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Dr. Carl McQueen ACD (Students) SWY CCT

LMSU Advanced Student Doctor Course. Obstetrics and Gynaecology on Duty. Dr. Carl McQueen ACD (Students) SWY CCT. Overview. This presentation will cover: Obstetric problems you may encounter on duty Gynaecological problems you may encounter on duty

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Dr. Carl McQueen ACD (Students) SWY CCT

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  1. LMSU Advanced Student Doctor Course Obstetrics and Gynaecology on Duty Dr. Carl McQueen ACD (Students) SWY CCT

  2. Overview • This presentation will cover: • Obstetric problems you may encounter on duty • Gynaecological problems you may encounter on duty • Female sexual health and GUM histories/treatments

  3. Pregnancy • Always consider if a woman of ‘childbearing age’ is pregnant • ???? ‘childbearing age’ • 10-55yrs?? • Always ask: • When was your last period (need dates if possible) • Is there any chance that you may be pregnant • Often requires sensitivity

  4. Dates in Pregnancy • Human gestation lasts for 40 weeks • The majority of women in the UK have excellent antenatal care and are usually sure of dates • Useful dates to remember: • 12/40- uterus palpable in abdomen. Fetal heart audible with Doppler • 16-18/40- mother feels fetal movements • 20/40- uterine contractions and fetal movements palpable • 24/40- fetal heart audible with fetal stethoscope • 26/40- fetal parts palpable

  5. Complications in Pregnancy • Bear in mind the stage of the pregnancy • First trimester 0-12 weeks • Second trimester 13-28 weeks • Third trimester 29-40 weeks • Can be loosely classified into 4 main categories • Vaginal bleeding • GI symptoms (vomiting) • CNS symptoms (eclampsia) • Abdominal pain

  6. Vaginal Bleeding in Pregnancy • PV bleeding occurs in up to 20% of all pregnancies • In over half of cases the pregnancy will continue successfully • Before 20 weeks PV bleeding may be: • A threatened abortion • An incomplete abortion • A complete abortion • PV bleeding NOT associated with pregnancy • Loss of the fetus is accompanied by: • Heavy or continued bleeding • Passage of placental material as well as blood • Significant pain and tenderness

  7. Vaginal Bleeding in Pregnancy • For the purpose of emergency management any PV bleed AFTER 20 weeks is classed as an antepartum haemorrhage • APH is caused by placental abruption, placenta praevia or other less common lesions • In abruption, severe blood loss and shock may occur in the absence of significant external haemorrhage. There may be pain and a ‘wooden’ uterus • In placenta praevia bleeding is usually painless and starts around 32/40

  8. Vaginal Bleeding in Pregnancy • Bleeding occurring soon after delivery or later on in the puerperium is classed as post partum haemorrhage • The causes of PPH are retained products of conception and infection

  9. PV Examination • PV examination is contraindicated in APH • As SJA volunteers you should NEVER perform a PV!!!!!!!! • If you think you need to perform a PV what you actually need is an OBS/GYNAE SHO!!!

  10. Management of Bleeding in Pregnancy • Initial management remains ABCDEFG • Transfer/referral is determined by the suspected cause and the stage of pregnancy • 1st trimester: if suspect abortion but not clinically shocked may refer to OBS/GYN as OP for scan • 2nd/3rd trimesters: if suspect APH need to be transferred to nearest ED after initial stabilisation • This is not your call- ALWAYS refer to senior

  11. GI Symptoms in Pregnancy • The most common GI symptom in pregnancy is vomiting • ‘Morning sickness’ occurs in the first trimester • May be one of the first indications of pregnancy • In a minority of cases may be extremely debilitating- hyperemesis gravidarum

  12. CNS Symptoms in Pregnancy • Eclampsia occurs in 1/2000 deliveries in the UK • It contributes to 10% of maternal deaths • Patients present with fits • There is a recognised condition called pre-eclampsia: • Hypertension (NB up to 75% of eclampsia occurs without hypertension) • Oedema • Proteinuria • EVERY pregnant woman that you see on duty should have a set of baseline obs- including a urine dipstick • Treatment of eclamptic fits is ABCDEFG and transfer to the nearest ED

  13. Abdominal Pain in Pregnancy • Remember that abdominal pain in pregnancy may NOT be related to pregnancy • Need to rule out other causes of abdominal pain: • Appendicitis • Gastroenteritis • Gallstones • Full set of baseline obs/temp/urine dipstick and discussion with senior

