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Guide for gynaecology & obstetric internship- Yapa Wijeratne
Guide for gynaecology & obstetric internship
By Yapa Wijeratn...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
2. Tocolytic → Nifidipine 20mg 6 hrly x 48 hrs
PIH
1. PET scr...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Aqueos cream local application
Routine growth scan- sample
TA...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
CTG in ½ hr, 2hr, 6hr (It is always better to take a CTG prio...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
How many episodes? – to assess the severity
Blood stained? ––...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Surgery
Pre-op investigations
FBC
UFR
FBS
CBS stat
SE
S.Cr
>4...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Bowel open
Urine output
FBC
PPBS
D3
Wound inspection → bath
V...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Saturation for atypical pneumonia
Clinic
If Rh (-)→ unexplain...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Infected LSCS wound- Iodosorb
Dysmenorrhea- Etovax 120mg 5 ta...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
Op notes
These are sample diagnosis cards that you may write....
Guide for gynaecology & obstetric internship- Yapa Wijeratne
B/L ligation and resection of tubes done
Skin sutured with su...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
MAJOR SURGERIES
EM/EL LOWER SEGMENT CAESAREAN SECTION
On -
Do...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
IV Metronidazole 500mg tds x 24hrs
O. Cefuroxime 500mg bd x 3...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
L/S ovary and uterus were not dissected due to dense adhesion...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
O. Cefuroxime 500mg bd x 5 days
O. Metronidazole 400mg 8 hour...
Guide for gynaecology & obstetric internship- Yapa Wijeratne
MANCHESTER REPAIR Done Under SA
Procedure:
Patient in Lithoto...
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Guide for gynaecology & obstetric internship

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Guide for gynaecology & obstetric internship

  1. 1. Guide for gynaecology & obstetric internship- Yapa Wijeratne Guide for gynaecology & obstetric internship By Yapa Wijeratne History taking 6 questions to filter the diagnosis 1. Abdominal pain? a. ↑ frequency & duration, colicky 2. Back pain? 3. PV bleeding? a. Mucoid, brownish, scanty amount → show 4. Dribbling? a. Watery, clear, copious amount which wets bed sheets/ garments →true dribbling b. False dribbling: DD: 1. Show 2. Candidiasis 3. Urine 4. Hind water rupture 5. Fetal movements? 6. PET symptoms? a. Headache, epigastric pain, visual disturbances Mx 1. CTG-stat & daily 2. FHS-tds 3. KCC 4. USS 5. FBC 6. PPBS 7. UFR 8. Continue haematinics 9. On any suspicion of going for a LSCS- fill DT 1Θ PCM 1g 6hrly or Panadine 1g 6 hrly (outside chit) If already on any drugs you need to add here e.g. metformin 500mg tds if < 37 wk & having a possibility of early delivery give IM dexa 6 mg 12 hrs apart 4 doses or 12 mg 2 doses. Dexa can be given IV if needed immediate action. Dribbling 1. HVS 2. Bed rest 3. Erythromycin 250mg 6hrly 10 days or 500mg 6hrly 4. Sterile pads 5. QHT 6. Better check FHS frequently ( ¼ hrly if possible, like in labor room as there is a risk of cord prolapse) 7. Inform PMO (Paediatric Medical Officer) for PBU care if preterm or any risk of PBU/SBU care Preterm labor 1. Lung maturity → IM dexamethasone 12mg 12 hrly 2 doses or 6mg 4 doses in 48 hours a. Dexamethasone action lasts for 7 days. But within a month no need to repeat. b. Need to monitor CBS if GDM before giving dexamethasone
