What the Bleep?

Common calls for junior doctors in

O&G
Dr Alice Knowles
 What shall we talk about?
• Foundation year jobs in O&G
• How to survive
• Things that you will find useful
• Common things
• Scary things
• You will do more Gynae than Obs as a
foundation year trainee. Leave the really
terrifying stuff to the Reg!
 Common Calls/ Scary Calls
GYNAE OBS
• Early pregnancy • Pre-eclampsia and
complications/ ectopic? eclampsia
• Hyperemesis • Major obstetric
haemorrhage
• Bartholin’s/Labial cysts
• PV bleeding in pregnancy
• Pelvic pain and or bleeding
• Abdominal pain in
PV outside of pregnancy
pregnancy
• Prolapses and Procedentia
• Spontaneous rupture of
• Post operative membranes
complications • Premature labour
 Women Bleed
• Grade 1 Up to about 15% loss of effective blood volume (~750ml in an
average adult who is assumed to have a blood volume of 5 liters). This leads
to a mild resting tachycardia and can be well tolerated in otherwise healthy
individuals.
• Grade 2 Between 15-30% loss of blood volume (750-1500ml) will provoke a
moderate tachycardia and begin to narrow the pulse pressure. The time
taken for the capillaries to refill after 5 seconds of 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 (<0.5ml/kg/hr in adults) are seen.
• Grade 4 At 40-50% loss of blood volume (2000 -2500 ml) profound
hypotension will develop and if prolonged will cause end-organ damage and
death.
 Case 1 Mrs W
• 32 year old P0G1
• 8/40 by dates
• 2 days of brownish PV loss and mild cramps
• Heavier this morning with fresh red blood and
clots
• 5/10 severity lower abdominal pain
 Bleeding and/ or abdominal pain with a
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 (UTI, appendicitis, renal calculi)
 Early pregnancy losses
• Miscarriage is a loss of pregnancy before 24 weeks
(age of viability). Most common <12/40
• Threatened miscarriage, bleeding and or crampy pain.
Closed cervical os.
• Inevitable miscarriage, heavy bleeding and pains. Open
cervical os.
• Incomplete miscarriage, retained products of
conception closed cervical os.
• Missed miscarriage. Non viable pregnancy but
retained, closed cervical os.
 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!
 History
• Previous pregnancies and outcomes.
• LMP and menstrual history.
• Has a pregnancy test been done? Where and
when?
• Has the patient been scanned in this
pregnancy?
• Any signs or symptoms of infection?
• ALWAYS THINK ABOUT ECTOPIC PREGNANCY
 Examination
• Remember to check for signs of shock, look at the
vital signs, look at the patient as a whole.
• Abdominal examination. Any features of
peritonitis?
• Look at the pads, ask yourself is the patient
soaking through pads/clothing/bedding?
• Speculum- cervical os open or closed? Products
of conception seen? If in cervical canal get them
out. Cervical cause for bleeding seen?
 Immediate management
• ABC systematic approach to the sick patient.
• IV access
• Bloods FBC, HCG, Progesterone, G&S
• Analgesia
• IV fluids as required Crystalloid or if required
blood
 Next steps
• Interpretation of blood tests.
• Discuss with on call SPR, does this patient
need medical management/surgical
management of bleeding
• TV USS. If CVS stable, not heavy bleeding or
severe pain consider EPAU
 Looking at the blood results
• Normal βhCG levels and ultrasound findings
• < 25 iu/l – consider as if negative
• 100 on first day of missed period
• <1000 – No intrauterine (IU) gestation sac visible on TVS
• >1500 - consistent with visible gestation sac (4mm) equivalent to
5+4 weeks
• Twin pregnancy will be associated with a relatively high βhCG for a
smaller sac size
• βhCG levels double over 48hrs in 85% of normal pregnancies. An
empty uterus and suboptimal rise in βhCG to over 1000 iu/l is
suggestive of ectopic pregnancy (Sensitivity 90%, specificity 98%).
Remember its not always straight forward

• Ectopic pregnancy can be associated with a low

level of βhCG

• 15% of normal intrauterine pregnancies have a

sub-optimal βHCG rise.

