Obstetrics and Obstetrics and Gynaecology ForumGynaecology Forum

Pradnya PisalPradnya Pisal

Jyoti ShahJyoti Shah

Annie FowlerAnnie Fowler

Early Pregnancy UnitEarly Pregnancy Unit

Lead Consultant: Pradnya PisalLead Consultant: Pradnya Pisal

0208 3751250, 1267, 19790208 3751250, 1267, 1979

Lead Sister: Annie FowlerLead Sister: Annie Fowler

0208 3751240, 19580208 3751240, 1958

Lead Sonographer: Jyoti ShahLead Sonographer: Jyoti Shah

0208 37519790208 3751979

EPUEPU

Pregnant women with pain and/or bleeding Pregnant women with pain and/or bleeding from 6-14 weeks amenorrhoea (positive from 6-14 weeks amenorrhoea (positive UPT)UPT)Pregnant women with <6 weeks Pregnant women with <6 weeks amenorrhoea who have an abnormally amenorrhoea who have an abnormally light last period where there is a suspicion light last period where there is a suspicion of or who have a high risk factor for of or who have a high risk factor for ectopic pregnancyectopic pregnancyAppointment system accessible only to Appointment system accessible only to GPs and midwives and hospital doctorsGPs and midwives and hospital doctors

EPUEPU

Routine scanning in very early pregnancy is Routine scanning in very early pregnancy is not advised as it will generate unnecessary not advised as it will generate unnecessary anxiety if the pregnancy is not visualised on anxiety if the pregnancy is not visualised on scanscanPatients should be given a realistic idea Patients should be given a realistic idea about the scan appointment and only genuine about the scan appointment and only genuine cases should be referred to EPU as there are cases should be referred to EPU as there are only fixed slots available (not for routine only fixed slots available (not for routine dating)dating)

Early pregnancy scansEarly pregnancy scansEarliest gestational sac on TA scan: 6 weeksEarliest gestational sac on TA scan: 6 weeksEarliest viable pregnancy on TA scan:7 weeksEarliest viable pregnancy on TA scan:7 weeksEarliest gestational sac on TV scan: 5 weeksEarliest gestational sac on TV scan: 5 weeksEarliest viable pregnancy on TV scan: 6 weeksEarliest viable pregnancy on TV scan: 6 weeksAt 1000 IU, an intrauterine gestational sac on TV At 1000 IU, an intrauterine gestational sac on TV scanscan85% of viable intrauterine pregnancies show 85% of viable intrauterine pregnancies show doubling of HCG in 48 hrsdoubling of HCG in 48 hrsSuboptimal increase in HCG over 48 hrs without Suboptimal increase in HCG over 48 hrs without intrauterine gestational sac seen on TV scan is s/o intrauterine gestational sac seen on TV scan is s/o ectopic pregnancyectopic pregnancy

Value of USS post-miscarriageValue of USS post-miscarriage

1 in every 5 clinically known pregnancies will 1 in every 5 clinically known pregnancies will miscarry in the first trimestermiscarry in the first trimester

Post miscarriage or post TOP bleeding: scans Post miscarriage or post TOP bleeding: scans are unreliable to confirm or exclude retained are unreliable to confirm or exclude retained products of conceptionproducts of conception

USS cannot differentiate between blood, clots or USS cannot differentiate between blood, clots or POC in the uterine cavityPOC in the uterine cavity

Surgical evacuation: complications in 2% cases: Surgical evacuation: complications in 2% cases: uterine perforation, cervical tears, intra-uterine perforation, cervical tears, intra-abdominal trauma, intrauterine adhesions, abdominal trauma, intrauterine adhesions, haemorrhage, mortality 0.5/100,000haemorrhage, mortality 0.5/100,000

Management of post-miscarriage or post-Management of post-miscarriage or post-TOP bleeding will depend on clinical TOP bleeding will depend on clinical findingsfindingsIf the bleeding is heavy and worrying, refer If the bleeding is heavy and worrying, refer to A&Eto A&EIf cervical os closed even with moderate If cervical os closed even with moderate bleeding with/without uterine tenderness, bleeding with/without uterine tenderness, treat with augmentin or combination of treat with augmentin or combination of cephelexin and metronidazole for 7 days.cephelexin and metronidazole for 7 days.Screen for PID, especially chlamydiaScreen for PID, especially chlamydia