  2. 2. Guide for gynaecology & obstetric internship- Yapa Wijeratne 2. Tocolytic → Nifidipine 20mg 6 hrly x 48 hrs PIH 1. PET screening a. BU b. S.cr c. SGPT/SGOT d. SE e. PT/ INR 2. Urine albumin stat & chart 3. BP tds 4. Nifidipine 20mg bd Need same day FBC if going for EM-LSCS Look for PLT, PCV (there will be haemo-concentration) Placenta previa Ready 3Θ DT always in the ward Bed rest GDM Insulin 10 U mane Metformin 500mg tds BSS 1. FBS 2. BS-post BF 3. Pre lunch BS 4. Post lunch BS- urgent chit 5. Pre dinner BS- urgent chit 6. Post dinner BS- urgent chit OGTT FBS : 92 mg/dl 1st hr : 180 mg/dl 2nd hr : 153 mg/dl IUGR CTG daily/ bd 2 weekly growth scan- tabulate them clearly Every 3rd day / EOD doppler Pruritus Risk of IUD: reason not clear If bad obs history but still not willing early delivery, always document everything Total bilirubin with fractions PET screen Mx Piriton 4 mg tds 1% hydrocortisone cream
  3. 3. Guide for gynaecology & obstetric internship- Yapa Wijeratne Aqueos cream local application Routine growth scan- sample TAS- Dr.----- (Reg) SLF, CP BPD 33+2 HC 33+5 33 +5 AC 34 FL 33+ 6 Placenta- fundal/ anterior/ posterior Liquor average or AFI 8cm Doppler good diastolic flow. RI 0.7 PI 0.9 EFW (estimated fetal weight) In early USS, (1st trimester & early trimester scans) , USS EDD is important In twin pregnancy, EFW of both twins important- twin to twin transfusion In IUGR, →EFW, Doppler diastolic flow, RI PI values 1st scans → CRL (in extended position) In early scans till about 13-15 weeks, BPD & HC alone is enough. Routine clerking P1C0 38+1 P/C No complains FM+ Plan:- Foley insertion VE Os has to be less than 1.5cm Cuscos speculum & visualize Os. Foley inserted & catheter balloon was filled with 60 or 70 ml of N/S. Traction is applied till the balloon get stuck at Os. Keep NBM till CTG in ½ hr Inform when the folley is fallen. Then do a VE & assess the cervix PG insertion Primi 2mg → 1mg → 1mg (can insert 4mg 6 hrly) Multi 1mg → 1mg → 1mg (can insert 3mg 6 hrly) PGE2 inserted. Keep NBM.
  4. 4. Guide for gynaecology & obstetric internship- Yapa Wijeratne CTG in ½ hr, 2hr, 6hr (It is always better to take a CTG prior PGE2 insertion, as fetus may already in distress & PGE2 can worsen) ARM (Artificial rupture of membranes) 1. ARM done under aseptic conditions. 2. Liquor- clear/ thin to moderate / thick meconium. 3. No hand or cord prolapse. 4. VE a. Os-1cm b. Effacement- 30% c. Station- (-1) 5. Mx a. Start IV syntocinon 5U (primi)/ 2U (multi) in 1Θ N/S. i. Drop rate 10/min → maximum 60/min. b. CTG in ½ hr. c. FHS ¼ hourly d. Pain relief i. IM pethidine 75mg (1mg/kg) stat ii. IV maxalone 10 mg or IM phenagan 25 mg (here giving phenagan is beneficial as its sedative effect can reduce the labor pain) iii. Entonox SOS e. R/v in 3 hrs. f. In PIH patients- BP ½ hourly g. In GDM patients- RBS with CBS 4 hourly Episiotomy 1. Episiotomy sutured under aseptic conditions. 2. No active bleeding. 3. Swabs & clots removed. 4. Per rectal examination-PRE done. 5. Placenta & membrane examination-PME done. 6. KUO for bleeding. 7. If bleeding occurs a. Start 20 units of IV syntocinon in 1Θ N/S. b. Inform HO stat. 8. If no bleeding within 2 hrs, send the pt to ward ----. LSCS premedication IV ranitidine 50 mg mane IV maxalone 10 mg mane Or Omeprazole/Famotidine 20 mg nocte/mane O. maxalone 10 mg nocte/mane Gynecology Vomiting
  5. 5. Guide for gynaecology & obstetric internship- Yapa Wijeratne How many episodes? – to assess the severity Blood stained? –– to assess the severity Content? – partially digested foods? Can tolerate oral? → if yes oral antiemetics (domperidone 10mg stat & tds or oral maxalone 10mg) to control the vomiting & then without cannulating the patient, you may be able to manage the vomiting. Abdominal pain? Urinary symptoms? UTI also can cause vomiting Hyperemesis Gravidarum Oral metochlopramide 10mg tds IV ondansetron 4mg tds UFR & urine for ketone bodies- ward test SE (can be done if you suspect severe dehydration) RBS stat with CBS (expensive, but less painful & you get quick results) 1 vial of polybion in 1Θ N/S IV ranitidine 50 mg stat & bd IV maxalone 10mg stat tds N/S 6Θ – 24hrs Hartmann 3Θ Some patients develop reactions for polybion / ranitidine. Try managing with IV hydrocortisone 200mg stat (Here you may request FBC to exclude other causes of vomiting, but hyperemesis gravidarum is common. Common things are common. ) If ketone bodies positive 1l → 0.5 hr 1l → 1 hr 1l → 2 hr 1l → 4 hr Threatened Miscarriage Do TVS If FHB seen then IM Prolutan 1 vial stat & weekly or Vageston 200mg daily x 2/52 till 13 weeks PV bleeding – in non- preganant Norethisteron 5mg tds (10mg tds) for 21 days Tranexamic acid 500mg tds during bleeding Mefanamic acid 500mg tds during bleeding FeSO4 1 or 2 tab daily Vit C 1 tab daily If pale, DT 1 or 2 pints Before ANY blood transfusion, take blood for blood picture