• 17 % ectopic pregnancies have a normal HCG

doubling time
 Progesterone
• Only one initial sample required at presentation.
• <12 nmol /L - suggests failed pregnancy
regardless of location
• 32-64 nmol/L - majority of ectopic pregnancies.
• Ectopics with high progesterone levels are more
likely to behave aggressively and rupture.
• >80 nmol/L - suggests viable intrauterine
pregnancy (98% viable IU pregnancies)
 Anti D
• Blood group testing and Anti-D
• Anti-D is not required before 12 weeks
gestation, unless bleeding is heavy and
associated with pain. Anti-D is required at any
gestation for ERPC, or ectopic pregnancy
managed medically or surgically. Where there
is clinical doubt Anti-D should be given. Dose:
Anti-D Immunoglobulin 1250iu. via a
preloaded syringe for all sensitising incidents.
 Management
• Expectant management
• Medical 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 and
Ashermann's Syndrome, with a repeat ERPC rate of 2-
3%.
 Follow up
• Advise them that they may continue to bleed for
up to 3 weeks
• Do a repeat urine pregnancy test in 2 weeks
• Rescans after miscarriage
• A scan is not required if the urine pregnancy test
is negative or the serum βHCG is less than 25iu/l.
• Do not rescan to investigate bleeding following a
previous scan diagnosing complete miscarriage
with ET <15mm.
 Ectopic Pregnancy
• Should always be considered
• Most commonly presents 6-8 weeks post the
LMP however this can vary, especially if not tubal
ectopic
• Classic symptoms include abdominal pain (99%
of cases) amenorrhoea (74%) and vaginal
bleeding (56%)
• Bleeding is often darker in colour and less heavy
than during miscarriage but not always
 Clinical signs
• These can vary wildly
• A small un-ruptured ectopic pregnancy will often
yield few or no clinical signs
• A larger ectopic may create a palpable adnexal
mass or tenderness, and or cervical excitation.
• A ruptured or leaking tube may cause shoulder
pain (blood under the diaphragm) an urge to
defecate (blood in the pouch of Douglas) or
peritonitis.
 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
 Remember
• This is an extremely emotional time for
woman and can be equally distressing for her
partner.
• Never make assumptions.
• Give information about the Miscarriage
association and psychological support.
 Case 2 Miss K
• 20 year P1G2
• Severe vomiting in her first pregnancy
• Has had severe nausea and vomiting in the
last 3 weeks
• Not responding to antiemetics from GP
• Last ate 3 days ago
• Was managing sips of fluid until yesterday.
 Hyperemesis
• 50% of pregnant women suffer with nausea and vomiting
• Hyperemesis gravidarum (HG) is defined as persistent
vomiting in pregnancy, resulting in the inability to
maintain adequate hydration and fluid and electrolyte
levels.
• It occurs in 1% of pregnancies.
• Severe/ poorly controlled cases risk intrauterine growth
restriction.
• At its worst it can lead to Wernicke’s encephalopathy,
central pontine myelinolysis and maternal death.
 Clinical features