  14. Gynaecological Problems on Duty • Many of the gynaecological problems that women can present with are associated with a deviation away from their ‘normal’ cycle • Enquire about what is ‘normal’- dates/amount of bleeding/length of cycle/age of menarche or menopause

  15. PV Bleeding • Women may present with: • Amenorrhoea • May be hormonal/physiological aetiology • Always consider the possibility of pregnancy!! • Can usually be managed/investigated by GP • Menorrhagia • Can be very distressing • Need to rule out pregnancy • Can usually be managed with NSAIDs and GP follow up • Dysmenorrhoea • Rule out other causes of abdominal pain • NSAIDs can give good relief • GP follow up

  16. 'Mittelschmerz' • Ovulation may sometimes be associated with pain and slight PV bleeding • Known as ‘Mittelschmerz’ • Can be followed up by GP • Knowledge of dates is essential

  17. Emergency Contraception • At some of the larger events you may be approached for emergency contraception • A medical and gynaecological history must be taken to discover normal cycle and exclude: • Hx of VTE • Recent/current liver disease • Focal migraine within the last 24 hours • Menstrual bleeding already overdue • You will need to refer on to a qualified HCP for further counselling and drug prescription • Hormonal therapy can be used on duty • It must be started within 72 hours of unprotected intercourse • Consists of 4 pills each containing ethinyloestrdiol (50μg) and levonorgestrel (250μg)

  18. Sexual Health • You should take a detailed sexual history • Takes sensitivity- worthwhile NOT doing it in a crowded tent!! • Number of partners/contraception/previous STIs etc • Reassure casualty that entirely confidential

  19. Sexual Health • Women may present with: • PV discharge • Post coital bleeding • Abdominal pain and discomfort- especially during sex • Dysuria • Full set of obs/temp/urine dipstick and referral to HCP

  20. Gynaecological Causes of Abdominal Pain • Abdominal/pelvic pain may be the presenting complaint for a variety of gynaecological problems • Ruptured ovarian cyst • Sudden lower abdominal pain with localised tenderness • Torsion of ovarian cyst • Lower abdominal pain and tenderness that may be recurrent. May be a mass on abdominal examination • Endometriosis • Gives rise to recurrent abdominal pain which is worse during menstrual bleeding • Pelvic Inflammatory Disease (PID) • Usually bilateral lower abdominal pain with malaise/nausea/vaginal discharge/menstrual disturbance • ‘PID shuffle’

  21. 'Lost' Tampons • Women can present with retained vaginal foreign bodies • Tampons • Condoms • Often become lodged in the posterior fornix • Can be removed by qualified, experienced HCP • Women with a retained vaginal FB are at risk of toxic shock syndrome

  22. Ectopic Pregnancy • Classified as a ‘gynaecological’ problem as women often do not know that they are pregnant • MUST be considered in any woman of childbearing age with abdominal pain or unexplained collapse • HISTORY is often the key • Can be ‘ruled out’ with a negative urine pregnancy test

  23. Pregnancy Testing on Duty • You should be familiar with the procedure • You CANNOT take consent for the PT- needs to be done by qualified HCP • No reason why you cant as SDs perform the test if casualty incapacitated.

  24. Sexual Assualt and Rape • It is possible that women will present on duty having been sexually assaulted • You will NOT be expected to manage such cases • You MUST ensure that they are referred to a qualified HCP on site and find a suitable location for the consultation to take place

  25. Case 1 • BM 37 years old • Normally on ‘Depo’ injections • Advised not to have last one 3 months ago as ‘oestrogen levels too low’ • Presents with 12 hour history of intermittent lower abdominal cramping and PV bleeding ‘loads…..with clots’

  26. Case 1 • A&B- • normal • C- • Pulse 88 reg • BP 120/80 • D- • GCS E4M6V5 • E- • Temp 36.9 • F&G- • normal Urinalysis- negative PT- negative O/e Abdomen soft Mild suprapubic tenderness but easily distractible No masses Rest of examination unremarkable Diagnosis: Likely 'normal' menstrual bleed

  27. Case 2 • SG 22 years old • 28/40 G1 P0 • Brought in by first aid walking party collapsed • Fresh blood noted between legs

  28. Case 2 • A- • Sats 99% on 15l/min via NRB • B • RR 30 BPM • C- • Pulse 130 reg • BP 90/60 • D- • GCS E2M5V3 • E- • Temp 36.9 • F&G- • normal Diagnosis: APH- needs immediate stabilisation and transfer to hospital

  29. Summary • This presentation has covered: • Obstetric problems you may encounter on duty • Gynaecological problems you may encounter on duty • Female sexual health and GUM histories/treatments

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