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Obstetrics and Gynaecology Forum. Pradnya Pisal Jyoti Shah Annie Fowler. Early Pregnancy Unit. Lead Consultant: Pradnya Pisal 0208 3751250, 1267, 1979 Lead Sister: Annie Fowler 0208 3751240, 1958 Lead Sonographer: Jyoti Shah 0208 3751979. EPU.

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obstetrics and gynaecology forum

Obstetrics and Gynaecology Forum

Pradnya Pisal

Jyoti Shah

Annie Fowler

early pregnancy unit
Early Pregnancy Unit

Lead Consultant: Pradnya Pisal

0208 3751250, 1267, 1979

Lead Sister: Annie Fowler

0208 3751240, 1958

Lead Sonographer: Jyoti Shah

0208 3751979

slide3
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
slide4
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)
early pregnancy scans
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
value of uss post miscarriage
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
post miscarriage or post top
Post - miscarriage or post - TOP
  • 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 top8
Post - miscarriage or post - TOP
  • 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
screening for ovarian cancer
Screening for ovarian cancer
  • Not recommended in low risk population
  • Screening can be considered in women with:
    • 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
    • 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
    • 3 first or second degree relatives with bowel cancer and one case of ovarian cancer in the family
screening for ovarian cancer10
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 25-65 years age
  • Prophylactic oophorectomy and mastectomy does not prevent primary peritoneal cancer
suspected gynaecology pathology
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
endometrial assessment on pelvic scan
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
slide13
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
slide14
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
endometriosis
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
slide16
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
ovarian cysts in pm women
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)
    • M=3 for all PM women

- RMI >250: 70% sensitivity and 90% specificity

ovarian cysts in pm women18
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
slide19
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
slide20
PCOS
  • Small risk of endometrial hyperplasia, carcinoma: regular atleast 3-4monthly withdrawal bleeds
  • COC (dianette)
  • Ovulation induction for infertility
  • Exercise and weight control
  • Metformin 250-500mg bd
investigations for infertility
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, <19, will take longer to conceive
investigations for infertility22
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
menorrhagia
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

uss requests
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