1) The document provides information on referral issues and systems for the obstetrics and gynecology clinic, including contact details, clinic schedules, and guidance on when to refer common issues like early pregnancy problems, hypertension in pregnancy, medical conditions, antenatal cases, postpartum issues, and menstrual disorders. 2) It emphasizes referring early for issues like ectopic pregnancy, molar pregnancy, severe hyperemesis gravidarum, preeclampsia symptoms, and known medical disorders. 3) The document outlines criteria for referring cases of anemia, diabetes, asthma, thyroid disorders, connective tissue diseases, and abnormal pap smears.

1. UPDATE INUPDATE IN
OBSTETRICS ANDOBSTETRICS AND
GYNECOLOGYGYNECOLOGY
SATURDAYSATURDAY
17 NOVEMBER 201217 NOVEMBER 2012

2. REFERRAL /REFERRAL /
ISSUES :ISSUES :
WHAT ? WHEN ?
And HOW ?

3. REFERRAL SYSTEMREFERRAL SYSTEM
 CLINIC O&G – PAKAR 1CLINIC O&G – PAKAR 1
 EXT NUMBER : 152EXT NUMBER : 152
 HOSPITAL NUMBER : 07-9433333HOSPITAL NUMBER : 07-9433333
 DAY AND TIME:DAY AND TIME:
- MONDAY AND WEDNESDAYMONDAY AND WEDNESDAY
( 2.00PM – 5.00 PM )( 2.00PM – 5.00 PM )
- FRIDAY ( 2.45 PM – 5.00 PM )FRIDAY ( 2.45 PM – 5.00 PM )

4.  CLINIC SCHEDULE:CLINIC SCHEDULE:
 MONDAY ( 2.00 PM – 5.00 PM)MONDAY ( 2.00 PM – 5.00 PM)
PRE PREGNANCY CLINIC &PRE PREGNANCY CLINIC &
COMBINED CLINICCOMBINED CLINIC
 TUESDAY ( 8.00 AM – 1.00 PM )TUESDAY ( 8.00 AM – 1.00 PM )
ANTENATAL CLINICANTENATAL CLINIC
 THURSDAY ( 8.00 AM – 1.00 PM )THURSDAY ( 8.00 AM – 1.00 PM )
GYNAE CLINICGYNAE CLINIC
 FRIDAY ( 8.00 AM – 12 NOON )FRIDAY ( 8.00 AM – 12 NOON )
POSTNATAL CLINICPOSTNATAL CLINIC

5. Cont.Cont.
 CONSULTATIONCONSULTATION
 WORKING HOURS: MO INCHARGEWORKING HOURS: MO INCHARGE
ACCORDING TO CLINICACCORDING TO CLINIC
 AFTER WORKING HOURS / PUBLICAFTER WORKING HOURS / PUBLIC
HOLIDAY: MO ONCALLHOLIDAY: MO ONCALL
 SPECIALIST ONCALLSPECIALIST ONCALL

6. EARLY PREGNANCYEARLY PREGNANCY
PROBLEMSPROBLEMS
 MISSED MISCARRIAGEMISSED MISCARRIAGE
 INCOMPLETE MISCARRIAGEINCOMPLETE MISCARRIAGE
 THREATHEN MISCARRIAGETHREATHEN MISCARRIAGE
 TRO ECTOPIC PREGNANCY ( ASAP )TRO ECTOPIC PREGNANCY ( ASAP )
 MOLAR PREGNANCY ( ASAP )MOLAR PREGNANCY ( ASAP )
 MODERATE/SEVERE HYPEREMESISMODERATE/SEVERE HYPEREMESIS
GRAVIDARUM ( ASAP )GRAVIDARUM ( ASAP )
 RECURRENT MISCARRIAGE ( Clinic )RECURRENT MISCARRIAGE ( Clinic )

7. HYPERTENSION INHYPERTENSION IN
PREGNANCYPREGNANCY
 BP > 140 / 90BP > 140 / 90
 Symptoms and signs of ImpendingSymptoms and signs of Impending
EclampsiaEclampsia
 Albuminuria 2+ and moreAlbuminuria 2+ and more
 Whenever UNSURE, please do referWhenever UNSURE, please do refer
 AndAnd REFER EARLY / IMMEDIATELYREFER EARLY / IMMEDIATELY

8. MEDICAL - DIABETESMEDICAL - DIABETES
 All known diabetics ( as early as possible )All known diabetics ( as early as possible )
 IMGTT with BSP > 7 mmol/lIMGTT with BSP > 7 mmol/l
 AS PER PROTOCOLAS PER PROTOCOL
 GDM on diet control can be managed inGDM on diet control can be managed in
the health side and refered for IOL at EDDthe health side and refered for IOL at EDD

9. ANTENATAL CASESANTENATAL CASES
 Parameters in mm ( Growth Chart )Parameters in mm ( Growth Chart )
 Twins for chorionicity as early as possible ( 1Twins for chorionicity as early as possible ( 1stst
trimester, before 14 weeks )trimester, before 14 weeks )
 Dating scan ( as early as possible, 8 weeks – 13Dating scan ( as early as possible, 8 weeks – 13
weeks )weeks )
 Symphisiofundal height measurement (serialSymphisiofundal height measurement (serial
measurements, diff of 4cm )measurements, diff of 4cm )
 Low lying placenta ( PP ) – after 28 weeksLow lying placenta ( PP ) – after 28 weeks
 Abnormal Lie ( non cephalic presentation) - afterAbnormal Lie ( non cephalic presentation) - after
36 weeks36 weeks

