Gynaecology | Bits & Bumps

Managing Acute Menorrhagia

November 25, 2015 · by drmarlenepearce

This week (after a very long break) we get back to business. We’ll take you through the diagnosis, management and investigation of acute menorrhagia.

Take Home Messages:

Acute Menorrhagia can be severe enough to create haemodynamic instability, assess for shock first.
Always perform a B-hCG to exclude pregnancy/miscarriage
Be sure to exclude a pelvic infection in your work-up
Consider inherited platelet dysfunction or coagulopathies in the adolescent with new menorrhagia
Consider endometrial hyperplasia or cancer in the woman over 35
Medical management may include NSAIDs, high-dose Progesterone, Tranexamic Acid
Surgical management may include Dilation & Curettage

References & Resources:

Adolescent Gynaecology – Menorrhagia Clinical Practice Guidelines, Royal Children’s Hospital Melbourne (Australia)

Menorrhagia (PDF) Australian Doctor Magazine ‘How To Treat’ (2009)

Heavy Menstrual Bleeding NICE Guideline UK (2007, updated 2013)

B&B Basics: The Gynaecological Examination

July 17, 2015 · by Penny Wilson

In this episode we go back to the basics with a chat about gynaecological exams. This is one for the students, junior doctors or those that feel their speculum exams are less than spec-tacular. We discuss issues such as:

The use of chaperones for intimate examinations
Patient positioning for success
How to wield the speculum
What swabs to use when
Tips and tricks for those particularly tricky ones

From http://intranet.tdmu.edu.ua/data/kafedra/internal/ginecology2/classes_stud/en/nurse/bsn/ptn/4/Nursing%20Care%20of%20Childbearing%20Family_Practicum/01.%20Clinical%20Anatomy%20and%20physiology%20of%20female%20reproductive%20system.htm

A. Lithotomy B. “M” position C. Lateral position D. “Diamond” position E. “V” Position. With thanks, from Clinical Anatomy and Physiology of Female Reproductive System

If you’ve got any gynae gems to share, leave a comment below. We’d love to hear your tips!

References & Resources

Statement about the use of chaperones from RACGP and guidelines for undertaking gynaecological examinations from RANZCOG

Broome Docs blog post on SOLVS vs clinical swabs for STIs

Cervix sampling guide with pictures of different normal and abnormal cervical appearances – from the Cancer Council Victoria

Handy and comprehensive guide from the WA health department silver book: Quick Guide to STI Screening

Step-by-step guide to bimanual examination and taking a cervical smear from Osce Skills

King Edward Memorial Hospital Speculum Examination Guideline

RCOG 2015 World Congress Wrap Up

April 20, 2015 · by Penny Wilson

We’re back on the podcasting bandwagon, and this episode Penny is joined by self-proclaimed twit and legendary Aussie GP obstetrician, Ewen McPhee (@Fly_texan), to discuss what they learned at the recent RCOG World Congress.

We cover a range of topical issues including:

An update of GDM diagnosis and management
NIPT for aneuploidy screening
The use of progesterone for threatened miscarriage
Pre-term labour – screening and treatment
Menopausal hormone therapy
Fertility, the place of AMH and the legal and ethical dilemmas of fertility preservation
Future therapies for pre-eclampsia

If this has whet your appetite, why not come along to RCOG World Congress 2016 in Birmingham, or RANZCOG 2016 Annual Scientific Meeting in Perth.

References & Resources

Official RCOG World Congress 2015 page, and Storify summaries for day 1, 2 & 3

Australian Diabetes in Pregnancy Society – Consensus Guidelines for Diagnosis of GDM (2014 Revision)

RACGP Clinical Guidelines for GDM (2014-215)

WHO Diagnostic Criteria for Hyperglycaemia in Pregnancy (2013)

International Society for the Study of Womens’ Sexual Health page

International Menopause Society page

Dr Alan Altman’s page – Menopause and Sexual Dysfunction

Cochrane Review – Hormone Therapy for Preventing Cardiovascular Disease in Post-menopausal Women – 2015

Climacteric 15(3) 2012 – The Women’s Health Initiative 10 years on

Your Fertility – Fertility information for professionals and patients

The Whole Nine Months – Western Australian pre-term birth initiative

Bleeding in Early Pregnancy: Diagnosing Miscarriage

November 10, 2014 · by drmarlenepearce

This week we discuss bleeding and pain in early pregnancy, and how to diagnose miscarriage.

