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Topics covered

Keeping the right patients away from Hospital Park Inn Hotel Telford 16 September 2015 Bernie Bentick. Topics covered. Infertility Ovarian Hyperstimulation Syndrome (OHSS) Bleeding in Early Pregnancy Hyperemesis Gravidarum. Infertility Definition: NICE.

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Topics covered

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  1. Keeping the right patients away from HospitalPark Inn Hotel Telford 16 September 2015Bernie Bentick

  2. Topics covered • Infertility • Ovarian Hyperstimulation Syndrome (OHSS) • Bleeding in Early Pregnancy • Hyperemesis Gravidarum

  3. Infertility Definition: NICE Failure to conceive after regular unprotected intercourse for 2 years in the absence of known reproductive pathology BUT: If no conception after 1 year, couples should be offered further investigation, including semen analysis and assessment of ovulation

  4. Infertility – NICE Guidelines for General Practice General Pre-conception advice & folic acid Rubella antibody screening Cervical screening, when appropriate Early referral ( at presentation ) if history of problem which could cause subfertility

  5. NICE: Principal Investigations in Primary Care Semen analysiswith repeat after 3 months, if abnormal, but ASAP if severe abnormality Ovulation testsProgesterone mid luteal Day 21 / 28 Hormone profile if cycle irregular, Day 2 to 8 Day 2 FSH Ovulation Prediction Kits – available over the counter

  6. NICE : General Lifestyle Advice in Primary Care Sexual intercourse every 2-3 days  1-2 units alcohol/week for women  2-3 units alcohol /week for men Smoking cessation programme for smokers Body mass index of 19-29 Information about prescribed, over the counter and recreational drugs Information about occupational hazards

  7. NICE: WHEN TO REFER At presentation when history of predisposing factors or woman age  35 years regardless of duration of subfertility After 1 year when investigations abnormal or woman 30 to 34 years After 2 years when investigations normal and woman < 30 years Discourage when woman  41 years - very poor pregnancy rates / high miscarriage rates - unless considering Donor Oocyte IVF – 50% preg per cycle - minimal NHS funded treatment in this age group

  8. Internet Resources for GP’s and patients www.shropshirefertility.co.uk www.shropshireivf.co.uk www.hfea.gov.uk http://guidance.nice.org.uk/CG11/NICEGuidance/pdf/English http://guidance.nice.org.uk/CG11/PublicInfo/pdf/English

  9. Incidence of OHSS Some degree in all women who respond to ovulation induction (including clomiphene, gonadotrophins and GnRH analogues) Mild 20-33% (of IVF cycles) Moderate 3-6% Severe 0.1 -2%

  10. Usually Out-Patient Management • 1 Mild OHSS:- Abdominal bloating • Mild abdominal pain • Ovarian size usually ‹8 cm • 2 Moderate OHSS:- Moderate abdominal pain • Nausea ± vomiting • Ultrasound evidence of ascites • Ovarian size usually 8–12 cm

  11. Out-Patient Management of suspected mild/moderate OHSS • Analgesia: Paracetamol (occasionally Opiates) • Anti-emetic if significant vomiting (see Hyperemesis drugs) • Drink to quench thirst • Contact Fertility Nurse of Treatment Unit (Office Hours) • Fertility Nurse will arrange clinical review, ultrasound & necessary bloods then see/contact every 2-3 days until resolves

  12. In-Patient Treatment required • 3 Severe OHSS: Clinical ascites (occasionally hydrothorax) • Oliguria • Haemoconcentration haematocrit ›45% • Hypoproteinaemia • Ovarian size usually ›12 cm • 4 Critical OHSS: Tense ascites or large hydrothorax • Haematocrit ›55% • White cell count ›25 000/ml • Oligo/anuria • Thromboembolism • Acute respiratory distress syndrome