10. ANTENATAL CASESANTENATAL CASES
 Breech – at term ( > 36 weeks )Breech – at term ( > 36 weeks )
 Previous scar – at 36 weeksPrevious scar – at 36 weeks
 Teenage pregnancy / Single Parents – 36Teenage pregnancy / Single Parents – 36
weeksweeks
 Post Date - 40/52 + 6 daysPost Date - 40/52 + 6 days
- AFI & CTG at EDD- AFI & CTG at EDD

11. MEDICAL – RHESUSMEDICAL – RHESUS
NEGATIVENEGATIVE
 SENSITISED MOTHERS ( Coombs testSENSITISED MOTHERS ( Coombs test
positive )positive )
 HISTORY OF HYDROPS FETALISHISTORY OF HYDROPS FETALIS
 ALL RHESUS NEGATIVE MOTHERSALL RHESUS NEGATIVE MOTHERS
(BEFORE 28 WEEKS For IM Rhogem)(BEFORE 28 WEEKS For IM Rhogem)

12. MEDICAL - ANAEMIAMEDICAL - ANAEMIA
 Severe anaemia – Hb < 8g/dlSevere anaemia – Hb < 8g/dl
 Not tolerating oral iron supplementsNot tolerating oral iron supplements
 Not responding to oral iron supplementsNot responding to oral iron supplements
 THALASSAEMIA ( especially if bothTHALASSAEMIA ( especially if both
parents are carriers )parents are carriers )
 Kindly pls do anaemia work out beforeKindly pls do anaemia work out before
referring patient ( Ferritin, Iron, TIBC,referring patient ( Ferritin, Iron, TIBC,
FBP )FBP )

13. MEDICAL - CARDIACMEDICAL - CARDIAC
 Known cardiac diseaseKnown cardiac disease
 Heart murmur and symptomsHeart murmur and symptoms
 Symptoms and signs suggestive ofSymptoms and signs suggestive of
cardiac pathology ( ECHO )cardiac pathology ( ECHO )
 Kindly pls arrange for ECHO prior to apptKindly pls arrange for ECHO prior to appt
in Combine Clinicin Combine Clinic

14. MEDICAL - ASTHMAMEDICAL - ASTHMA
 Uncontrolled bronchial asthma (CombineUncontrolled bronchial asthma (Combine
Clinic )Clinic )
 Well controlled asthma can be managed inWell controlled asthma can be managed in
health sidehealth side

15. MEDICAL – THYROIDMEDICAL – THYROID
DISORDERSDISORDERS
 Patients on treatment for thyroid disordersPatients on treatment for thyroid disorders
 Kindly pls don't do TFT in first trimesterKindly pls don't do TFT in first trimester
unless very suggestive symptoms.unless very suggestive symptoms.
(Difficult to interpret )(Difficult to interpret )
 If abnormal in first trimester, can repeat inIf abnormal in first trimester, can repeat in
second or third trimestersecond or third trimester
 Patients can breast feed if on low dosePatients can breast feed if on low dose
treatmenttreatment
 T4 drops as pregnancy progressesT4 drops as pregnancy progresses

16. MEDICAL – CONNECTIVEMEDICAL – CONNECTIVE
TISSUE DISEASETISSUE DISEASE
 REFER ALL PATIENTS IMMEDIATELYREFER ALL PATIENTS IMMEDIATELY
( SLE / RA / NEPHROTIC SYNDROME )( SLE / RA / NEPHROTIC SYNDROME )

17. POSTPARTUMPOSTPARTUM
 Episiotomy wound breakdown – pls refer to clinicEpisiotomy wound breakdown – pls refer to clinic
( No need admission unless symptomatic )( No need admission unless symptomatic )
 LSCS wound breakdownLSCS wound breakdown
 Postpartum high blood pressurePostpartum high blood pressure
 Urinary retentionUrinary retention
 SECONDARY PPHSECONDARY PPH
 POSTPARTUM PYREXIAPOSTPARTUM PYREXIA
 HEART DISEASE WITH SYMPTOM OFHEART DISEASE WITH SYMPTOM OF
FAILUREFAILURE
 POST PARTUM BLUES/ DEPRESSION/POST PARTUM BLUES/ DEPRESSION/
PSYCHOSISPSYCHOSIS

18. MENSTRUAL DISORDERSMENSTRUAL DISORDERS
 Menorrhagia ( > 40 years old, nulliparous,Menorrhagia ( > 40 years old, nulliparous,
DM, Obesity)DM, Obesity)
 Menorrhagia not responding to treatment (Menorrhagia not responding to treatment (
< 40 years old )< 40 years old )
 Post menopausal bleeding (ASAP)Post menopausal bleeding (ASAP)
 Amenorhoea ( primary and secondary )Amenorhoea ( primary and secondary )
 Dysmenorhoea ( especially failedDysmenorhoea ( especially failed
treatment like NSAIDS )treatment like NSAIDS )

19. GENERALGENERAL
GYNAECOLOGYGYNAECOLOGY
 ABNORMAL PAP SMEARSABNORMAL PAP SMEARS
 INFERTILITYINFERTILITY
 PELVIC MASSPELVIC MASS

20. ANY
QUESTIONS ???
?

21. THANK YOUTHANK YOU