what the bleep

8/7/2019 What the Bleep

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What the Bleep?

Common calls for junior doctors in

O&GDr Alice Knowles


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What shall we talk about?

Foundation year jobs in O&GHow to survive

Things that you will find usefulCommon thingsScary things

You will do more Gynae than Obs as afoundation year trainee. Leave the reallyterrifying stuff to the Reg!


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Common Calls/ Scary Calls

GYNAEEarly pregnancycomplications/ ectopic?HyperemesisBartholin s/Labial cystsPelvic pain and orbleeding PV outside of pregnancy

Prolapses andProcedentiaPost operativecomplications

OBSPre-eclampsia andeclampsiaMajor obstetrichaemorrhagePV bleeding in pregnancyAbdominal pain inpregnancy

Spontaneous rupture of membranesPremature labour


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Women BleedGrade 1 U p to about 15% loss of effective blood volume (~750ml inan average adult who is assumed to have a blood volume of 5liters). This leads to a mild resting tachycardia and can be welltolerated in otherwise healthy individuals.Grade 2 Between 15-30% loss of blood volume (750-1500ml) willprovoke a moderate tachycardia and begin to narrow the pulsepressure. The time taken for the capillaries to refill after 5 secondsof pressure (capillary refill time) will be extended.Grade 3 At 30 - 40% loss of effective blood volume (1500 - 2000 ml)the compensatory mechanisms begin to fail and hypotension,tachycardia and low urine output (


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Case 1 Mrs W

32 year old P0G18/40 by dates

2 days of brownish PV loss and mild crampsHeavier this morning with fresh red blood andclots

5/10 severity lower abdominal pain


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Bleeding and/ or abdominal pain witha positive pregnancy test

Miscarriage

Ectopic pregnancy

Other causes Ruptured or torted copus luteal cyst Inplantation bleed Degenerating fibroid Ectropion/ cervical pathology Non gynae cause of pain ( U TI, appendicitis, renal calculi)


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Early pregnancy losses

Miscarriage is a loss of pregnancy before 24weeks (age of viability). Most common


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Approach to the patient

Initial assessment- how sick is the patient?How much blood loss? How much pain?

If the patient is unstable deal with this first!


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History

Previous pregnancies and outcomes.LMP and menstrual history.

Has a pregnancy test been done? Where andwhen?Has the patient been scanned in this

pregnancy?Any signs or symptoms of infection?ALWAYS THINK ABOU T ECTOPIC PREGNANCY


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Examination

Remember to check for signs of shock, look at thevital signs, look at the patient as a whole.Abdominal examination. Any features of peritonitis?

Look at the pads, ask yourself is the patientsoaking through pads/clothing/bedding?

Speculum- cervical os open or closed? Productsof conception seen? If in cervical canal get themout. Cervical cause for bleeding seen?


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Immediate management

ABC systematic approach to the sick patient.IV access

Bloods FBC, HCG, Progesterone, G&SAnalgesiaIV fluids as required Crystalloid or if required

blood


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Next steps

Interpretation of blood tests.Discuss with on call SPR, does this patient

need medical management/surgicalmanagement of bleedingTVU SS. If CVS stable, not heavy bleeding orsevere pain consider EPA U


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Looking at the blood resultsNo rmal hCG levels and ultras o und findings< 25 iu/l consider as if negative100 on first day of missed period1500 - consistent with visible gestation sac (4mm)equivalent to 5+4 weeksTwin pregnancy will be associated with a relatively high

hCG for a smaller sac size

hCG levels do

ubleo

ver 48hrs in 85%o

f no

rmalpregnancies. An empty uterus and sub o ptimal rise inhCG to o ver 1000 iu/l is suggestive o f ect o pic pregnancy

(Sensitivity 90%, specificity 98%).


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Remember its not always straightforward

Ectopic pregnancy can be associated with a lowlevel of hCG

15% of normal intrauterine pregnancies have asub-optimal HCG rise.

17 % ectopic pregnancies have a no rmal HCGdo ubling time


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Progesterone

Only one initial sample required at presentation.

80 nmol/L - suggests viable intrauterinepregnancy (98% viable I U pregnancies)


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Anti D

B loo d gr o up testing and Anti-DAnti-D is not required before 12 weeksgestation, unless bleeding is heavy andassociated with pain. Anti-D is required at anygestation for ERPC, or ectopic pregnancymanaged medically or surgically. Where thereis clinical doubt Anti-D should be given. Dose:Anti-D Immunoglobulin 1250iu. via apreloaded syringe for all sensitising incidents.


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Management

Expectant managementMedical management

Delayed miscarriage can have Mifepristone first Incomplete miscarriage Misoprostol 400-800mcg If heavy bleeding consider 400mcg Misoprostol PR

Surgical management (up to 13/40) ERPC: Complication rate of 2-3% due to infection,

uterine perforation, incomplete evacuation andAshermann's Syndrome, with a repeat ERPC rate of 2-3%.


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Follow up

Advise them that they may continue to bleed forup to 3 weeksDo a repeat urine pregnancy test in 2 weeksR escans after miscarriageA scan is not required if the urine pregnancy testis negative or the serum HCG is less than 25iu/l.

Do not rescan to investigate bleeding following aprevious scan diagnosing complete miscarriagewith ET


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Ectopic Pregnancy

Should always be consideredMost commonly presents 6-8 weeks post theLMP however this can vary, especially if nottubal ectopicClassic symptoms include abdominal pain(99% of cases) amenorrhoea (74%) and

vaginal bleeding (56%)Bleeding is often darker in colour and lessheavy than during miscarriage but not always


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Clinical signs

These can vary wildlyA small un-ruptured ectopic pregnancy willoften yield few or no clinical signsA larger ectopic may create a palpable adnexalmass or tenderness, and or cervical excitation.A ruptured or leaking tube may cause

shoulder pain (blood under the diaphragm) anurge to defecate (blood in the pouch of Douglas) or peritonitis.


