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Update in obstetrics and gynecology 2012

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o&g update course 2012 hospital segamat

o&g update course 2012 hospital segamat


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  • 1. UPDATE INUPDATE IN OBSTETRICS ANDOBSTETRICS AND GYNECOLOGYGYNECOLOGY 16TH JUNE 2012 DR.ARIVENDRAN M.D (UKM) MRCOG (UK)
  • 2. MILLENIUM DEVELOPMENTMILLENIUM DEVELOPMENT GOAL 4GOAL 4 REDUCE CHILD MORTALITY Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate ◦ Under-five mortality rate ◦ Infant (under 1) mortality rate ◦ Proportion of 1-year-old children immunized against measles
  • 3. MILLENIUM DEVELOPMENTMILLENIUM DEVELOPMENT GOAL 5GOAL 5 IMPROVING MATERNAL HEALTH Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio ◦ Maternal mortality ratio ◦ Increase proportion of births attended by skilled health personnel Target 5B: Achieve, by 2015, universal access to reproductive health ◦ Contraceptive prevalence rate ◦ Adolescent birth rate ◦ Antenatal care coverage ◦ Unmet need for family planning
  • 4. Women to the top   Life expectancy: females as a % of males, 2010 106 Adult literacy rate: females as a % of males, 2005-2010* 95 Enrolment ratios: females as a % of males, Primary GER, 2007-2010* 99 Enrolment ratios: females as a % of males, Secondary GER, 2007-2010* 107 Survival rate to last grade of primary: females as a % of males, 2006-2009* - Contraceptive prevalence (%), 2006-2010* – Antenatal care coverage (%), At least once, 2006-2010* 79 Antenatal care coverage (%), At least four times, 2006-2010* – Delivery care coverage (%), Skilled attendant at birth, 2006-2010* 99 Delivery care coverage (%), Institutional delivery, 2006-2010* 98 Delivery care coverage (%), C-section, 2006-2010* – Maternal mortality ratio† , 2006-2010*, reported 29 Maternal mortality ratio† , 2008, adjusted 31 Maternal mortality ratio† , 2008, Lifetime risk of maternal death: 1 in: 1200
  • 5. OUTLINE OF PRESENTATIONOUTLINE OF PRESENTATION HYPEREMESIS GRAVIDARUM MISCARRIAGES MOLAR PREGNANCY ECTOPIC PREGNANCY
  • 6. HYPEREMESIS GRAVIDARUMHYPEREMESIS GRAVIDARUM  Severe persistent vomiting in pregnancy, which causes weight loss (more than 5% of body mass) associated with ketosis and electrolyte imbalance  Affects 0.3%-1.5% of pregnant women.
  • 7. NAUSEA AND VOMITING in pregnancy, which effects about 80 % pregnant women
  • 8. PATHOPHYSIOLOGYPATHOPHYSIOLOGY  Still poorly understood.  Various hormonal, mechanical and psychological factors have been implicated.  The temporal relationship between the level of human chorionic gonadotrophin (hCG) (peaking between 6– 12 weeks) and severity of vomiting suggest hCG may have a causative role.