Post - miscarriage or post - TOPPost - miscarriage or post - TOP

Post - miscarriage or post - TOPPost - miscarriage or post - TOP

If bleeding not settled after course of antibiotics, If bleeding not settled after course of antibiotics, refer as urgent case to a consultant to be seen refer as urgent case to a consultant to be seen in the next consultant clinicin the next consultant clinic

If bleeding is >6 weeks post miscarriage, and If bleeding is >6 weeks post miscarriage, and bimanual examination is unremarkable, treat bimanual examination is unremarkable, treat with a short course of hormones: COC or with a short course of hormones: COC or progestogensprogestogens

Counsel women to expect moderate bleeding for Counsel women to expect moderate bleeding for postnatally, (at any gestation)postnatally, (at any gestation)

Next period may be delayed to 6 weeksNext period may be delayed to 6 weeks

Screening for ovarian cancerScreening for ovarian cancer

Not recommended in low risk populationNot recommended in low risk populationScreening can be considered in women with:Screening can be considered in women with:

2 first degree relatives with ovarian cancer2 first degree relatives with ovarian cancer 1 first degree relative with ovarian cancer and 1 first 1 first degree relative with ovarian cancer and 1 first

degree relative with breast cancer diagnosed under degree relative with breast cancer diagnosed under the age of 50 the age of 50

One first degree relative with ovarian cancer and 2 One first degree relative with ovarian cancer and 2 first or second degree relatives with breast cancer, first or second degree relatives with breast cancer, diagnosed under the age of 60diagnosed under the age of 60

Presence of faulty ovarian cancer causing gene in the Presence of faulty ovarian cancer causing gene in the familyfamily

3 first or second degree relatives with bowel cancer 3 first or second degree relatives with bowel cancer and one case of ovarian cancer in the family and one case of ovarian cancer in the family

Screening for ovarian cancerScreening for ovarian cancer

Women with a significant family history can be Women with a significant family history can be referred to a genetics clinic from where they can referred to a genetics clinic from where they can either be referred for the UKFOCSS or for either be referred for the UKFOCSS or for BRCA1 gene testing if appropriateBRCA1 gene testing if appropriate

Yearly CA125 and ovarian scan from 25-65 Yearly CA125 and ovarian scan from 25-65 years ageyears age

Prophylactic oophorectomy and mastectomy Prophylactic oophorectomy and mastectomy does not prevent primary peritoneal cancerdoes not prevent primary peritoneal cancer

Suspected gynaecology pathologySuspected gynaecology pathology

Incidental finding in asymptomatic women withIncidental finding in asymptomatic women with-uterine size 8-10 weeks: reassure-uterine size 8-10 weeks: reassure-uterine size >10 weeks: pelvic scan, refer if -uterine size >10 weeks: pelvic scan, refer if appropriate appropriate

Symptomatic women < 40 yrs old: pelvic scan if uterus Symptomatic women < 40 yrs old: pelvic scan if uterus is bulky, refer if appropriateis bulky, refer if appropriateAsymptomatic women < 40 yrs old with adnexal mass: Asymptomatic women < 40 yrs old with adnexal mass: pelvic scan and refer if appropriatepelvic scan and refer if appropriateAll women =/> 40 yrs old with adnexal mass: request All women =/> 40 yrs old with adnexal mass: request pelvic scan + referpelvic scan + referPelvic pain without menstrual problems in young Pelvic pain without menstrual problems in young women with satisfactory & normal bimanual women with satisfactory & normal bimanual examination: pelvic scan not needed, refer if examination: pelvic scan not needed, refer if appropriateappropriate

Endometrial assessment on pelvic scanEndometrial assessment on pelvic scan

Asymptomatic postmenopausal women: Asymptomatic postmenopausal women: endometrial scan thickness of >/= 4mm, or fluid endometrial scan thickness of >/= 4mm, or fluid in the uterine cavity, should have endometrial in the uterine cavity, should have endometrial assessment with pipelle or hysteroscopyassessment with pipelle or hysteroscopy

