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Common Gynaecology Conditions By Dr Swetha Sripathi (ST3 Registrar) and Dr Sonia Arnowalt (ST3 Registrar) Obstetrics and Gynaecology University Hospitals of Leicester NHS Trust 10/04/24 @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS BRITISH INDIAN MEDICAL @BIMA ASSOCIATION Saipem Classification - General Useal and OSCE series The British Indian Medical Association (BIMA) - The British Indian Medical Association (BIMA) is a national non-profit organisation founded on developing a supportive network amongst students and doctors across the UK - Provides tutorial series, conference events, networking, careers talks, socials and more! - For more information follow us on social media and stay up to date with latest academic events by joining our mailing lists: BIMA Clinical and OSCE series: https://forms.gle/CidGvWAc9YY9WSSs8 BIMA Fundamentals of Medicine & Pathology series: https://forms.gle/KfAgeoX55GPAWqee8 Saipem Classification - General Useand OSCE seriesTalk Outline  Case based discussion on common gynaecology conditions - Ectopic pregnancy - Gestational trophoblastic disease - Hyperemesis Gravidarum - Miscarriages - OHSS  SBA questions Saipem Classification - General Usel and OSCE seriesLearning Objectives - Recognise common presentations of common and important gynaecological conditions - Understand key investigations and management for these conditions - Apply this knowledge to clinical cases in gynaecology BIMA Clinical and OSCE series Saipem Classification - General UseBefore we start…. How interested are you in gynaecology topics? Saipem Classification - General UseCE seriesCase 1 ● Vanessa is a 15-year-old girl who comes with her friend to the gynaecology ward. Her GP has informed you that she has had a positive pregnancy test. She is complaining of vaginal bleeding and lower abdominal pain. ● What information you would like to know in the history? BIMA Clinical and OSCE series Saipem Classification - General UseCase 1 - History  Vanessa is 15 years old and has been sexually active for the last year.  She was shocked to find out that the pregnancy test was positive when it was carried out in her GP surgery.  This morning, she started having pain in her right iliac fossa and PV spotting. She thought that she had started her period, but the pain increased in severity and did not feel like period pain. She did not have any shoulder tip pain and was not feeling dizzy. Her current boyfriend is also 15 years old and he lives next door.  She asks you not to inform her mother. She denied having any pelvic inflammatory disease in the past, but she did complain of having dull lower abdominal pain. She felt sick this morning and her appetite has been reduced for the past 2 days. ** BIMA Clinical and OSCE series Saipem Classification - General UseCase 1 - What examination should you perform? You should perform a general physical examination, including:  Vital signs  Pulse  Blood pressure  Temperature You should also perform an abdominal, speculum and bimanual examination. BIMA Clinical and OSCE series Saipem Classification - General UseCase 1 - Results of the examination Her pulse is 85, blood pressure is 112/74 and her temperature is 36.9°C. P/A:- Soft with positive tenderness in the right iliac fossa but there is no rebound or guarding. P/S:- There was slight brown discharge, her cervical os was closed and at this stage you took triple swabs. BME:- Uterus was anteverted, not tender, there was no cervical excitation, no adnexal masses felt and there was definite tenderness on the right side. Her ward pregnancy test is positive. BIMA Clinical and OSCE series Saipem Classification - General UseCase 1 – Differential diagnosis Obstetrics and Gynaecology: - Ovarian torsion - Ovarian Cyst accident - Tubo-ovarian abscess - Ectopic pregnancy GI - Appendicitis - Bowel perforation/ischaemia/obstruction/malrotation BIMA Clinical and OSCE series Saipem Classification - General UseCase 1 – Beside the swabs, what other investigation you will do?  