  13. Management of suspected severe OHSS • Contact Gynae on-call team to arrange immediate emergency admission to Gynae Ward • Severe OHSS protocol will be commenced • On-call Consultant & Fertility Team involved • HFEA will be informed

  14. Bleeding in early pregnancy(1) • Positive pregnancy test & bleeding/pain ‹ 16 weeks • Occurs in at least 20% of all pregnancies • Refer to EPAS for next appointment within 48hrs

  15. Bleeding in early pregnancy(2) • Only if unwell or high risk of ectopic: refer via GATU for review before 6 pm, otherwiseGynae Ward • GATU & Gynae Ward are NOT a fast track to scan • If <5/40 commence serial BHCG’s in the surgery – ask EPAS for advice

  16. Hyperemesis Gravidarum (HEG) • HEG refers to persistent nausea and vomiting associated with fluid & electrolyte disturbance or nutritional deficiency. weight loss >5% of prepregnancy weight. • Most severe manifestation of the spectrum of nausea & vomiting of pregnancy.

  17. Morning Sickness: Dotted line-nausea Solid line-vomiting

  18. Anti-emetics • No evidence that any one anti-emetic is superior to another • Anticholinergics/Antihistamines (H1 receptor antagonists): Cyclizine & Promethazine • Phenothiazines: Prochlorperazine & Chlorpromazine • Dopamine receptor antagonists: Metoclopramide & Domperidone • Selective 5-hydroxytryptamine receptor antagonists (5-HT3): Ondansetron • or combinations of these agents • Proton pump inhibitors & H2 receptor antagonists for dyspepsia: Omeprazole & Ranitidine

  19. Vitamins • Folic acid 400ug daily • Consider Vitamin B1 & B6 in patients with protracted course • Vitamin B1 (Thiamine) 25 - 50mg PO TDS for those with prolonged vomiting OR • Pabrinex weekly injections. • Vitamin B6 (Pyridoxine) 10mg TDS especially for those with nausea is the main symptom.

  20. HYPEREMESIS FLOW CHART Severe nausea, vomiting, dehydration, ketonuria Admit to GATU for rapid rehydration before 12noon or 9am* the following day ▼ History Investigations – FBC, U&E, LFT, MSU TFT& Blood sugar (1st visit only) On subsequent visits – U&Es only USS to be arranged (1st visit only if not had previous scan) ▼ Rapid intravenous (IV) hydration 3 litres of Sodium Chloride 0.9% or Hartmann’s solution at 500 mls/hr (3litres in 6 hrs) If K < 3.3 mmol give Sodium chloride 0.9% + 40 mmols of KCL per bag X 2 bags at 250ml/hour ▼ Anti-emetics Cyclizine 50 mgs IV ▼▼ Good response, normal U&E’s Poor response or Ultrasound (1st admission) K+ < 3.3mmol/l ▼▼ Discharge after 4 to 6 hours Do not discharge on regular anti-emetics VTE risk assessment Cyclizine 50 mgs tds and Promethazine 25 mgs bd *GP to give antiemetic in the Surgery if for following day

  21. OTHER CAUSES OF VOMITING IN PREGNANCY • Urinary tract infection • Gastritis • Cholecystitis • Appendicitis • Peptic ulcer • Hepatitis • Pancreatitis • Migraine • CNS disease • Labyrinthitis • Meniere’s disease • Thyrotoxicosis • Addison’s disease • Uremia • Hypercalcemia • Eating disorders • Iron • Opioids

  22. SUMMARY • Fertility Referrals according to NICE (adopted by CCG) • OHSS usually managed as an Outpatient by Fertility Unit • Bleeding/pain in early pregnancy managed by EPAS, with admission rarely needed (for haemodynamically unstable patient) • Hyperemesis gravidarum is managed as Day Case by GATU & ward admission rare

  23. GENERAL FERTILITY STATISTICS -UNSELECTED POPULATION 80% chance of pregnancy in 1st year 86% chance of pregnancy by 2nd year BUT: fertility declines with a woman’s age

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