Update in obstetrics and gynecology 2012

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Update in obstetrics and gynecology 2012

  1. 1. UPDATE INUPDATE IN OBSTETRICS ANDOBSTETRICS AND GYNECOLOGYGYNECOLOGY 16TH JUNE 2012 DR.ARIVENDRAN M.D (UKM) MRCOG (UK)
  2. 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. 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. 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. 5. OUTLINE OF PRESENTATIONOUTLINE OF PRESENTATION HYPEREMESIS GRAVIDARUM MISCARRIAGES MOLAR PREGNANCY ECTOPIC PREGNANCY
  6. 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. 7. NAUSEA AND VOMITING in pregnancy, which effects about 80 % pregnant women
  8. 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. 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. 10. INVESTIGATIONSINVESTIGATIONS FULL BLOOD COUNT RENAL PROFILE LIVER FUNCTION TEST URINE DIPSTIX / BIOCHEMISTRY URINE C&S PELVIC ULTRASOUND
  11. 11. MANAGEMENTMANAGEMENT Bed rest Hydration Antiemetics Small carbohydrate meals Carbonated drinks Psychological support
  12. 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. 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. 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. 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. 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. 17. COMPLICATIONSCOMPLICATIONS Mallory Weis tear Acute renal failure Central pontine myelinolisis Wernicke encephalopathy Korasakoff psychosis Depression
  18. 18. MISCARRIAGESMISCARRIAGES THREATHEN MISCARRIAGE COMPLETE/ INCOMPLETE MISCARRIAGE SILENT MISCARRIAGE/ DELAYED MISCARRIAGE
  19. 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. 20. DEFINITION/TERMINOLODEFINITION/TERMINOLO GYGY Silent miscarriage ( Blighted ovum ) Inevitable miscarriage (Inevitable abortion) Miscarriage with infection ( Septic abortion ) Early fetal demise
  21. 21. THREATHEN MISCARRIAGETHREATHEN MISCARRIAGE Clinically : Vaginal bleeding abdominal pain CERVIX CLOSE Pelvic ultrasound: Intrauterine gestation sac Fetal pole with cardiac activity seen
  22. 22. MANAGEMENTMANAGEMENT REASSURANCE / SUPPORTIVE REST VITAMIN SUPPLEMENTS ( FOLIC ACID ) PROGESTOGENS ( ORAL / IM ) PAD CHART
  23. 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. 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. 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. 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. 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. 28. INEVITABLEINEVITABLE MISCARRIAGEMISCARRIAGE Bleeding without passage of tissue but with an open cervix Product of conception at the cervical os
  29. 29. MANAGEMENTMANAGEMENT EXPECTANT MEDICAL (PROSTAGLCANDINS ) SURGICAL ( ERPOC/ D&C )
  30. 30. MOLARMOLAR PREGNANCYPREGNANCY
  31. 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. 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. 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. 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. 35. DIAGNOSISDIAGNOSIS Ultrasound characteristically shows an absent gestational sac and a complex echogenic intrauterine mass with cystic spaces. ( SNOW STORM APPEARANCE )
  36. 36. SUSPECT MOLARSUSPECT MOLAR PREGNANCY !PREGNANCY ! PLEASE SEND IMMEDIATELY AS AN URGENT REFERRAL
  37. 37. MANAGEMENTMANAGEMENT SUCTION CURRETAGE CLOSE FOLLOW UP WITH BETA HCG MONITORING AVOID PREGNANCY WITH BARRIER CONTRACEPTION FOR AT LEAST 6 MONTHS
  38. 38. ECTOPIC PREGNANCYECTOPIC PREGNANCY
  39. 39. RISK FACTORSRISK FACTORS Previous history of ectopic Pelvic Inflammatory Disease Endometrosis Previous tubal surgery
  40. 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. 41. SITES OF ECTOPICSITES OF ECTOPIC PREGNANCYPREGNANCY
  42. 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. 43. MANAGEMENTMANAGEMENT GENERAL SURGICAL MEDICAL EXPECTANT
  44. 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. 45. SURGICALSURGICAL MANAGEMENTMANAGEMENT LAPARASCOPY – method of choice Salpingectomy/ Salpingostomy
  46. 46. SURGICALSURGICAL MANAGEMENTMANAGEMENT LAPARATOMY- Large haemoperitoneum, patient clinically unstable or dense pelvic adhesions
  47. 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. 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. 49. THANK YOU !!!!

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