FBC  Blood group and typing  Quantitative beta-HCG  Pelvic ultrasound scan Saipem Classification - General UseE seriesCase 1 – USG Empty uterus, no adnexal masses and a small amount of free fluid. Blood test results: • Haemoglobin level of 13 • White blood cell at 12,000 • Blood group B positive • Serum beta-hCG level of 560 What do you think the results mean? Saipem Classification - General Use OSCE seriesCase 1 – Repeat Blood Test after 48hrs ● White cells of 11,000 ● β-HCG is 800 What do you think is the cause of the rise? The β-hCG level has nearly doubled in 48 hours, which can suggest an ectopic pregnancy or failing pregnancy, or even, very uncommonly, a viable intrauterine pregnancy (there is increased risk of about 66%). What do you think the subsequent management procedure should be? This will very much depend on Vanessa's symptoms. If there is no pain and vitals are stable, an outpatient follow-up with a β-hCG test and a scan can be done. If there is a concern about patient symptoms, blood results or the scan results, then laparoscopy should be done. Saipem Classification - General Useal and OSCE seriesReference: Ectopic pregnancy: Video, Anatomy & Definition |Osmosis BIMA Clinical and OSCE series Saipem Classification - General UseReference: What Is An Ectopic Pregnancy? - The Ectopic Pregnancy Trust Saipem Classification - General Use BIMA Clinical and OSCE series Symptoms Signs amenorrhoea or abdominal or pelvic vaginal bleeding with cervical motion rebound tenderness or missed period pain or without clots tenderness peritoneal signs pallor breast tenderness gastrointestinal dizziness, fainting or abdominal distension enlarged uterus orthostatic hypotension symptoms syncope tachycardia rectal pressure or pain on defecation urinary symptoms shock or collapse (more than 100 beats hypotension (less than 100/60 mmHg) BIMA Clinical and OSCE series Saipem Classification - General UseDiagnosis ● A transvaginal ultrasound scan to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. ● An empty uterus ● A collection of fluid within the uterine cavity (sometimes described as a pseudo-sac; this collection of fluid must be differentiated from an early intrauterine sac, which is identified by the presence of an eccentrically located hypoechoic structure with a double decidual sign [gestational sac surrounded by 2 concentric echogenic rings] in the endometrium). ● An adnexal mass, moving separately to the ovary (sometimes called the 'sliding sign'), with an empty gestational sac (sometimes described as a 'tubal ring' or 'bagel sign') Reference: Ultrasound diagnosis of ectopic pregnancy. - Abstract - Europe PMC Saipem Classification - General Usel and OSCE seriesReference: Ultrasound diagnosis of ectopic pregnancy. - Abstract - Europe PMC BIMA Clinical and OSCE series Saipem Classification - General UseLaparoscopic view of right tubal ectopic pregnancy. Reference: https://mfec.com.au/clinical-problems-index/ectopic-pregnancy/ Saipem Classification - General Usend OSCE seriesManagement: Reference: ACE MRCOG, Ectopic Pregnancy [5].pdf Saipem Classification - General Usend OSCE seriesFollow Up: Reference: ACE MRCOG, Ectopic Pregnancy [5].pdf Saipem Classification - General Usend OSCE seriesSTRANGE SITES OF ECTOPIC- CERVICAL ECTOPIC Reference: https://www.researchgate.net/figure/Cervical- ectopic-pregnancy-18_fig1_336790124 Saipem Classification - General Use BIMA Clinical and OSCE series CAESAREAN SCAR ECTOPIC Definition: Implantation into the myometrial cavity at the site of uterine incisi.n Primary diagnostic modality, using a transvaginal ultrasound shows:  Empty uterine cavity.  Gestational sac or solid mass of trophoblast located anteriorly at the level of the internal os embedded at the site of the previous lower uterine segment caesarean section scar.  Thin or absent layer of myometrium between the gestational sac and the bladder. Management: Primary medical treatment consists of using methotrexate, which may be administered by local injection into the gestational sac under ultrasound guidance or systemically by intramuscular injection. Local injection seems to be a more effective means of terminating the pregnancy . Reference: https://www.intechopen.com/chapters/68790 Saipem Classification - General Useal and OSCE series Case 2 An otherwise healthy 24-year-old GO presents to her gynaecologist because of irregular, heavy vaginal bleeding for the past few days. Complains of worsening nausea, vomiting, headache, and dizziness over the past few weeks. Last regular menstrual