In symptomatic women, endometrial assessment In symptomatic women, endometrial assessment is recommended even is endometrium <4mmis recommended even is endometrium <4mm

For symptomatic women on HRT, investigate at For symptomatic women on HRT, investigate at same level (4mm) of endometrial thickness same level (4mm) of endometrial thickness

PIDPID

Lower abdo pain & tendernessLower abdo pain & tenderness

Deep dyspareuniaDeep dyspareunia

Abnormal vaginal dischargeAbnormal vaginal discharge

Cervical excitation & adnexal tendernessCervical excitation & adnexal tenderness

Fever (>38deg C)Fever (>38deg C)

Diagnosis: endocervical swab for chlamydia and Diagnosis: endocervical swab for chlamydia and gonorrhoea and HVS, urine HCGgonorrhoea and HVS, urine HCG

USS if clinical suspicion of TO abscessUSS if clinical suspicion of TO abscess

Ofloxacin 400mg BD + metronidazole 400mg BD Ofloxacin 400mg BD + metronidazole 400mg BD for 14 daysfor 14 days

PIDPID

IM ceftriaxone 250mg stat or IM cefoxitin 2g with IM ceftriaxone 250mg stat or IM cefoxitin 2g with oral probenecid 1g foll by doxycycline 100mg BD oral probenecid 1g foll by doxycycline 100mg BD + metronidazole 400mg BD for 14 days+ metronidazole 400mg BD for 14 days

IUCD may be left in situ with mild disease but IUCD may be left in situ with mild disease but remove with severe diseaseremove with severe disease

Offer screening and contact tracing for partnersOffer screening and contact tracing for partners

Women on COC with breakthrough bleeding Women on COC with breakthrough bleeding should be screened for chlamydiashould be screened for chlamydia

EndometriosisEndometriosis

Pelvic scan only if clinical suspicion of Pelvic scan only if clinical suspicion of endometriotic cyst or adnexal pathologyendometriotic cyst or adnexal pathology

0.06% risk of major complications, 1.3% 0.06% risk of major complications, 1.3% with operative laparoscopywith operative laparoscopy

Therapeutic trial with COC or progestogenTherapeutic trial with COC or progestogen

Induce amenorrhoea with danazol, GnRH Induce amenorrhoea with danazol, GnRH analogues(3-6 months), add-back HRT if analogues(3-6 months), add-back HRT if longer duration of treatment usedlonger duration of treatment used

HRTHRT

Increase in risk ofIncrease in risk of

-coronary artery disease( odds ratio 1.29)-coronary artery disease( odds ratio 1.29)

-Breast cancer (odds ratio 1.26)-Breast cancer (odds ratio 1.26)

-Stroke (odds ratio 1.41)-Stroke (odds ratio 1.41)

-Pulmonary embolism-Pulmonary embolism

Reduced risk of colorectal cancer and Reduced risk of colorectal cancer and reduced hip fracturesreduced hip fractures

Ovarian cysts in PM womenOvarian cysts in PM women

TVS and CA 125TVS and CA 125

No role for routine CT,MRI or colour doppler No role for routine CT,MRI or colour doppler assessmentassessment

Risk of malignancy index:Risk of malignancy index: U x M x CA 125 (USS- 1 point each for multilocular U x M x CA 125 (USS- 1 point each for multilocular

cyst, evidence of solid areas, evidence of metastases, cyst, evidence of solid areas, evidence of metastases, ascites, bilateral lesions, U=0 for USS score of 0, U=1 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)for USS score of 1, U=3 for USS score of 2-5)

- M=3 for all PM womenM=3 for all PM women

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

Ovarian cysts in PM womenOvarian cysts in PM women

Is ovarian cyst <5cm, unilateral, unilocular, Is ovarian cyst <5cm, unilateral, unilocular, echo-free with no solid parts or papillary echo-free with no solid parts or papillary formations, CA 125 <30: conservative formations, CA 125 <30: conservative management as 50% will resolve in 3 management as 50% will resolve in 3 months, repeat scan in 4 monthsmonths, repeat scan in 4 monthsIf cyst reduced or unchanged and CA 125 If cyst reduced or unchanged and CA 125 normal, discharge after 1 yrnormal, discharge after 1 yrIf persists and women requests surgery: If persists and women requests surgery: laparoscopic oophorectomylaparoscopic oophorectomy