  6. 6. Guide for gynaecology & obstetric internship- Yapa Wijeratne Surgery Pre-op investigations FBC UFR FBS CBS stat SE S.Cr >40 years ECG CXR 2D ECHO HIV 1 & 2 antibody HepBsAg Clean enema- just to empty the feces from sigmoid colon/ rectum if past surgeries- need to give Klean prep Diclofenac sup 100mg- for post op pain relief Postnatal LSCS D0 Active PV bleeding Abdo soft Uterus hard Pallor Pulse Volume D1 Complains? Active pv bleeding? UOP → >1000 ml → OK. Remove catheter Pallor Pulse rate, volume Abdomen soft? Uterus hard Mobilize Diclofenac 50 mg tds Famotidine 20 mg bd PCM 1g tds D2 Fever
  7. 7. Guide for gynaecology & obstetric internship- Yapa Wijeratne Bowel open Urine output FBC PPBS D3 Wound inspection → bath VE→ No clots. No swabs → Discharge PIH D1 Check BP Normal > stop drugs > 150/90 & PET symptoms: urine albumin & continue drugs NO diclo sup. Give Tramadol 50 mg tds BP is highest in D3-D6. So need to measure that BP. Nifidipine 20 mg bd → if not controlled + HCT 25 mg mane Admit if > 150/100mmHg R/v in 2/52 or 6/52 for BP GDM RBS stat D1: stop metformin & insulin D2: PPBS → (Normal 7.1) → Discharge On discharge No fever Haemodynamically stable Abdomen soft Wound healthy Plan on discharge Calcium lactate 1 tab daily for 6 months Family planning advices given R/v at MOH clinic in 6/52 for family planning advices If anemic→ (8-10g/dl) FeSO4 tab daily x 1/12 If GDM→ R/v at ward in 2/52 with PPBS R/v at ward in 6/52 with OGTT Dr.Janaka Post partum fever Episiotomy? LSCS wound? 3 undiagnosed Neck stiffness for meningitis (LSCS patients- spinal anesthesia- risk of infection → may be misdiagnose as pp psychosis Calf tenderness for DVT
  8. 8. Guide for gynaecology & obstetric internship- Yapa Wijeratne Saturation for atypical pneumonia Clinic If Rh (-)→ unexplained antibody level UFR Pus cells >10 U culture → cephalexin 500mg 8H x 5 days → repeat UFR Referral letters Gyn/ Medical clinic [ ] hospital DMO/MO/RMO [ ] hospital Dear Doctor, Ref: Mrs. ……………………….. Could you kindly arrange the follow up of this patient with ………………………. [e.g. T2DM] at your institution. We shall review the patient, if the necessity arises/ in one year. Thank you. ……………….. VOG/ MO Follow up plans Gyn/ Medical clinic Follow up plan 1. Review in ……………… weeks/ months o Red number- o Blue number 2. Referred to local hospital/ other clinic 3. Review SOS Some useful tips Past section patient suddenly collapse-think of “Uterine rupture” Patient collapsed following “precipitated labor”- para vaginal hematoma. Needs to open & ligate internal iliac. Patient complains continuously of pain- may be meconium. Keep nill by mouth (cz she may need LSCS). Do ARM & see liquor. IUGR patient- document to compare two weekly growth scan. Chronic pelvic pain- Meloxicam 15 mg mane. Amytriptiline 20 mg nocte
  9. 9. Guide for gynaecology & obstetric internship- Yapa Wijeratne Infected LSCS wound- Iodosorb Dysmenorrhea- Etovax 120mg 5 tab monthly during menstruation CTS- keep hand over 2 pillows when sleeping Candidiasis- Gynoperyl vaginal pessary for 3 days Primapore plaster- non allergy plaster cheaper than “Tegaderm (LSCS size 25 x 10 cm) Metformin- Panfor SR daily for 3/12 GDM mother delivers baby: Check cleft palate & anus Mx Early assisted breast feeding RBS in 2 hrs & 4 hrly for 24 hrs Diane-35 tablet contains cyproterone acetate 2 mg + ethinyl estradiol 0.035 mg. Yasmin (drospirenone and ethinyl estradiol) Primolut N (norethisterone) Ovidac 5000 iu/ml (Freeze Dried Powdered HCG Injection)