period before her current bleeding started was 6 weeks ago. On examination, a slight tremor in both hands, an enlarged 10-week- sized uterus, and blood coming from the cervical os. Urine β-hCG is positive. Reference: https://www.pocus.org/resources/molar-pregnancy/ Vital signs are temperature 36.8, heart rate 100 beats/min, blood pressure 160/100 mmHg, and respiratory rate 16 breaths/min. BIMA Clinical and OSCE series Saipem Classification - General UseCase 2 - Diagnosis What is the most likely diagnosis? a. Missed abortion b. Incomplete abortion c. Gestational hypertension d. Molar pregnancy e. Ectopic pregnancy BIMA Clinical and OSCE series Saipem Classification - General UseDefinition of GTD Definition GTN defines a heterogeneous group of lesions that represent an aberrant fertilization event the pathogenesis is unique because the maternal tumor arises from fetal tissue it is the most curable gynaecologic malignancy. Saipem Classification - General Useal and OSCE seriesReference: https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/gestational-trophoblastic-disease BIMA Clinical and OSCE series Saipem Classification - General UseReference: https://www.cambridge.org/core/books/abs/clinical-gynecology/gestational-trophoblastic- disease/4D8EF427B852EC86A3CB6030034D5198# Saipem Classification - General Use BIMA Clinical and OSCE seriesSigns and symptoms - Vaginal bleeding is the most common symptom. - Patients with complete mole may have: first trimester pre-eclampsia, hyperthyroidism, hyperemesis, increased uterine size and theca-lutein cysts - Patients with partial moles are diagnosed clinically as missed or incomplete abortion. - Nausea and vomiting because of high Beta-HCG level. Saipem Classification - General Usend OSCE series Diagnosis CLINICAL: The first evidence is the passage of vesicular tissue A quantative pregnancy test of greater than 100,000 IU/L, an enlarged uterus, and vaginal bleeding suggest a diagnosis of a hydatidiform mole INVESTIGATIONS: Ultrasound (test of choice) will show multiple echoes (snow storm). β-hCG assays. The definitive diagnosis of molar pregnancy is Histological examination which shows absence of fetal tissue; extensive hydropic change to the villi; and excess trophoblast proliferation. Features of a partial molar pregnancy include: presence of fetal tissue; focal hydropic change to the villi; and some excess trophoblast proliferation. Ploidy status and immunohistochemistry staining for p57, a paternally imprinted gene, may help in distinguishing partial from complete molar pregnancies. Saipem Classification - General UseClinical and OSCE seriesManagement of Molar pregnancy. ● Ultrasound guidance during removal and curettage may be of use to minimise the chance of perforation and to ensure that as much tissue as possible is removed. ● Suction curettage is the method of choice for removal of partial molar pregnancies except when the size of fetal parts deters the use of suction curettage and then medical removal can be used. ● Anti-D prophylaxis is recommended following removal of a molar pregnancy. Pregnancy-with-a-Kle-Kle/6a6dc204f1cd67a74447902dda5db49fe8e3509ert%3A-Partial-Molar- Saipem Classification - General Useal and OSCE series Case 3 A 28-year-old, G1PO, presents to the emergency department with hemoptysis. Which of the following is the most likely diagnosis? She reports that she has had increasing cough and shortness of breath over the past 8 weeks and that she coughed up a dime-sized blood clot this morning. a. Missed abortion b. Incomplete abortion On review of systems, the patient endorses heavy and irregular vaginal bleeding. c. Choriocarcinoma She says that she had a spontaneous abortion 6 months ago and that she started d. Molar pregnancy having increasingly irregular and heavy periods about 4 months ago. e. Ectopic pregnancy On examination, her uterus is enlarged to 12-week size. Serum β-hCG is elevated, haemoglobin is 10 mg/dL, and chest X-ray reveals two dense areas in her lungs, one in the right upper lobe and one in the left lower lobe. BIMA Clinical ad OSCE series Saipem Classification - General Use Management of GTN ● Women with GTN may be treated with single-agent or multi-agent chemotherapy. ● Treatment used is based on the International Federation of Gynaecology