if clinical suspicion of TO abscess Ofloxacin 400mg BD + metronidazole 400mg BD for 14 days

14 PID IM ceftriaxone 250mg stat or IM cefoxitin 2g with oral probenecid 1g foll by doxycycline 100mg BD + metronidazole 400mg BD for 14 days IUCD may be left in situ with mild disease but remove with severe disease Offer screening and contact tracing for partners Women on COC with breakthrough bleeding should be screened for chlamydia

15 Endometriosis Pelvic scan only if clinical suspicion of endometriotic cyst or adnexal pathology 0.06% risk of major complications, 1.3% with operative laparoscopy Therapeutic trial with COC or progestogen Induce amenorrhoea with danazol, GnRH analogues(3-6 months), add-back HRT if longer duration of treatment used

16 HRT Increase in risk of -coronary artery disease( odds ratio 1.29) -Breast cancer (odds ratio 1.26) -Stroke (odds ratio 1.41) -Pulmonary embolism Reduced risk of colorectal cancer and reduced hip fractures

17 Ovarian cysts in PM women TVS and CA 125 No role for routine CT,MRI or colour doppler assessment Risk of malignancy index: U x M x CA 125 (USS- 1 point each for multilocular cyst, evidence of solid areas, evidence of metastases, ascites, bilateral lesions, U=0 for USS score of 0, U=1 for USS score of 1, U=3 for USS score of 2-5) U x M x CA 125 (USS- 1 point each for multilocular cyst, evidence of solid areas, evidence of metastases, ascites, bilateral lesions, U=0 for USS score of 0, U=1 for USS score of 1, U=3 for USS score of 2-5) - M=3 for all PM women - RMI >250: 70% sensitivity and 90% specificity

18 Ovarian cysts in PM women Is ovarian cyst <5cm, unilateral, unilocular, echo-free with no solid parts or papillary formations, CA 125 <30: conservative management as 50% will resolve in 3 months, repeat scan in 4 months If cyst reduced or unchanged and CA 125 normal, discharge after 1 yr If persists and women requests surgery: laparoscopic oophorectomy

19 PCOS Truncal obesity, oligomenorrhoea, anovulation, infertility, hirsutism, acne, Familial Diagnosis by >LH/FSH ratio, USS 10-20% risk in middle age for type II diabetes FBS, urinalysis for glycosuria annually Lipid profile: fasting cholesterol, lipids and TGs Risk of gestational diabetes

20 PCOS Small risk of endometrial hyperplasia, carcinoma: regular atleast 3-4monthly withdrawal bleeds COC (dianette) Ovulation induction for infertility Exercise and weight control Metformin mg bd

21 Investigations for infertility Screening for chlamydia before uterine instrumentation If no significant gynae history: HSG + scan If significant gynae history: laparoscopy + dye test 84% couples conceive within 1 yr and 92% in 2 yrs 94% at 35yrs age and 77% at 38 yrs age will conceive within 3yrs of trying If BMI >29, 29, <19, will take longer to conceive

22 Investigations for infertility Advise folic acid 400mcg/day (5mg with antiepileptic medication or prev history) Rubella susceptibility screening D2 FSH, LH D21 progesterone in 28 day cycle TFT and prolactin, if oligoamenorrhoea Limited treatment cycles with clomiphene If BMI>25, offer metformin with clomiphene

23 Menorrhagia If no IMB or PCB and no other symptoms: -uterus 8-10wks: FBC, TFT, reassure -Uterus >10wks/pelvic mass: scan, refer -If taking tamoxifen, unopposed oestrogens, PCOS, obese: refer Treatment: -COC, POP, Depo provera -Mefenamic acid 500mg tds & Tranexamic acid 1g tds for 3 months initially -Mirena IUS

24 USS requests Accurate patient details with contact number LMP Result of UPT History / clinical findings and/or suspected diagnosis - in order to prioritise appropriately Patients may have unrealistic expectations about appointment times Approximately 130 gynaecology scan requests are received each week At present there is a 16 week waiting list for non- urgent USS requests

25 Thank you


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