  • 9. DIAGNOSISDIAGNOSIS Hyperemesis is a DIAGNOSIS OF EXCLUSION. Onset is always in the first trimester, usually weeks six to eight Other causes of vomiting, such as urinary tract infection, appendicitis, cholecystitis, hepatitis should be excluded
  • 10. INVESTIGATIONSINVESTIGATIONS FULL BLOOD COUNT RENAL PROFILE LIVER FUNCTION TEST URINE DIPSTIX / BIOCHEMISTRY URINE C&S PELVIC ULTRASOUND
  • 11. MANAGEMENTMANAGEMENT Bed rest Hydration Antiemetics Small carbohydrate meals Carbonated drinks Psychological support
  • 12. HYDRATIONHYDRATION  Intravenous rehydration with Normal Saline (sodium chloride 0.9 % )  Potassium chloride supplement is usually required with each bag of saline  Solutions containing dextrose should be avoided (e.g. dextrose saline) because they do not contain enough sodium and may precipitate Wernicke’s encephalopathy
  • 13. ANTIEMETICSANTIEMETICS Metoclopramide ( MAXOLON ) 10 mg three times a day intravenously or orally ( BE WARY OF OCCULOGYRIC CRISIS ) ANCOLOXIN( VELOXIN ) Combination of meclozine 25mg and pyridoxine 50 mg( vit b6), 1 tab bd Prochlorperazine ( STEMETEIL ) Oral 5mg three times a day oral or IM 12.5mg three times a day
  • 14. INITIAL MANAGEMENTINITIAL MANAGEMENT (Daycare management )(Daycare management ) IV Maxolon 10 mg 6 - 8 hourly TWO LITRES ( 4 PINTS ) of intravenous normal saline solution given over four to six hours with / without potassium chloride Investigations taken and reviewed
  • 15. If symptoms persist than forIf symptoms persist than for admission….admission…. Regular IV Maxolon 8 hourly, 6 pint IV drip of N/Saline with potassium supplement Daily urine ketone Vomit chart I/O Chart
  • 16. PLEASE REFER IF :PLEASE REFER IF : Evidence of dehydration ( URINE KETONE 2+ AND MORE ) Severe electrolyte imbalance ( Na+ < 130, K+ < 3.0 ) Unable to maintain oral intake Clinical evidence of moderate to severe dehydration Clinically unstable ( tachycardia, hypotensive )
  • 17. COMPLICATIONSCOMPLICATIONS Mallory Weis tear Acute renal failure Central pontine myelinolisis Wernicke encephalopathy Korasakoff psychosis Depression
  • 18. MISCARRIAGESMISCARRIAGES THREATHEN MISCARRIAGE COMPLETE/ INCOMPLETE MISCARRIAGE SILENT MISCARRIAGE/ DELAYED MISCARRIAGE
  • 19. DEFINITION/TERMINOLOGYDEFINITION/TERMINOLOGY  Threatened miscarriage (Threatened abortion )  Complete miscarriage (Complete abortion )  Incomplete miscarriage ( Incomplete abortion )  Missed( Silent ) miscarriage (Missed abortion )  Delayed ( Silent ) miscarriage ( Anembryonic pregnancy )
  • 20. DEFINITION/TERMINOLODEFINITION/TERMINOLO GYGY Silent miscarriage ( Blighted ovum ) Inevitable miscarriage (Inevitable abortion) Miscarriage with infection ( Septic abortion ) Early fetal demise
  • 21. THREATHEN MISCARRIAGETHREATHEN MISCARRIAGE Clinically : Vaginal bleeding abdominal pain CERVIX CLOSE Pelvic ultrasound: Intrauterine gestation sac Fetal pole with cardiac activity seen
  • 22. MANAGEMENTMANAGEMENT REASSURANCE / SUPPORTIVE REST VITAMIN SUPPLEMENTS ( FOLIC ACID ) PROGESTOGENS ( ORAL / IM ) PAD CHART
  • 23. COMPLETE MISCARRIAGECOMPLETE MISCARRIAGE  Clinically: Cessation of vaginal bleeding and abdominal pain with a closed cervix  PELVIC ULTRASOUND : Endometrial thickness 15 OR less No evidence of retained products of conception
  • 24. INCOMPLETE MISCARRIAGEINCOMPLETE MISCARRIAGE  Clinically : Passage of pregnancy-related tissue ,bleeding and/or abdominal pain; CERVIX OPEN Pelvic ultrasound : Heterogenous tissues / sac distorting midline endometrial echo Endometrial thickening
  • 25. MISSED / SILENT/ DELAYEDMISSED / SILENT/ DELAYED MISCARRIAGEMISCARRIAGE  Clinically : Minimal vaginal bleeding or pain; loss of pregnancy symptoms; CERVIX CLOSE Pelvic ultrasound : Fetal pole > 7 mm with no fetal activity. Gestation sac diameter >25 mm with no fetal pole or yolk sac
  • 26. Addendum to GTG No 25 (Oct 2011): TheAddendum to GTG No 25 (Oct 2011): The Management of Early Pregnancy LossManagement of Early Pregnancy Loss  Ultrasound diagnosis of miscarriage should only be considered with a mean gestation sac diameter >/= 25mm (with no obvious yolk sac), or with a fetal pole with crown rump length >/=7mm (the latter without evidence of fetal heart activity)  A transvaginal ultrasound scan should be performed in all cases
  • 27. Addendum to GTG No 25 (Oct 2011): TheAddendum to GTG No 25 (Oct 2011): The Management of Early Pregnancy LossManagement of Early Pregnancy Loss  Where there is any doubt about the diagnosis and/or a woman requests a repeat scan, this should be performed at an interval of at least one week from the initial scan before medical or surgical measures are undertaken for uterine evacuation.