and Obstetrics (FIGO) 2000 scoring system for GTN following assessment at the treatment centre. ● PSTT and ETT are now recognised as variants of GTN. They may be treated with surgery because they are less sensitive to chemotherapy. Reference: GESTATIONAL TROPHOBLASTIC DISEASES BY DR SHASHWAT JANI | PPT Saipem Classification - General Use ad OSCE seriesWomen with scores of 6 or less are at low risk and are treated with single-agent intramuscular methotrexate, alternating daily with folinic acid for 1 week followed by 6 rest days. Women with scores of 7 or greater are at high risk and are treated with intravenous multi-agent chemotherapy, which includes combinations of methotrexate, dactinomycin, etoposide, cyclophosphamide and vincristine. Treatment is continued, in all cases, until the hCG level has returned to normal and then for a further 6 consecutive weeks. FOLLOW UP: Complete molar pregnancy, if hCG has reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from the date of uterine removal. If hCG has not reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from normalisation of the hCG level. Partial molar pregnancy: Its concluded once the hCG has returned to normal on two samples, at least 4 weeks apart. Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event. Saipem Classification - General Uselinical and OSCE seriesCase 4 History: Primigravida, spontaneous pregnancy, no previous scans, constantly vomiting for the past 3 days. Can’t tolerate oral intake, insignificant medical history. Examination: looks ill, not pale, dehydrated, BP 90/50, PR110/min, RR-12/M, T37.2, mild tender epigastrium,6% weight loss compared to her pre pregnancy weight. Investigations: FBC,RFT,LFT – normal limits. Urine dipstick- 3+ ketones, no pus cells and no RBC What could be the most likely diagnosis and quote the differential diagnosis. Saipem Classification - General Use and OSCE series Peptic Ulcers Cholecystitis Metabolic conditions Drug-induced Gastroenteritis Hepatitis nausea Genitourinary conditions such as urinary tract Neurological Pancreatitis infection or conditions pyelonephritis Hyperemesis gravidarum Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 Saipem Classification - General UseClinical and OSCE seriesHistory Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 BIMA Clinical and OSCE series Saipem Classification - General Use Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 Saipem Classification - General Use BIMA Clinical and OSCE seriesReference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 BIMA Clinical and OSCE series Saipem Classification - General UsePUQE Score Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. in Pregnancy and https://doi.org/10.1111/1471-0528.17739 BIMA Clinical and OSCE series Saipem Classification - General UseRecommended Simplified Management Algorithm for NVP/HG Management in Primary Care Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 Saipem Classification - General Use BIMA Clinical and OSCE seriesRecommended antiemetic therapies and dosages Reference: Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 Saipem Classification - General Use BIMA Clinical and OSCE seriesFurther reading The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69): Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024; 00: 1–30. https://doi.org/10.1111/1471-0528.17739 NICE guidelines for Ectopic pregnancy https://www.nice.org.uk/guidance/ng126 TOG article on caesarean scar ectopic https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/tog.12355 Gestational Trophoblastic Disease (Green-top Guideline No. 38) https://www.rcog.org.uk/guidance/browse-all-guidance/green-top- guidelines/gestational-trophoblastic-disease-green-top-guideline-no-38/ Saipem Classification - General Useal and OSCE seriesCase 5 31 y/o female was brought in by ambulance to A&E with vaginal bleeding. Observations: HR 90bpm, BP 126/81, RR 20, Sats 95% OA, T 37.0, Urine pregnancy test positive. She was awaiting a dating scan in a few days. On examination, she has a soft and non-tender abdomen. A bimanual examination showed an enlarged soft, non-tender uterus. Adnexa was non-tender and free. What are your top differentials? BIMA Clinical and OSCE series Saipem Classification - General Use Differential Diagnosis