PCOSPCOS

Truncal obesity, oligomenorrhoea, anovulation, Truncal obesity, oligomenorrhoea, anovulation, infertility, hirsutism, acne, infertility, hirsutism, acne,

FamilialFamilial

Diagnosis by >LH/FSH ratio, USSDiagnosis by >LH/FSH ratio, USS

10-20% risk in middle age for type II diabetes10-20% risk in middle age for type II diabetes

FBS, urinalysis for glycosuria annuallyFBS, urinalysis for glycosuria annually

Lipid profile: fasting cholesterol, lipids and TGsLipid profile: fasting cholesterol, lipids and TGs

Risk of gestational diabetesRisk of gestational diabetes

PCOSPCOS

Small risk of endometrial hyperplasia, Small risk of endometrial hyperplasia, carcinoma: regular atleast 3-4monthly carcinoma: regular atleast 3-4monthly withdrawal bleeds withdrawal bleeds

COC (dianette)COC (dianette)

Ovulation induction for infertilityOvulation induction for infertility

Exercise and weight controlExercise and weight control

Metformin 250-500mg bdMetformin 250-500mg bd

Investigations for infertilityInvestigations for infertility

Screening for chlamydia before uterine Screening for chlamydia before uterine instrumentationinstrumentationIf no significant gynae history: HSG + scanIf no significant gynae history: HSG + scanIf significant gynae history: laparoscopy + dye If significant gynae history: laparoscopy + dye testtest84% couples conceive within 1 yr and 92% in 2 84% couples conceive within 1 yr and 92% in 2 yrsyrs94% at 35yrs age and 77% at 38 yrs age will 94% at 35yrs age and 77% at 38 yrs age will conceive within 3yrs of tryingconceive within 3yrs of tryingIf BMI >29, <19, will take longer to conceiveIf BMI >29, <19, will take longer to conceive

Investigations for infertilityInvestigations for infertility

Advise folic acid 400mcg/day (5mg with Advise folic acid 400mcg/day (5mg with antiepileptic medication or prev history)antiepileptic medication or prev history)

Rubella susceptibility screeningRubella susceptibility screening

D2 FSH, LHD2 FSH, LH

D21 progesterone in 28 day cycleD21 progesterone in 28 day cycle

TFT and prolactin, if oligoamenorrhoeaTFT and prolactin, if oligoamenorrhoea

Limited treatment cycles with clomiphene Limited treatment cycles with clomiphene

If BMI>25, offer metformin with clomipheneIf BMI>25, offer metformin with clomiphene

MenorrhagiaMenorrhagia

If no IMB or PCB and no other symptoms: If no IMB or PCB and no other symptoms: -uterus 8-10wks: FBC, TFT, reassure-uterus 8-10wks: FBC, TFT, reassure-Uterus >10wks/pelvic mass: scan, refer-Uterus >10wks/pelvic mass: scan, refer-If taking tamoxifen, unopposed oestrogens, -If taking tamoxifen, unopposed oestrogens, PCOS, obese: refer PCOS, obese: referTreatment:Treatment:-COC, POP, Depo provera-COC, POP, Depo provera-Mefenamic acid 500mg tds & Tranexamic acid -Mefenamic acid 500mg tds & Tranexamic acid

1g tds for 3 months initially1g tds for 3 months initially-Mirena IUS-Mirena IUS

USS requestsUSS requests

Accurate patient details with contact numberAccurate patient details with contact numberLMPLMPResult of UPTResult of UPTHistory / clinical findings and/or suspected History / clinical findings and/or suspected diagnosis - in order to prioritise appropriatelydiagnosis - in order to prioritise appropriatelyPatients may have unrealistic expectations Patients may have unrealistic expectations about appointment timesabout appointment timesApproximately 130 gynaecology scan requests Approximately 130 gynaecology scan requests are received each weekare received each weekAt present there is a 16 week waiting list for non-At present there is a 16 week waiting list for non-urgent USS requestsurgent USS requests

Thank youThank you