Management of common problems in Obstetric and gynecology for primary care Doctors

Approached in a different way. from complaints to diagnosis. and when to refer

1. Management of common O&G problems at primary care level Dr. N. R. Reena, MBBS, DGO, DNB Consultant Gynecologist, Health Service Department .

2. COMMON COMPLAINTS 1. Discharge PV 2. Bleeding PV 3. Lower abdominal pain 4. Amenorrhea 5. Pruritus vulvae 6. Lumps and swellings of vulva 7. Obstetric problems USS report

3. 1. DISCHARGE PV >50% of cases are physiological Always take history Usually physiological if not associated with pruritus, foul smell or blood staining Always look the cervix

4. Pathological leucorrhoea Poor hygiene Foreign body Sexual abuse Pinworm Neoplastic Infective -- Candida, Chlamydia, Nesseria , Trichomonas, Bacterial vaginosis Iatrogenic – Spermicides, pessary , trauma Urinary and fecal fistula

5. P/s examination No abnormality – mucoid or white discharge

6. CANDIDIASIS -Thick curdy white discharge -erythema -Irritation

7. Treatment C lotrimazol cream 1% 5g intravaginally x 7 days or Clotrimazol suppository 100 mg x 6 days or Miconazol suppository 200 mg vaginally x 3 days or Oral antifungal Fluconazole 150 mg single dose More than four episodes per year – Recurrent candidiasis-- refer

8. Bacterial vaginosis Discharge is thinner Fishyodour with a drop of KOH

9. Treatment T. Metronidazole 200mg bd x 7days Metronidazole cream 0.75% 5g intravaginally bd for 5 days Clindamycin ovules 100 vaginally once at bedtime for 3 days Routine treatment of partner is not recommended

10. Trichomonas vaginalis

11. TMV Symptoms Usually asymptomatic Frothy/yellow green discharge Strawberry spots

12. Treatment Metronidazol 2g single dose orally or Tinidazol 2g orally single dose orally or Metronidazol 500mg bd for 7 days Sex partner should be treated

13. PURULENT CERVICITIS

14. PURULENT CERVICITIS

15. Purulent cervicitis Causative organisms – C. Trachomatis N. gonorrhoea

16. Presumptive treatment C. Trachomatis T. Azithromycin 1g orally single dose or T. Doxycycline 100 mg bd x 7 days orally Abstinence until therapy is over

17. N. G onorrhea Cefixime 400mg orally x 1 or Ciprofloxacin 500mg orally x 1 Sex partners in last 60 days should be treated

18. 2. AUB What is abnormal uterine bleeding 1. HMB 2. Inter menstrual bleeding 3. Post coital bleeding 4. Not attained menopause 5. Pre/ post menstrual spotting Post menopausal bleeding

19. BLEEDING IN ANY PATIENT IN REPRODUCTIVE AGE GROUP , RULE OUT PREGNANCY

20. Evidence based good clinical practice recommendations for Indian women Guidelines have been put forth by FOGSI

21. Types of AUB Acute Chronic Intermenstrual

22. Obsolete terms Menorrhagia Metrorrhagia Polymenorrhoia DUB

23. PALM COEIN Classification P olyp A denomyosis L eiomyoma M alignancy and hyperplasia C oagulopathy O vulatory disorders E ndometrial factors I atrogenic N on classified Structural abnormalities Coagulation disorders and hormonal dysfunction

24. HISTORY Bleeding disorder menstrual history Thyroid disease

25. 0N EXAMINATION PER ABDOMEN PER SPECULAM PV USS

26. PER SPECULAM Vaginitis Polyp Ca cervix uterine bleeding Urethral carruncle Anal bleeding

27. POLYP

28. CANCER CERVIX

29. Senile vaginitis

30. PAP SMEAR

31. BIMANUAL EXAMINATION

32. USS P-- polypectomy A –appropriate surgery if symptomatic L -- >4cm and symptomatic appropriate surgery M– Hyperplasia -- histopathology

33. NEVER MISS PREGNANCY / CANCER CERVIX

34. 3. LOWER ABDOMINAL PAIN UTI Dysmenorrhea Torsion ovarian cyst Ectopic pregnancy Surgical causes

35. HISTORY Menarche, LMP, PMP, Flow, duration Dysmenorrhea– Spasmodic/Congestive Dysuria, frequency, urgency

36. General examination PR BP Pallor Whether patient is in shock or not

37. Per Abdomen Hypo gastric pain/RIF pain Adnexal pain Mass palpable or not Free fluid/ Shifting dullness Distended bowel loops

38. Mass abdomen

39. Twisted Ovarian cyst

40. Distended bowel loops

41. Per Vaginal examination Bleeding Cervical movement painful or not Adnexal mass Mass in anterior fornix

42. USS Third eye of Gynecologist-- TVS

43. UTI Commonest cause of abdominal pain Abdominal pain/frequency/urgency

44. UTI Classification 1. Uncomplicated Infection in normal urinary tract 2. Complicated presence of metabolic anatomic or functional abnormalities pregnancy Catheter in situ Diabetes mellitus Stone