  10. 10. Guide for gynaecology & obstetric internship- Yapa Wijeratne Op notes These are sample diagnosis cards that you may write. MINOR SURGERIES EUA + DIALATATION AND CURRETAGE By Dr (SHO) Under GA By Dr. (MOA) On 0/0/2016 Indication- Heavy menstrual bleeding P4 C3 EUA: Cervix firm and healthy Uterus anteverted. 8wks sized Curettage done: Curettings ++ and sent for histology TVS by Dr (SHO) Endometrial thickness 6.8mm R/S ovary- dominant follicle seen L/S ovary polycystic No products Investigations Hb: 13.3 g/dl Plt: 2267,000 UFR : normal FBS : 6.4 mmol/L Discharge plan Review in Gyn clinic with histology report In 4 weeks ( on 00/00/2016) B/L LRT + ERPC By Dr (Reg) Under GA By Dr. (MOA) On 05/0/2016 Indication- T1 - Missed miscarriage P4 C3 Skin incision supra pubic
  11. 11. Guide for gynaecology & obstetric internship- Yapa Wijeratne B/L ligation and resection of tubes done Skin sutured with subcuticular vicryl TVS by Reg Gestational sac diameter 26.3mm Foetal pole seen. Diameter 8mm No foetal heart beat seen Management Misoprostol 600micg inserted PV. TVS on discharge No products Investigations Hb: 13.2 g/dl Plt: 250,000 UFR : normal FBS : 5.4 mmol/L Discharge plan Review SOS T1 INCOMPLETE MISCARRIAGE P3 C2 POA: 9wk + 5d TVS by Reg Retained products of conception seen Endometrial thickness 19mm Management Misoprostol 800micg inserted PV TVS on discharge Uterine cavity empty Investigations Hb: 11.8 g/dl Plt: 244,000 UFR : normal RBS : 5.2 mmol/L Discharge plan Folic acid 1 tab daily Ferrup 1 cap daily R/V sos
  12. 12. Guide for gynaecology & obstetric internship- Yapa Wijeratne MAJOR SURGERIES EM/EL LOWER SEGMENT CAESAREAN SECTION On - Done under SA GA Done By :…Dr Assisted by :…Dr INDICATION: Procedure: Pfannenstiel incision made Peritoneal cavity opened in to. Routine LSCS done. Liquor : clear/ meconium Single live non asphyxiated baby delivered. Placenta and membranes delivered completely. Uterus sutured in two layers. B/L tubes and ovaries appeared normal. Complete haemostasis achieved. Routine closure done. Skin sutured with S/C vicryl Post op 1. NBM 6 hrs 2. QHT 3. IP/OP chart 4. Monitor BP, PR, RR a. ¼ hrly x 2hrs b. ½ hrly x 2hrs c. 1 hrly x 2hrs 5. Pain relief a. IM pethidine 50mg SOS b. IV metochlopramide 10mg SOS c. Diclofenac sodium 100mg sup stat d. Diclofenac sodium 50mg bd e. Omeprazole 20mg bd f. PCM 1g SOS 6. IV fluids a. IV NS 80cc/hr b. IV NS 2Θ c. IV hartmann 2Θ 24hr d. IV 5% dextrose 1Θ 7. Antibiotics a. IV Cefuroxime 750mg tds x 24hrs
  13. 13. Guide for gynaecology & obstetric internship- Yapa Wijeratne IV Metronidazole 500mg tds x 24hrs O. Cefuroxime 500mg bd x 3d KUO for bleeding [PIH → urine albumin stat & tds- chart] In GDM monitor RBS LAPAROSCOPIC CYSTECTOMY By Dr. (VOG), Dr (SR), Dr (Reg) Under GA By Dr. (MOA) Indication- Left side ovarian cyst Procedure – Loyd Davis position Closed verrus needle technique. Pneumo-peritonium acheived. 4 port entry into peritoneal cavity Findings – Large Left side ovarian cyst found. Endometrioma. Size 8x 8 cm. POD adhesions present, Grade 4 Endometriosis Large bowel adhered to ovarian cyst. Adhesions separated. Cystectomy done. Part of cyst wall sent for histology. Extensive surgery not done as POD adhesions were severe Skin –subcuticular-vicryl Discharge plan 1. Needs GnRH analogues – not affordable 2. DMPA started monthly for 6 months 3. May need second laparoscopic surgery EXPLORATORY LAPAROTOMY +TUMOUR DEBULKING By Dr. (VOG), Dr (SR), Dr (Reg) Under GA By Dr. (MOA) Indication- Right sided ovarian tumour Procedure – Midline paramedian incision made. Findings – 1. Moderate amount of ascetic fluid present in the peritoneal cavity. Straw in colour 2. R/S multilocular 6*8cm sized ovarian tumour found adhered to bowel loops. 3. L/S ovary and the uterus densely adhered to the rectum and lateral pelvic wall. 4. No macroscopic tumour deposits observed on the omental surface or under surface of the liver. Procedure: Peritoneal fluid sent for cytology. Tumour debulking done. L/S Oophorectomy done along with the tumour.