Pregnancy-Related Nonpregnancy related - Bleeding in a viable pregnancy Infections of the vagina or cervix - Threatened miscarriage Cervical abnormalities- ectropion, polyp, malignancy - Inevitable miscarriage Trauma - Missed miscarriage - Incomplete miscarriage - Complete miscarriage - Molar pregnancy BIMA Clinical and OSCE series Saipem Classification - General UseEarly Pregnancy Loss & Management How can we differentiate all these conditions? + UPT & bleeding PV - Proper History taking. - Examination – Abdominal, Speculum & examination. Images from medilinguist teachable.com Saipem Classification - General Use and OSCE series Clinical Features ● Symptoms and signs Miscarriage Cervical os Passage of product Other features Threatened closed No + IU pregnancy Inevitable open Not yet Passage of product imminent Incomplete open Some, but with delayed +RPOC passage of the rest Complete closed yes - IU pregnancy Missed closed no + IU pregnancy Nonviable fetus Septic Open/ closed Usually have RPOC + IU pre/ septic features Saipem Classification - General Useal and OSCE series Missed Miscarriage Ultrasound scan diagnosis - Diagnosis of miscarriage using 1 ultrasound scan cannot be guaranteed to be 100% accurate and there is a small chance that the diagnosis may be incorrect, particularly at very early gestational ages. - 2 measurements – Crown-rump length (CRL) / Mean gestational sac diameter (MSD). - First look to identify a fetal heartbeat. If there is no visible heartbeat but there is a visible fetal pole, measure CRL. Only measure the MSD if the fetal pole is not visible. BIMA Clinical and OSCE series Saipem Classification - General Use Missed Miscarriage Ultrasound diagnosis CRL with no MSD with no TVS TAS visible heart beat fetal pole < 7mm < 25mm Rescan in 7 days Rescan 1n 14 days >7mm > 25mm Second opinion Second opinion &/ &/ rescan in 7 rescan in 14 days days Saipem Classification - General Use and OSCE seriesManagement Threatened Miscarriage - Offer vaginal micronized progesterone 400 mg twice daily to women with an intrauterine pregnancy confirmed by a scan, if they have vaginal bleeding and have previously had a miscarriage - If a fetal heartbeat is confirmed, continue progesterone until 16 completed weeks of pregnancy. - If bleeding gets worse, or persists beyond 14 days, she should return for further assessment. - if the bleeding stops, she should start or continue routine antenatal care. BIMA Clinical and OSCE series Saipem Classification - General Use Management ● Missed Miscarriage Expectant Medical Surgical 7-14 days. 200mg oral Mifepristone, 48 hours MVA / later, 800 micrograms misoprostol Local or (vaginal, oral or sublingual) EVAC under GA Review after 1 week Review 48 hours after misoprostol Check treatment histology Scan If either absence of Discuss options again bleeding & pain (failed) or persisting bleeding ( incomplete) Saipem Classification - General Useal and OSCE seriesManagement Different Options Miscarriage Expectant Medical Surgical Inevitable  Analgesics Incomplete  Misoprostol MVA/ EVAC 800mcg Complete  Saipem Classification - General Use and OSCE seriesContraindications of Expectant Management - The woman is at increased risk of haemorrhage (for example, she is in the late first trimester) - she has previous adverse and/or traumatic experiences associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage) or - she is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion) - there is evidence of infection Saipem Classification - General Usend OSCE series Further Care An information leaflet is provided - Sensitive information, give enough time, and ensure privacy. - waiting for a repeat scan has no detrimental effects on the outcome of the pregnancy - Give women a 24-hour contact telephone number to seek medical help. - Offer all women receiving medical management of miscarriage pain relief and anti-emetics as needed. BIMA Clinical and OSCE series Saipem Classification - General Use Follow up Anti D  Offer anti-D immunoglobulin prophylaxis at a dose of 250 IU (50 micrograms) to all rhesus-negative women who have a surgical procedure to manage a miscarriage.  