Take Home Messages:

Miscarriage occurs in 1 in 5-6 confirmed pregnancies.
A pregnancy that has not yet been sighted on USS remains a ‘Pregnancy of Unknown Location’ and remains a possible ectopic pregnancy until proven otherwise.
Serial B-hCGs can be helpful in guiding your clinical decision making, however you cannot ‘locate’ a pregnancy with a blood test alone.
In the symptomatic patient, a falling, plateauing or rising B-hCG can ALL be associated with an ectopic pregnancy – these must be followed until an ectopic pregnancy can be diagnosed or excluded.
A rise of B-hCG in 48hrs of > 63% is relatively reassuring for an ongoing intrauterine pregnancy, make sure to confirm it with an USS as soon as you can.
The ultrasound diagnosis of both a blighted ovum and a missed miscarriage (with a foetal pole) have strict criteria – refer ASUM guidelines below.

References & Resources:

Early Pregnancy Ultrasound Rules and Report Card (LINK) – Ultrasound FOAM from The Sono Cave

First Trimester Bleeding Imaging Pathway (LINK) – Western Australia Health Department Flowchart

Clinical Guideline: Early Pregnancy Loss (PDF) – Queensland Health Guideline

First Trimester Bleeding Algorithm (PDF) – Reproductive Access Project, USA

ASUM Guidelines for Performance of First Trimester Ultrasound (PDF) – Australian Society for Ultrasound Medicine

NICE Guideline: Ectopic Pregnancy and Miscarriage (PDF) – UK Guidelines

How To Treat: Early Pregnancy Bleeding (PDF) – Australian Doctor Magazine, 2009

RANZCOG Guidelines – Anti-D use in Obstetrics (PDF) – Australia & New Zealand

Does speculum examination have a role in assessing bleeding in early pregnancy? (LINK) – Emergency Medicine Journal 2004

Quick Start Contraception – It’s Contraception, STAT!

October 15, 2014 · by drmarlenepearce

This week we discuss how to “Quick Start” contraception – on the day your patient requests it.

Take home messages:

Women are at unnecessary risk of pregnancy in the window between ASKING for contraception and STARTING contraception
There are clear protocols for starting contraception at any time in a woman’s menstrual cycle (see links below)
There are no known adverse effects on pregnancy from ordinary hormonal contraceptive methods (except IUDs)
Contraception can be started even if early pregnancy can’t be excluded, with a repeat pregnancy test in 4 weeks time.
Using this algorithm reduces unplanned pregnancies in high risk groups.

References & Resources

Quick Start Clinical Protocol – Family Planning Victoria (PDF) – Australia

Quick Start Flow Chart (PDF) – Please note this is a U.S. resource and has minor differences in timing of B-hCG retesting.

Quick Starting Contraception – RCOG UK Guidelines (LINK)

Initiating Hormonal Contraception (Quick Start) (LINK) – American Family Physician (Article by Lesnewski & Prine 2006)

LARC Contraception Methods – A Superior Choice

September 21, 2014 · by drmarlenepearce

This week, we discuss the benefits of Long Acting Reversible Contraceptive (LARC) methods, including IUDs and Implants.

Why are we so keen on LARC methods? Because they have a significantly higher continuation rate, higher satisfaction rate, and lower unplanned pregnancy rate than other methods (COCP, POP, DMPA). We also challenge the historical misconceptions regarding the use of IUDs in nulliparous women, and discuss how they are a safe first line option, endorsed by both RANZCOG and family planning groups in Australia.

References & Resources:

Time For A Change (PDF) Time For A Change – Increasing the Use of Long Acting Reversible Contraceptive Methods In Australia Statement by Sexual Health & Family Planning Australia October 2013

Contraception: A New Focus (PDF) Contraception: A New Focus by Dr Suzanne Pearson & Dr Sumudu Cooray, O&G Magazine p14-16 Volume 16 No 3 Spring 2014

The Choice Project (LINK)

Mirena modern-day miracle (PDF) – by Dr Edwina Morgan, O&G Magazine p21-23 Volume 16 No 3 Spring 2014

RANZCOG Guidelines for Intrauterine Contraception (LINK)

Management of Unscheduled Bleeding in Women Using Hormonal Contraception (LINK) Faculty of Sexual & Reproductive Healthcare Clinical Guidance, UK May 2009

Bleeding Pattern Changes with Progestogen-only Long-acting Reversible Contraceptives (LINK) Joint Statement, Sexual Health and Family Planning Australia

Mirena Fact Sheet (PDF)

Implanon Fact Sheet (PDF)

LARCs Fact Sheet (LINK)

Addit: Also check out this great article and awesome accompanying video from NEJM published a week after we published our podcast – Provision of No-Cost, Long-Acting Contraception and Teenage Pregnancy, N Engl J Med 2014; 371:1316-1323