  14. 14. Guide for gynaecology & obstetric internship- Yapa Wijeratne L/S ovary and uterus were not dissected due to dense adhesions found with the sigmoid colon and the rectum. Omental biopsy taken. Skin –interrupted nylon. In any case of ovarian tumor/ suspicious cyst or suspicion of malignancy document about omentum, bowel, rectum, liver, undersurface of diaphragm, ascetic fluid (if present) as that information is essential for staging of tumor if histology came as malignant. Total Abdominal Hysterectomy + Bilateral Salphingo-oophorectomy By Dr. (VOG), Dr (SR), Dr (Reg) Under GA By Dr. (MOA) On 03-10-2016 Indication: Heavy menstrual bleeding not responding to medical treatment/ multiple fibroid uterus Procedure: Pfannenstiel / midline incision made. Peritoneal cavity opened into. Findings: B/L ovaries and tubes appeared normal. Three pedicles identified, ligated and resected. Routine TAH + BSO done. Uterus- Multiple fibroids. Complete haemostasis achieved Vaginal vault and Rectus sheath sutured with vicryl. Skin sutured with Vicryl subcutucular. Specimen sent for histology. Investigations: Hb: 12.8 g/dl WBC: 10.0 x 103/ul Plt count: 350 x 103/ul BU: 3.5 mg/dl SE: Na 145mmol/L K 4.5 mmol/L FBS: 5.9 mmol/L CXR: NAD ECG: SR 2D Echo: Good LV function. EF >60%. No RWMA. Mild MR HIV I, II Ab: Hep B sAg: Post Op: Recovery uneventful. IV Cefuroxime 750mg 8 hourly IV Metronidazole 500mg 8 hourly Post op Hb Management and follow-up:
  15. 15. Guide for gynaecology & obstetric internship- Yapa Wijeratne O. Cefuroxime 500mg bd x 5 days O. Metronidazole 400mg 8 hourly x 5 days Review in Gyn clinic with histology report in 4 weeks ( on 00/00/2016) ANTERIOR REPAIR Done Under SA INDICATION: Cystocele Procedure: Patient in lithotomy position. Bladder emptied. Vertical incision made. Bladder separated from vaginal wall. Buttress suture applied. Anterior repair done. Complete haemostasis achieved. LAPAROSCOPIC + DYE TEST+ OVARIAN DRILLING under GA INDICATION: Primary Sub fertility Findings – Uterus Normal Size and Anteverted, B/L Ovaries polycystic. B/L Ovarian Drilling Done POD Normal. No evidence of PID or Endometriosis Bilateral Fallopian tubes appeared normal Sub mucus Fibroid (2*2cm) in posterior aspect. Dye test - both tubes patent. Discharge plan - Wait for menstruation - Ovulation induction with clomephine citrate 100mg daily from D2-D6 -Metformin 500mg nocte -D12 TVS for follicular tracking (at ward at 8:30 am) EXPLORATORY LAPAROSCOPY + Rt-SALPHINGECTOMY DONE under GA Findings – Haemoperitoneum noted (approximately 50ml of blood) Right sided TUBAL ECTOPIC Left tube appears normal BL ovaries looks normal Uterus Normal looking No adhesions, cysts or masses Rt- Salphingectomy done – Sample sent for histology
  16. 16. Guide for gynaecology & obstetric internship- Yapa Wijeratne MANCHESTER REPAIR Done Under SA Procedure: Patient in Lithotomy position. Bladder emptied. Tear drop shaped incision made. Bladder was separated from the vaginal wall. Partial amputation of the cervix done. Utero-sacral ligaments were cut and anchored tightly to the anterior aspect of the cervical stump Amputated part of the cervix sent for histology. Anterior repair done. Haemostasis achieved. Vaginal wall sutured with vicryl .

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