Do not offer anti-D immunoglobulin prophylaxis - - Medical management for miscarriage - - Threatened miscarriage - - Complete miscarriage Saipem Classification - General Usend OSCE series Follow up - UPT in 3 weeks - Positive pregnancy test - to report to hospital to rule out RPOC, molar pregnancy, or ectopic pregnancy - Negative UPT, still bleeding- assess the need for further investigations or treatment BIMA Clinical and OSCE series Saipem Classification - General Use Early Pregnancy Bleeding CASE 6 A 28-year-old woman presents to the early pregnancy unit with 2 days history of heavy vaginal bleeding and abdominal cramps. Now the bleeding and pain settled. She missed her period 2 days back. Observations are stable. Abdominal examination - soft, non-tender abdomen Speculum examination - mild bleeding, os closed. Pregnancy test positive What are the differentials? How will you confirm your diagnosis? BIMA Clinical and OSCE series Saipem Classification - General Use Further reading Nice guideline Published: 17 April 2019 Last updated: 23 August 2023, Ectopic pregnancy and miscarriage: diagnosis and initial management. www.nice.org.uk/guidance/ng126 BIMA Clinical and OSCE series Saipem Classification - General UseCase 7 31 y/o female presents to the gynecology early assessment unit referred by her GP with 5 5-day history of lower abdominal pain, nausea, and bloating. She has been trying to conceive for 2.5 years. She underwent fertility treatment in Morocco. She was treated with gonadotropin injections for ovarian stimulation. She started symptoms a few days after taking an HCG trigger injection which was administered 1 week back. Observations She was tachycardic and tachypnoeic with normal oxygen saturation and BP. She was able to lie flat and speak a full sentence without any difficulty. HCG test is positive. What are your differentials? Saipem Classification - General Use and OSCE series Differential Diagnosis - Ovarian hyperstimulation syndrome ( OHSS) - Ovarian torsion - Ovarian cyst rupture - Pelvic infection - Pelvic abscess - Appendicitis - Ectopic pregnancy - Bowel perforation Mireproductivemedicine.com Saipem Classification - General Used OSCE series Pathophysiology - Fertility drugs, usually gonadotrophins, are used to stimulate the ovaries during IVF treatment to make eggs grow. Sometimes there is an excessive response to these drugs, leading to OHSS. - Incidence; Mild OHSS - 33% Moderate or severe OHSS - 1% - The risk is higher in women who: - have polycystic ovaries - are under 30 years old - have had OHSS previously - have multiple pregnancies Picture from www.stmother.com BIMA Clinical and OSCE series Saipem Classification - General Use Clinical Features Symptoms ; History ; Abdominal bloating Abdominal discomfort/pain, need for Time of onset of symptoms relative to trigger analgesia Medication used for trigger (hCG or GnRH agonist) Nausea and vomiting Breathlessness, Number of follicles on final monitoring scan inability to lie flat or talk in full sentences Number of eggs collected Reduced urine output Were embryos replaced and how many? Leg swelling Vulval swelling Polycystic ovary syndrome diagnosis? Associated comorbidities such as thrombosis Examination ; General: assess for dehydration, edema (pedal, vulval, and sacral); record heart rate, respiratory rate, blood pressure, body weight Abdominal: assess for ascites, palpable mass, and peritonism; measure the girth Respiratory: assess for pleural effusion, pneumonia, pulmonary edema Saipem Classification - General Usecal and OSCE series Investigations Other tests that may be - Full blood count indicated - Haematocrit (haemoconcentration) Arterial blood gases - C-reactive protein (severity) D-dimers - Urea and electrolytes (hyponatraemia and Electrocardiogram hyperkalaemia) (ECG)/echocardiogram - Serum osmolality (hypo-osmolality) Chest X-ray - Liver function tests (elevated enzymes and reduced Computerised albumin) tomography pulmonary - Coagulation profile (elevated fibrinogen and reduced angiogram (CTPA) or antithrombin) ventilation/perfusion (V/Q) - hCG (to determine the outcome of the treatment cycle) scan if appropriate - Ultrasound scan: ovarian size, pelvic and abdominal free fluid. Consider ovarian Doppler if torsion suspected Saipem Classification - General Useal and OSCE series Classification Category Features - Mild Abdominal bloating, Mild abdominal pain, Ovarian size usually < 8 cm Moderate Moderate