Obstetrics and Gynaecology Forum

1. Obstetrics and Gynaecology Forum Pradnya Pisal Jyoti Shah Annie Fowler

2. Early Pregnancy Unit Lead Consultant: Pradnya Pisal 0208 3751250, 1267, 1979 Lead Sister: Annie Fowler 0208 3751240, 1958 Lead Sonographer: Jyoti Shah 0208 3751979

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

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

5. Early pregnancy scans • Earliest gestational sac on TA scan: 6 weeks • Earliest viable pregnancy on TA scan:7 weeks • Earliest gestational sac on TV scan: 5 weeks • Earliest viable pregnancy on TV scan: 6 weeks • At 1000 IU, an intrauterine gestational sac on TV scan • 85% of viable intrauterine pregnancies show doubling of HCG in 48 hrs • Suboptimal increase in HCG over 48 hrs without intrauterine gestational sac seen on TV scan is s/o ectopic pregnancy

6. Value of USS post-miscarriage • 1 in every 5 clinically known pregnancies will miscarry in the first trimester • Post miscarriage or post TOP bleeding: scans are unreliable to confirm or exclude retained products of conception • USS cannot differentiate between blood, clots or POC in the uterine cavity • Surgical evacuation: complications in 2% cases: uterine perforation, cervical tears, intra-abdominal trauma, intrauterine adhesions, haemorrhage, mortality 0.5/100,000

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

8. Post - miscarriage or post - TOP • If bleeding not settled after course of antibiotics, refer as urgent case to a consultant to be seen in the next consultant clinic • If bleeding is >6 weeks post miscarriage, and bimanual examination is unremarkable, treat with a short course of hormones: COC or progestogens • Counsel women to expect moderate bleeding for postnatally, (at any gestation) • Next period may be delayed to 6 weeks

9. Screening for ovarian cancer • Not recommended in low risk population • Screening can be considered in women with: • 2 first degree relatives with ovarian cancer • 1 first degree relative with ovarian cancer and 1 first degree relative with breast cancer diagnosed under the age of 50 • One first degree relative with ovarian cancer and 2 first or second degree relatives with breast cancer, diagnosed under the age of 60 • Presence of faulty ovarian cancer causing gene in the family • 3 first or second degree relatives with bowel cancer and one case of ovarian cancer in the family

10. Screening for ovarian cancer • Women with a significant family history can be referred to a genetics clinic from where they can either be referred for the UKFOCSS or for BRCA1 gene testing if appropriate • Yearly CA125 and ovarian scan from 25-65 years age • Prophylactic oophorectomy and mastectomy does not prevent primary peritoneal cancer

11. Suspected gynaecology pathology • Incidental finding in asymptomatic women with -uterine size 8-10 weeks: reassure -uterine size >10 weeks: pelvic scan, refer if appropriate • Symptomatic women < 40 yrs old: pelvic scan if uterus is bulky, refer if appropriate • Asymptomatic women < 40 yrs old with adnexal mass: pelvic scan and refer if appropriate • All women =/> 40 yrs old with adnexal mass: request pelvic scan + refer • Pelvic pain without menstrual problems in young women with satisfactory & normal bimanual examination: pelvic scan not needed, refer if appropriate

12. Endometrial assessment on pelvic scan • Asymptomatic postmenopausal women: endometrial scan thickness of >/= 4mm, or fluid in the uterine cavity, should have endometrial assessment with pipelle or hysteroscopy • In symptomatic women, endometrial assessment is recommended even is endometrium <4mm • For symptomatic women on HRT, investigate at same level (4mm) of endometrial thickness

13. PID • Lower abdo pain & tenderness • Deep dyspareunia • Abnormal vaginal discharge • Cervical excitation & adnexal tenderness • Fever (>38deg C) • Diagnosis: endocervical swab for chlamydia and gonorrhoea and HVS, urine HCG • USS if clinical suspicion of TO abscess • Ofloxacin 400mg BD + metronidazole 400mg BD for 14 days

14. PID • IM ceftriaxone 250mg stat or IM cefoxitin 2g with oral probenecid 1g foll by doxycycline 100mg BD + metronidazole 400mg BD for 14 days • IUCD may be left in situ with mild disease but remove with severe disease • Offer screening and contact tracing for partners • Women on COC with breakthrough bleeding should be screened for chlamydia

15. Endometriosis • Pelvic scan only if clinical suspicion of endometriotic cyst or adnexal pathology • 0.06% risk of major complications, 1.3% with operative laparoscopy • Therapeutic trial with COC or progestogen • Induce amenorrhoea with danazol, GnRH analogues(3-6 months), add-back HRT if longer duration of treatment used

16. HRT • Increase in risk of -coronary artery disease( odds ratio 1.29) -Breast cancer (odds ratio 1.26) -Stroke (odds ratio 1.41) -Pulmonary embolism • Reduced risk of colorectal cancer and reduced hip fractures

17. Ovarian cysts in PM women • TVS and CA 125 • No role for routine CT,MRI or colour doppler assessment • Risk of malignancy index: • U x M x CA 125 (USS- 1 point each for multilocular cyst, evidence of solid areas, evidence of metastases, 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) • M=3 for all PM women - RMI >250: 70% sensitivity and 90% specificity

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

19. PCOS • Truncal obesity, oligomenorrhoea, anovulation, infertility, hirsutism, acne, • Familial • Diagnosis by >LH/FSH ratio, USS • 10-20% risk in middle age for type II diabetes • FBS, urinalysis for glycosuria annually • Lipid profile: fasting cholesterol, lipids and TGs • Risk of gestational diabetes

20. PCOS • Small risk of endometrial hyperplasia, carcinoma: regular atleast 3-4monthly withdrawal bleeds • COC (dianette) • Ovulation induction for infertility • Exercise and weight control • Metformin 250-500mg bd

21. Investigations for infertility • Screening for chlamydia before uterine instrumentation • If no significant gynae history: HSG + scan • If significant gynae history: laparoscopy + dye test • 84% couples conceive within 1 yr and 92% in 2 yrs • 94% at 35yrs age and 77% at 38 yrs age will conceive within 3yrs of trying • If BMI >29, <19, will take longer to conceive

22. Investigations for infertility • Advise folic acid 400mcg/day (5mg with antiepileptic medication or prev history) • Rubella susceptibility screening • D2 FSH, LH • D21 progesterone in 28 day cycle • TFT and prolactin, if oligoamenorrhoea • Limited treatment cycles with clomiphene • If BMI>25, offer metformin with clomiphene

23. Menorrhagia • If no IMB or PCB and no other symptoms: -uterus 8-10wks: FBC, TFT, reassure -Uterus >10wks/pelvic mass: scan, refer -If taking tamoxifen, unopposed oestrogens, PCOS, obese: refer • Treatment: -COC, POP, Depo provera -Mefenamic acid 500mg tds & Tranexamic acid 1g tds for 3 months initially -Mirena IUS

24. USS requests • Accurate patient details with contact number • LMP • Result of UPT • History / clinical findings and/or suspected diagnosis - in order to prioritise appropriately • Patients may have unrealistic expectations about appointment times • Approximately 130 gynaecology scan requests are received each week • At present there is a 16 week waiting list for non-urgent USS requests

25. Thank you