• Onset in always in first trimester, usually 5-6 weeks gestation,

peaking at 11 weeks gestation

• Nausea and vomiting

• Weight loss and muscle wasting

• Ketosis

• Signs of dehydration – tachycardia and postural hypotension

 Initial assessment
• Weight
• Pulse
• Lying and standing blood pressure
• Urinalysis + MSU – no indication for IV fluids if normal urine
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 once
hyperemesis resolved, recommend re-check TFT in 2nd Trimester.
• Ultrasound scan only if not yet done to exclude molar/twin pregnancy
 Management
• Rehydrate and replace electrolytes
• Do not give Glucose in fluids as it can precipitate
Wernickes
• Twice daily urinalysis
• Thiamine
• Anti-emetics (cyclizine/metoclopramide/stemetil
• VTE prophylaxis
• If refractory to treatment discuss with senior, may decide
to give ondansetron, steroids or even elect for TOP in life
threatening cases/ maternal request.
 Case 3 Mrs E
• 72 year old lady
• Painful lump down below
• Started 5 days ago
• Can’t walk because it is so sore
• Seen by GP who gave antibiotics but it has not
helped.
Bartholin’s and labial abscesses
• Bartholins glands: two
small glands next to the
entrance of the vagina
• Secrete fluid to keep the
area moist
• The ducts are about 2cm
long and can get blocked!
• If blocked they can swell
and form a cyst
• If this gets infected it
becomes an abscess
 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 or
are large, fluctuant and painful they will need
I&D
• The only difference in management is that you
won’t marsupialise a labial abscess.
 Marsupialisation
• Suture the duct open to aid drainage and
prevent recurrence of the cyst.
• Recurrence can also be prevented by
removing the offending gland altogether.
• In an older patient or if there is anything
unusual about the look of the lump, send a
sample for histology.
 Case 4 Mrs S
• 24 year old woman P2G2 both NVD
• Negative HCG today
• Chronic pelvic pain on regular opioid analgesia
• Attending A&E with severe exacerbation of LIF
pain
 Approach to the patient
• Chronic pain patients get sick too!
• History of the pain in detail SOCRATES

• Site - Where is the pain?

• Onset - When did the pain start, and was it sudden or gradual?
• Character - What is the pain like? An ache? Stabbing?
• Radiation - Does the pain radiate anywhere?
• Associations - Any other signs or symptoms associated with the pain?
• Time 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

 Initial assessment
• Observations
• General Examination
• Abdominal Examination
• Pelvic examination including speculum and swabs
• MSU is always important, confirm negative HCG “oh
no doctor there is no way I could be pregnant”
• Bloods for FBC, CRP, Also cultures and consider G&S
if required
• Transvaginal Ultrasound scan
 Differential diagnosis
• Non gynae abdo/pelvic pain
– Related to bowel, bladder, kidneys and renal tract or even referred hip pain. Sickle
cell disease.
• Mittelshmertz
• Ovarian Cyst Accident
• Ovarian torsion
• Degenerating fibroid
• Pelvic inflammatory disease
• Endometritis - infection of the endometrium
• Endometrosis- endometrial tissue in the wrong place
• Menstrual pain
• Uterine anomoly- only to be considered in the young patients
• Ovarian hyperstimulation syndrome
PV Bleeding with a negative pregnancy test

• Is the bleeding definitely PV?

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

Normal menstruation can be characterised by

• Duration 2-7 days
• Flow less than 80ml
• Occurring in cycles of 24-35 days
 Approach to the patient
• Are they compromised?
• Where is the bleeding
– Lower genital tract (vulva, vagina, cervix)
– Upper genital tract (Uterine, fallopian tubes
ovaries)
– Renal/urinary tract, bowel
• Do they need admission?
 Diagnosis and management
• History and examination including PV and if
required PR
• MSU, FBC, U&E, CRP, G&S
• If menstrual consider hormone therapy
(contraceptive pill or IUS) and Tranexamic acid
• If not requiring admission then arrange an
outpatient ultrasound and gynae clinic follow
up.
 Prolapses and Procedentia
• Usually dealt with in outpatients
• Will only come as emergency admission if
there is complete uterine prolapse with
suspected compromise of the tissues and
ulceration.
• Really only mentioning it because it looks
pretty scary but is quite easy to deal with.
 Post operative complications
• Similar to any surgical speciality
• It will be your bread and butter of ward work
– Bleeding
– Infections
– Post op ileus
– Urinary retention
 Final Slide
• Be organised and enthusiastic
• Prioritise
• Always get a chaperone for intimate
examination
• Don’t be afraid to ask for help
• Remember that most women can be
emotionally labile, especially when hormonal.
 Thank you
• References:
• Up to date online resource
• Hospital guidelines
• Patient.co.uk