abdominal pain, Nausea ± vomiting Ultrasound evidence of ascites , Ovarian size usually 8–12 cm Severe Clinical ascites (± hydrothorax) Oliguria (< 300 ml/day or < 30 ml/hour) Haematocrit > 0.45 Hyponatraemia (sodium < 135 mmol/l) Hypo-osmolality (osmolality < 282 mOsm/kg) Hyperkalaemia (potassium > 5 mmol/l) Hypoproteinaemia (serum albumin < 35 g/l) Ovarian size usually > 12 cm Critical Tense ascites/large hydrothorax Haematocrit > 0.55 White cell count > 25 000/ml Oliguria/anuria Thromboembolism Acute respiratory distress syndrome Saipem Classification - General Useal and OSCE series Management Follow up Outpatient Mx- mild or moderate OHSS and in Reviewed urgently if they selected cases with severe OHSS develop symptoms or signs of - provide verbal and written information worsening OHSS. - avoid NSAID In the absence of these, a - encourage to drink to thirst rather than a set amount review every 2–3 days is likely and maintain fluid input–output charts to be adequate. -urine output of less than 1000 ml per 24 hours or a Baseline laboratory positive fluid balance of greater than 1000 ml over 24 investigations should be repeated if the severity of OHSS hours should prompt medical review is thought to be worsening. severe OHSS – thromboprophylaxis provided Haematocrit is a useful guide to the degree of intravascular volume depletion Saipem Classification - General Usel and OSCE series Worsening OHSS Signs Indication for hospital admission/ IP mx - increasing abdominal distension and pain - shortness of breath ● are unable to achieve satisfactory pain - tachycardia or hypotension control - reduced urine output (less than 1000 ● are unable to maintain adequate fluid intake due to nausea ml/24 hours) or positive fluid balance ● show signs of worsening OHSS despite (more than 1000 ml/24 hours) outpatient intervention - weight gain and increased abdominal ● are unable to attend for regular girth outpatient follow-up - increasing haematocrit (greater than ● have critical OHSS. 0.45). Saipem Classification - General Useal and OSCE series Management Indications for paracentesis ● severe abdominal distension and Fluid Mx abdominal pain secondary to ascites - Fluid replacement by the oral route, guided by thirst, is the most physiological approach to ● shortness of breath and respiratory correcting intravascular dehydration compromise secondary to ascites and increased intra-abdominal pressure - Persistent haemoconcentration despite volume ● oliguria despite adequate volume replacement with intravenous colloids may need replacement, secondary to increased invasive monitoring with anesthetic input. abdominal pressure causing reduced renal perfusion. - Diuretics should be avoided as they further Paracentesis should be carried out under ultrasound guidance and can be performed deplete intravascular volume, but they may have a abdominally or vaginally. Intravenous colloid role in a multidisciplinary setting if oliguria persists therapy should be considered for women who despite adequate fluid replacement and drainage of have large volumes of fluid removed by paracentesis ascites. Saipem Classification - General Usecal and OSCE series Thrombosis Managment Indication of surgery in patients with OHSS Severe or critical OHSS and those admitted with OHSS should receive LMWH prophylaxis. If there is a coincident problem such as adnexal torsion The duration of LMWH prophylaxis should be ovarian rupture individualized according to patient risk factors and the outcome of treatment. or ectopic pregnancy Moderate OHSS should be evaluated for predisposing risk factors for thrombosis and prescribed either antiembolism stockings or LMWH if indicated. Pregnancies complicated by OHSS may be at increased risk of pre-eclampsia and preterm delivery. Thromboembolism at upper body sites or arterial system can present with unusual neurological symptoms- dizziness, loss of vision, neck pain Saipem Classification - General Useical and OSCE series Further Reading RCOG Green-top guideline on Management of ovarian hyperstimulation syndrome, No: 5, 2016. BIMA Clinical and OSCE series Saipem Classification - General UseSaipem Classification - General Usend OSCE seriesTHANK YOU FOR LISTENING ANY QUESTIONS BIMA Clinical and OSCE series Saipem Classification - General Use