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Management

Expectant management Close follow up with EPMS, specific entry criteria.

Medical management Methotrexate ( kills the rapidly dividing cells)

Surgical management Laparoscopy with salpingectomy/salpingotomy


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Remember

This is an extremely emotional time forwoman and can be equally distressing for herpartner.Never make assumptions.Give information about the Miscarriageassociation and psychological support.


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Case 2 Miss K

20 year P1G2Severe vomiting in her first pregnancy

Has had severe nausea and vomiting in thelast 3 weeksNot responding to antiemetics from GP

Last ate 3 days agoWas managing sips of fluid until yesterday.


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Hyperemesis

50% of pregnant women suffer with nausea andvomitingHyperemesis gravidarum (HG) is defined as persistent

vomiting in pregnancy, resulting in the inability tomaintain adequate hydration and fluid and electrolytelevels.It occurs in 1% of pregnancies.

Severe/ poorly controlled cases risk intrauterinegrowth restriction.At its worst it can lead to Wernicke s encephalopathy,central pontine myelinolysis and maternal death.


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Clinical features

Onset in always in first trimester, usually 5-6 weeksgestation, peaking at 11 weeks gestation

Nausea and vomiting

Weight loss and muscle wasting

Ketosis

Signs of dehydration tachycardia and posturalhypotension


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Initial assessment

WeightPulseLying and standing blood pressureU

rinalysis + MSU

no indication for IV fluids if normalurine output and no ketones. Ketonuria requires hydration.

Bloods U +E s, creatinine, FBC, LFT, TFT (if persists)Thyroid function may be abnormal in 2/3 of cases. If clinically euthyroid,no action required unless grossly abnormal. Highly likely to resolve oncehyperemesis resolved, recommend re-check TFT in 2 nd Trimester.U ltrasound scan only if not yet done to exclude molar/twinpregnancy


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Bartholin s and labial abscesses

Bartholins glands: twosmall glands next to theentrance of the vaginaSecrete fluid to keep thearea moistThe ducts are about 2cmlong and can get blocked!If blocked they can swelland form a cystIf this gets infected itbecomes an abscess


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Basic points

Take the history and examine the patient

Is it a Bartholin s abscess or a labial abscess?

Labial abscess will not be in the classic position,usually starts as a spot or an ingrown hair.If they have failed treatment with antibiotics orare large, fluctuant and painful they will need I&DThe only difference in management is that youwon t marsupialise a labial abscess.


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Marsupialisation

Suture the duct open to aid drainage andprevent recurrence of the cyst.

Recurrence can also be prevented byremoving the offending gland altogether.In an older patient or if there is anythingunusual about the look of the lump, send asample for histology.


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Case 4 Mrs S

24 year old woman P2G2 both NVDNegative HCG today

Chronic pelvic pain on regular opioid analgesiaAttending A&E with severe exacerbation of LIFpain


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Approach to the patientChronic pain patients get sick too!History of the pain in detail SOCRATES

Site - Where is the pain?O nset - When did the pain start, and was it sudden or gradual?Character - What is the pain like? An ache? Stabbing?R adiation - Does the pain radiate anywhere?Associations - Any other signs or symptoms associated with the pain?T ime course - Does the pain follow any pattern?Exacerbating/Relieving factors - Does anything change the pain?

Severity - How bad is the pain? Scale out of 10

Menstrual History, Sexual History and Surgical History are important


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Initial assessment

ObservationsGeneral ExaminationAbdominal Examination

Pelvic examination including speculum and swabsMSU is always important, confirm negative HCG

oh no doctor there is no way I could bepregnant

Bloods for FBC, CRP, Also cultures and considerG&S if requiredTransvaginal U ltrasound scan


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Differential diagnosisNon gynae abdo/pelvic pain

Related to bowel, bladder, kidneys and renal tract or even referred hippain. Sickle cell disease.

MittelshmertzOvarian Cyst AccidentOvarian torsionDegenerating fibroidPelvic inflammatory diseaseEndometritis - infection of the endometriumEndometrosis- endometrial tissue in the wrong placeMenstrual painU terine anomoly- only to be considered in the young patientsOvarian hyperstimulation syndrome


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PV Bleeding with a negative pregnancytest

Is the bleeding definitely PV?Is the bleeding cyclical or not?Has this patient gone through the menopause.

Normal menstruation can be characterised byDuration 2-7 daysFlow less than 80ml

Occurring in cycles of 24-35 days


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Approach to the patient

Are they compromised?Where is the bleeding

Lower genital tract (vulva, vagina, cervix) U pper genital tract ( U terine, fallopian tubes

ovaries) Renal/urinary tract, bowel

Do they need admission?


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Diagnosis and management

History and examination including PV and if required PR

MSU

, FBC,U

&E, CRP, G&SIf menstrual consider hormone therapy(contraceptive pill or I U S) and Tranexamic acid

If not requiring admission then arrange anoutpatient ultrasound and gynae clinic followup.


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Prolapses and Procedentia

U sually dealt with in outpatientsWill only come as emergency admission if

there is complete uterine prolapse withsuspected compromise of the tissues andulceration.Really only mentioning it because it lookspretty scary but is quite easy to deal with.


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Post operative complications

Similar to any surgical specialityIt will be your bread and butter of ward work

Bleeding Infections Post op ileus U rinary retention


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Final Slide

Be organised and enthusiasticPrioritise

Always get a chaperone for intimateexaminationDon t be afraid to ask for help

Remember that most women can beemotionally labile, especially when hormonal.


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Thank you

References:U p to date online resource

Hospital guidelinesPatient.co.uk

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