Be ready !!!The basics are changing

Dr/ Mahmoud Abdel-AleemAssistant Professor of Obstetrics and

Gynecology

INTRODUCTION

• Human mind is always scrutinizing and searching for new information.

• Science is always changing and evolving.– Meticulous research is being done.– More new types of research.– Better assessment methods.

What do we need to discuss?

Major changes in our basic practice involving common day-to day problems

FOR WHOM IS THIS PRESENTATION?

• For guidelines developers: adopt the recent change to be up-to-date.

• For academics: lecture preparation• For specialists: application and standardization of

new knowledge and practice.• For postgraduate students: preparation for an exam• For undergraduate students: preparation for an

exam• For researchers: for conducting and publishing

research.

IT LOOKS LIKE AN “ORANGE AND PEACHES PRESENTATION”

Selected Hot Topics• Pregnancy:

– Pre-eclampsia.– Diabetes mellitus during pregnancy.

• Normal labour– First stage.– Second stage.– Third stage.

• Venous Thromboembolism during pregnancy and labour.

• Gynecology: Abnormal uterine bleeding.

Common.Practical.

Recent Major changes.

Hypertensive disorders during pregnancy

Why important?

Increasing incidence

Contribution to

prematurity

Less than optimal care

Contribution to near-miss

cases

Contribution to maternal

mortality

• ACOG Task Force on Hypertension in Pregnancy.• A 99-page report. • Published on November 2013.• Inclusive of the diagnosis and management of

preeclampsia.• Culmination of two years of hard work by

the 16-member ACOG task force.

Classification

• Pre-eclampsia / Eclampsia• Chronic HT.• Chronic HT with superimposed PE.• Gestational HT.

A changing paradigm !!!

• The problem is that many patients with preeclampsia don't have enough proteinuria to meet the former criteria, so their diagnosis and treatment are delayed.

Starting by definitionNow Was

No longer requires the detection of proteinuria.

Persistent HT that develops during pregnancy or during the postpartum period that is associated with:Proteinuria

ORNew development of thrombocytopenia.hepatic or renal dysfunction.Pulmonary edema.Signs of brain trouble such as seizures and/or visual disturbances.

Hypertension

Plus

Proteinuria

Next: typesNow Was

PreeclampsiaPreeclampsia with severe features.

Mildsevere

Preeclampsia is a dynamic disease:We don’t know

When or at Which rate

or in Whom it will change from mild to severe

IUGR is eliminated. Not a feature of severity

Hypertension

• As it is; no change• 140/90 mmHg or more on 2 readings 6 hours

apart at bed rest unless anti-HT drugs were given.

• 160/110 mmHg or more on single reading at bed rest unless anti-HT drugs were given.

Proteinuria

• Proteinuria: 300 mg/protein in a 24-hr urine collection.

• A protein/creatinine 0.3

• Dipstick is not recommended because of wide variability. It is only to be used if other methods aren’t available. Proteinuria 1+ = diagnosis.

• Massive proteinuria > 5gm. Not to be used.

Protein dipstick grading

DesignationApprox. amount

Concentration[6] Daily[7]

Trace 5–20 mg/dL

1+ 30 mg/dL Less than 0.5 g/day

2+ 100 mg/dL 0.5–1 g/day

3+ 300 mg/dL 1–2 g/day

4+ More than 300 mg/dL More than 2 g/day

Then: treatmentNow Was Prophylactic magnesium sulphate is used in:BP 160/110 or more.BP 140/90-159/109 PLUS symptoms.

Prophylactic Magnesium sulphate was used in Severe PE with symptoms

Termination is at:37 weeks: no severe features34 weeks: associated severe features

Termination is at:38 weeks: mild cases34 weeks: severe cases

Last of All: Prevention of PE

• Vitamin C: no role• Vitamin E: no role.• Calcium:– Normal takers: no role.– Low takers: reduces the severity of PE.

• Aspirin: 60-80 mg/day.– Low risk: no value– High risk: slight decrease in PE and adverse

perinatal outcome.

Take home message

• Don’t wait proteinuria to diagnose PE. • On diagnosis of new onset HT: do platelet

count, liver enzymes, serum creatinine, ask for visual symptoms.

• There is no method to predict, to prevent PE. The only way to help women is early diagnosis and early treatment.

• Use low dose aspirin only in high risk women.

Abnormal Uterine Bleeding

FIGO classification.

Why important?

High incidence

Contribution to anemia

Lowering the effective

woman load weight in society

Contribution to increasing

surgical interventions

Contribution to low

quality of life

• The Federation Internationale de Gynecologie et d’Obstetrique (FIGO)

• Date: November 2010.• The causes of AUB in the reproductive years. • A collaborative, international group consisting

of reproductive clinicians, haematologists, basic scientists.

• The group had representation from six continents

Normal values for menstrual flow

Definitions adopted

• Acute AUB: an episode of bleeding in a woman of reproductive age, who is not pregnant, that is of sufficient quantity to require immediate intervention to prevent further blood loss.

• Chronic AUB: bleeding from the uterus that is abnormal in frequency, duration and/or volume and has been present for the majority of the previous six months.

• Inter-menstrual bleeding (IMB): bleeding between clearly defined cyclic and predictable menses and includes random episodes as well as predictable episodes occurring at the same time each month.

Definitions abolished

PALM-COEIN SYSTEM

Take home message II

• The PALM-COEIN system is readily applicable.

• Let us try to use the new classification system for abnormal uterine bleeding as regards the norms, definitions, classification.

And So !!!

Do we have to follow the changes ?

• We should be in accordance with changes as the scientific society is now “A small village”.

• Although the changes may look both few and little, they are of great value in defining, standardizing, diagnosing and treating diseases.

• We were already following older recommendations, and once they change, we have to apply the changes especially if these are simple and not sophisticated.