Dr. Carl McQueen ACD (Students) SWY CCT

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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!!!

• 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

• 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

• 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

• 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

• 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

• 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

• 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

• 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)

• 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

• 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

• 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’

• 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

• 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

• 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.

• 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

• 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’

• 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

• SG 22 years old

• 28/40 G1 P0

• Brought in by first aid walking party collapsed

• Fresh blood noted between legs

• 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

• 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