45. Pyelonephritis Fever Flank pain Nausea Vomiting Abdominal pain UTI Cystitis dysuria Urgency Frequency Hematuria Suprapubic pain

46. Recurrent UTI 3 episodes of UTI in last 12 months Or 2 episodes in last 6 months 27%women experience recurrence

47. Management Uncomplicated UTI Urine RE.. >10 pus cells in HPF Start 1.Antibiotics 2. Alkalinizer 3. Flavoxate 4. Oral fluids

48. Recurrent or complicated UTI Do culture and sensitivity USS To R/o Stone/ mass Cystoscopy if associated with hematuria Post coital antibiotics if needed

49. Recurrent UTI Appropriate toilet habbits Avoidance of prolonged delaying of urination Voiding after intercourse Cranberry juice ... Cranberry form a protective layer over urinary bladder... Prevent adherence of bacteria Antibiotic prophylaxis ......Nitrofurantoin 50 to 100 mg daily for 1year

50. Never miss ectopic pregnancy Do pregnancy test in all cases of acute abdomen in reproductive age group

51. PRIMARY Not attained menarche by 14 years or 16 years with secondary sexual charecters SECONDARY More than 6 months of amenorrhea after menarche Physiological Stress PCOD Hyperprolactinemia Premature menopause 4. AMENORRHEA

52. On Examination Look for secondary sexual characters External genetalia for inter sex, Imperforate hymen Height, Androgen excess, FG scoring Hypo thyroidism S. TSH Hyper prolactinemia s. Prolactin USS-- Uterus , Endometrium, Ovaries

53. Turner syndrome

54. 5. PRURITUS VULVAE Whether generalized pruritus or not Localized Candidiasis Scabies Psoriasis parasitic infestation pin worm, pediculosis pubis Discharge from anus -- piles/fissures/Fecal incontinence

55. Management-- Candidiasis Correct the cause/predisposing factor Pregnancy Anemia DM Steroid therapy

56. Management- -Candidiasis Clotrimazol cream Flucanazol 150 mg weekly for 3weeks Itraconazol

57. 6. LUMPS AND SWELLINGS IN VULVA Trauma-- Hematoma Infection-- Condylomata acuminata(viral wart), syphylitic condyloma Boils Retension cyst--Bartholins cyst sebaceous cyst, wulfian duct remnant Genital prolapse Hydrocele of canal of nuck Benign tumors Malignant tumors urethral carruncle

58. Condyloma acuminata HPV 11

59. Condyloma lata

60. Herpes simplex

61. 7. USS 1. PCOD Premature but slow regression of follicles. Multiple cyst formation Chronic anovulation Increased level of estrogen

62. Treat the symptom Amenorrhea – OCP MPA Hirsuitism – Anti androgen Obesity – Life style modification

63. USS Fibroid -- Large Ut >12 weeks size – Surgery Symptomatic Fd – Treat Infertility HMB Retention of urine Torsion hm

64. 8. Obstetric problems At least one visit during first trimester Two in second trimester Two in third trimester

65. First visit Hb Blood group VDRL HBSAg RBS HIV ICT in Rh negative women BMI in all women USS between 11 and 13 weeks GCT in high risk cases Downs syndrome screening in appropriate couples

66. Second trimester Anomaly scan around 20 weeks 75g 2hr OGTT at 24-28 weeks Repeat Hb at 24-28 weeks Repeat ICT at28 weeks Urine albumin

67. Third trimester Repeat OGTT Repeat Hb USS 34 weeks Urine Albumin CTG 40 weeks

68. What to do at each visit Record weight, BP Fundal height in cm Two doses of TT at 4-6 weeks interval [If last pregnancy <5 years only one booster] Folic acid 5mg in early pregnancy, 0.5mg later Iron supplementation 100mg 12-14 weeks onwards Calcium 500-1000mg daily

69. Counseling Proper education through antenatal classes Involve husband and relatives Possible complications to be explained Delivery and Labor to be explained Advantages of vaginal delivery to be highlighted Pain relief measures

70. High Risk BP >140/90 mm of Hg Hb <10 mg/dl OGTT >140 Twin pregnancy Heart disease complicating IUGR APH Jaundice complicating

71. Symptoms to be managed Hyper emesis: Abdominal pain Spotting Loose stools Fever, ILI

72. drugs safe in pregnancy Cat B drugs Ampicillins Cephalosporins Erythromycin Azithromycin Acyclovir Clotrimazol Paracetamol

73. Cat C drugs Quinolons Diclophenac Trimethoprin Fluconozol Isoniasid Rifampicine Mebendazol VaccinesHep A.B.,Rubella measles etc

74. Cat D Phenitoin Tetracyclin Sulfa Anticonvulsants

75. Cat H DES Thalidomide Retinoids Ribaverine

76. THANK YOU