  • 28. INEVITABLEINEVITABLE MISCARRIAGEMISCARRIAGE Bleeding without passage of tissue but with an open cervix Product of conception at the cervical os
  • 29. MANAGEMENTMANAGEMENT EXPECTANT MEDICAL (PROSTAGLCANDINS ) SURGICAL ( ERPOC/ D&C )
  • 30. MOLARMOLAR PREGNANCYPREGNANCY
  • 31. MOLAR PREGNANCYMOLAR PREGNANCY 1 for every 700 live births The time of diagnosis is usually very difficult for women: they have to cope with the loss of a pregnancy, the details of follow-up, potential chemotherapy and the increased risks in future pregnancies.
  • 32. RISK FACTORSRISK FACTORS  AGE Extremes of the reproductive age, Girls under the age of 15 years have a risk approximately 20 times higher than women aged 20– 40 Aged over 45 have a several hundred-fold higher risk than those aged 20–40.1
  • 33. RISK FACTORSRISK FACTORS History of molar pregnancy In this group, the risk appears to be approximately 1 in 55 for those with one previous molar pregnancy and 1 in 10 for those with two.
  • 34. CLINCAL FEATURESCLINCAL FEATURES Exaggerated symptoms of early pregnancy Hyperemesis gravidarum Uterus larger than dates Per vaginal bleeding Symptoms of hyperthyroidism Pre-eclampsia ( Hypertension )
  • 35. DIAGNOSISDIAGNOSIS Ultrasound characteristically shows an absent gestational sac and a complex echogenic intrauterine mass with cystic spaces. ( SNOW STORM APPEARANCE )
  • 36. SUSPECT MOLARSUSPECT MOLAR PREGNANCY !PREGNANCY ! PLEASE SEND IMMEDIATELY AS AN URGENT REFERRAL
  • 37. MANAGEMENTMANAGEMENT SUCTION CURRETAGE CLOSE FOLLOW UP WITH BETA HCG MONITORING AVOID PREGNANCY WITH BARRIER CONTRACEPTION FOR AT LEAST 6 MONTHS
  • 38. ECTOPIC PREGNANCYECTOPIC PREGNANCY
  • 39. RISK FACTORSRISK FACTORS Previous history of ectopic Pelvic Inflammatory Disease Endometrosis Previous tubal surgery
  • 40. CLINICALCLINICAL PRESENTATIONPRESENTATION Period of amenorrhoea (POA) Positive urine pregnancy test Abdominal Pain Minimal per vaginal bleeding Shoulder tip pain Fainting / Black out episodes
  • 41. SITES OF ECTOPICSITES OF ECTOPIC PREGNANCYPREGNANCY
  • 42. Clinical diagnosis of early unruptured ectopic pregnancy remains a great challenge to the clinician. High Index of Suspicion combined with the application of technological advances(TVS) has made it possible to diagnose ectopic pregnancy earlier. FEMALE, ABDOMINAL PAIN , UPT POSITIVE = TRO ECTOPIC PREGNANCY
  • 43. MANAGEMENTMANAGEMENT GENERAL SURGICAL MEDICAL EXPECTANT
  • 44. GENERALGENERAL RESUSCITATION – 2 large bore branulas and run fluids Cross match blood Blood grouping and rhesus ( Anti D Ig if patient is Rh negative )
  • 45. SURGICALSURGICAL MANAGEMENTMANAGEMENT LAPARASCOPY – method of choice Salpingectomy/ Salpingostomy
  • 46. SURGICALSURGICAL MANAGEMENTMANAGEMENT LAPARATOMY- Large haemoperitoneum, patient clinically unstable or dense pelvic adhesions
  • 47. MEDICALMEDICAL  Clinically stable  Beta hcg < 3000 iu/l  Patient is able to return for frequent close monitoring  Fetak Heart activity is absent  Ectopic sixe < 3.5cm  No contraindication to MTX
  • 48. EXPECTANT MANGEMENTEXPECTANT MANGEMENT ONLY IF : Patient stable and asymptomatic Initial beta hcg < 1000 iu/l and falling serially Able to comply with close follow up with serial beta hcg and TVS
  • 49. THANK YOU !!!!

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