Hospital at night: obstetrics and gynaecology guidelines for immediate management

Do’s

• For many doctors obstetrics and gynaecology is an unfamiliar area of practice. Yes, it can be a bit scary, but you’re unlikely to be asked to do anything too heroic. Importantly obstetrics and gynaecology is much more interesting than any other specialty in medicine, bar none. 
• Be calm, think, and ask plenty of advice. Most midwives have usually seen more obstetrics than most SHOs. Please do ask their advice – they’re really not scary people (Extn 26897). 
• Be courteous to the patients. If you think you’re scared, try being one of them; and when you walk into a labour room, look at the parents before looking at the CTG. 
• If you’re called to assist at a caesarean section or trial of forceps, go first to labour ward to sort out consent and bloods (there’s a list of responsibilities on the labour ward desk).
• Have a very low threshold of suspicion for pulmonary embolus in pregnancy, even in the first trimester. Investigate fully.
• Non-emergency, non-pregnant gynae problems can be dealt with by emailing the generic gynae team inbox. They will be dealt with in the morning.

Don’ts

• Don’t be shy about admitting people to the ward if you feel it’s necessary. Generally 14 weeks or less is gynaecology (Ward 7) and more than that is labour ward or antenatal (Ward 17). Pregnant patients with medical problems are usually admitted to O&G unless requiring very specific medical attention (e.g. a cardiac problem, very severe asthma).
• Early pregnancy with either abdominal pain or PV bleeding should be thought of as an ectopic until proven otherwise.
• Don’t PV someone with bleeding in the second or third trimester unless you are certain that there is no placenta praevia.

Finally

• If you have been involved in a delivery, do your best to see the mother at some stage in her postnatal stay. She will usually be delighted that you took the trouble.
• If you’re very good, you can aspire to a career in obstetrics and gynaecology. But only if you’re very good.

History

• Age, parity, a brief history of previous pregnancies, how much blood has been lost and whether there is any pain.
• Ask about cycle length and LMP.
• Has a pregnancy test been done, and when was it first positive? (home pregnancy tests are usually reliable).
• Have there been any scans this pregnancy? (In particular, is the pregnancy known to be intrauterine?).
• How much bleeding has there been, and has anything solid has been passed? (if a fetus has been passed then not ectopic). Note fibrin in a clot can look like a gestational sac).

Examination

• Observations – are there any signs of shock (suggests either major blood loss PV, or intra-abdominal bleeding with ectopic)? Products of conception in the cervical canal can sometimes also lead to vagal hypotension.
• Gently examine abdomen for tenderness or rebound (again thinking of pain associated ectopic bleeding).
• Perform speculum examination with chaperone present. Is the uterus bulky (suggests, but doesn’t prove, an intrauterine pregnancy)? A cervical ectropion can account for light PV loss, but bleeding is unlikely to be heavy. Are any products of conception visible?

Investigation

• Pregnancy test if doubt (these can be done on Ward 16). If negative, an ectopic is exceptionally unlikely. A pregnancy test will often still be positive for several days after a complete miscarriage.
• Bloods for FBC, G+S and rhesus status (the timing of sending these will depend on the overall clinical picture).
• Urinalysis +/- MSU.
  
  

USS not available during the night unless in exceptional circumstances, but is available every weekday morning, and some weekend mornings.

Management

• If shocked, resuscitate! Suspected ectopic must be discussed immediately with the middle grade on call.
• If has obviously miscarried will require counseling and follow up scan if all products not passed. Discuss with nursing staff on Ward 7. 
• If not shocked and relatively well, discuss with nurses on Ward 7 about arranging an ultrasound scan the following day through Pregnancy Assessment Unit (if a weekday) or Ward 7 (if the weekend). They may wish to stay in, which is fine.
• Any plan for outpatient management should include a discussion that ectopic has not been excluded.
• The mother needs to know who to contact during the night if pain/heavy bleeding. Suggest they contact you directly.

While PID is classically characterised by abdominal tenderness, adnexal tenderness and cervical excitation, features are usually specific to the organism. Chlamydia PID, in particular, may present with only minor symptoms:

Lower abdominal pain may also be caused by an ovarian cyst (torsion, bleed into the cyst), ectopic pregnancy, miscarriage or the usual surgical and medical causes.

Investigations

Take a history, carry out a clinical examination and check the WCC, ESR ± CRP. A vaginal swab should be checked for chlamydia and gonorrhea.

Although the gold standard test for PID is laparoscopic evidence of tubal inflammation, laparoscopy is usually only carried out if there is a pelvic mass, failure to respond to treatment, or significant doubt about the diagnosis.

Treatment

If the patient is clinically well:

• ofloxacin 400mg bd for 14 days
• metronidazole 400mg bd for 14 days

If the patient is clinically unwell:

• IV Ceftriaxone 2mg od
• oral doxycycline 100mg bd

Followed by:

• Oral doxycycline 100mg bd for 14 days plus 
• Oral metronidazole 400mg bd for 14 days
  
  

Admit if dehydrated, ketotic or not coping. Check admission weight, urinalysis (ketones), U&E, glucose and LFTs.

Treatment
Admission/daycase treatment and IV fluid replacement with 0.9% saline with 20mmol KCl. Please see hyperemesis protocol.

• cyclizine 50 mg IM/IV TID 8 hourly
• prochlorperazine 25mg PR 12 hourly (max 8 hourly)
• metoclopramide 10 mg IM/IV TID 8 hourly

NB there is virtually no safety data on ondansetron.

Immediate thoughts:

• Has she had an abruption (is there bleeding, is the uterus hard and tender, what’s the CTG like)? If you think it’s an abruption, call the registrar.
• Is she in labour (don’t be slow to do a vaginal examination – if in doubt, ask the midwife to do it)? If she is in labour, and she is more than 37 weeks, let the midwives get on with it. If pre-term, discuss with the registrar.

If neither of the above, take a more detailed history:

• Age, parity, gestation.
• Onset, duration, character, severity, radiation, exacerbating and relieving factors.
• Additional GI and GU symptoms (common include reflux and UTI symptoms). Back pain (common during labour).
• Associated systemic upset (don’t forget that pre-eclampsia can present with abdominal pain (check BP and urine for proteinuria).
• History of premature labour with previous pregnancies (view old notes).
• Has she had her appendix taken out?

Examination

• Observations, general examination and palpate the uterus.
• Again, VE if there is any chance she’s in labour (note: if there is a history of SRM, speculum only). If there is unexplained bleeding in the second or third trimester and you are not certain that the placenta is low, do not do a VE.

Investigations

• Urinalysis +/- MSU.
• CTG to determine fetal wellbeing and maternal uterine activity.
• Bloods (include FBC, inflammatory markers, LFTs, amylase and urate if history suggests).

Management

• Analgesia (paracetamol safe in pregnancy. Do not give NSAIDs).
• Maalox if suspect reflux.
• Cephalexin 500 mg TID safe in pregnancy if evidence of UTI.
• Pregnant women can still have surgical problems – discuss with registrar if appropriate.
• If no cause found consider common diagnoses in pregnancy such as ligamentous pain.
• Discuss with registrar if planning to discharge home.