[RCSI Obstetrics & Gynecology Newsletter]  

→Spring 2018 vol.8 ← 

Let us present the OBGYN Society Executive Committee 2017/2018……. 

 

 

 

 

 

OBGYN 2017/2018 Committee 

 Back row: Angela Joannou (Event Coordinator), Reya Al-Nabhan (Secretary), Rachel Tan

(President), Danielle Wuebbolt (President), Bunmi Adesanya (Editor) Front row: Amy Pawson (Chief Editor), Vanessa Nguyen (Treasurer), Megan Shum (Public

Relations)

Missing Members…. 

Adaeze Emeka (Head Tutor), Traveen Singh (Editor), Kristyn Dunlop ( Event Coordinator) and Lauren Berry (Vice President)

 

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Contents

 Interview with OBGYN and Fertility Specialist 3-4

By: Amy Pawson

Why Do You Want to be an OBGYN? 5 By: Bunmi Adesanya

Reflection: OBGYN Observership 6-7 By: Ameera Khan

Seeing My First C-Section 8 By: Traveen Singh

An Overview of Premenstrual Syndrome 9-11

By: Bunmi Adesanya

Oral Contraceptive Options—Choosing the ‘pill’ that is right for you 12-14

By: Angela Joannou

A Case Review: Antepartum hemorrhage 15-19

By: Rachel Tan

A Surgical Case: Vaginal Hysterectomy for Uterine Prolapse 20-24

By:Jonavan Tan

An Obstetric Case: Antepartum Haemorrhage 25-28

By: Vanessa Nguyen

A Gynaecology Case: Laparoscopic Surgery for Hydrosalpinx 29-32

By: Danielle Wuebbolt

OBGYN Winning Essay: “GO FORTH AND MULTIPLY: AT WHAT COST?” 33-36

By:TISHELLE BOODOO

Available Conferences 37-38

Tips for Success 39

   

 

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A Conversation with Dr. Marjorie Dixon

By Amy Pawson

EDUCATION

Dr. Marjorie Dixon is a graduate of McGill University’s Faculty of Medicine.

Her initial postgraduate training was at the University of Toronto in Obstetrics and Gynecology.

She continued her postgraduate training with a three year subspecialty, American Board of Obstetrics and Gynecology accredited fellowship in Reproductive Endocrinology and Infertility at the University of Vermont.

ASSOCIATIONS

American Society of Reproductive Medicine

Canadian Fertility and Andrology Society

American College of Obstetrics and Gynecology

Society of Obstetricians and Gynecologists of Canada

1. When did you know you wanted to be an OBGYN?

I was in high school when I discovered my passion for Reproductive Biology and decided to embark upon a career path to be a fertility specialist. Becoming an OBGYN was simply a “means to an end.”

2. As we know obtaining a residency spot in Obstetrics and Gynecology is a triumph in itself, however, was this at the time your goal or did you have an interest in Reproductive Endocrinology and Infertility at that time? And if so why was this specialized area so interesting to you?

It all began around the 10th anniversary of Louise Brown’s (the world’s first IVF baby) birth in 1988. I was browsing through the periodicals during my high school library period and a TIME article caught my eye. It further predicted that the future of medicine was in the field of “Reproductive Biology”. It piqued my curiosity and seemed almost perfectly suited for me, as I had both a love of biology and planned a future in the field of medicine!

After reminiscing about Louise Brown, the world’s first IVF baby, I can also assert that my father had a huge influence on my choice of career. He was a high school biology teacher and used to bring me to his lab as a child; he never worried that I would be overwhelmed by any of

 

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his dissection specimens. Rather, he was very matter-of-fact about things: patiently explaining the reproductive habits of mice and rats. I can remember being intrigued to see where their litters grew (in bicornuate uteruses)! It must have been very formative- in retrospect…

3. What was the driving force behind Anova Fertility & Reproductive Health?

My goal was to create an environment that advocates for fertility health, that is innovative, that offers individualized, compassionate and evidence-based medical care for all patients, no matter their marital status, sexual orientation, ethnic or religious background … and Anova Fertility was born.

4. This year you were one of seven recipients who received the YMCA Toronto’s Women of Distinction award, how did that make you feel? Does it empower you to encourage women to do more or be better?

I must confess I was very surprised and extremely honoured to be considered a Woman of Distinction. The award definitely provides me with the platform to empower and uplift women. We have to stick together, especially during this day and age. As the Dalai Lama said in Vancouver at the Peace Summit in 2009, “The world will be saved by Western women.”

5. Where do you see yourself in ten years?

This is a hard question, as I would like to do so many things. Right now, I can say that I wouldn’t mind opening up more Anova Fertility centres in ten years. Contributing to family dreams coming true with the help of modern science is something that I am truly passionate about.

6. As a female surgeon, fertility specialist, mother of 3, and wife, what advice would you have for female medical students who aspire to have it all? While being the best person possible.

A career in medicine is both incredibly rewarding and fulfilling. You must find your passion and follow it unwaveringly: there are many subspecialties, so finding the right fit is key.

Your support system is important, it includes your friends and family. Never forget where you came from, as those close to you will help you navigate through the hard times and keep you true to yourself and your end goals.

 

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Why Do You Want to be an OBGYN?

By Bunmi Adesanya

“What kind of doctor would you like to be, what do you want to specialize in?” is the first thing people ask when you tell them you’re a medical student. Or they start to give you a detailed medical history and look at you expectantly waiting for a diagnosis (I can tell you based on my own experience, I am never right about this and me and said person just end up googling their symptoms together). But my answer to this is an OBGYN. Most of the time people look at me strangely in response, someone usually asks what it is and there’s always one brave soul that asks if I actually like vaginas that much. OB is the infamous specialty for being called in at all hours, not being terribly conducive to having a family of your own and its high malpractice insurance. Despite these cons I still feel it’s the specialty for me and below are the reasons why.

1. The nature of the medical field is intimate in general, however with OBGYN, I feel that this is even more so. Women are entrusting you with their most intimate organs, having one’s feet in stirrups is not the most comfortable position. Parents are entrusting you with their most prized possession their child. It is humbling to have so much faith placed in one doctor and I would do anything to show patients that I’m worthy of this trust.

2. The mix of clinical and surgical opportunities. This means that each day is full of variety, from delivering babies to pelvic exams to surgically removing ovarian cysts.

3. I feel that there is still so much stigma around women’s health and their bodies and I want to be able to give women the opportunity to speak freely about what they’re experiencing and how it affects their daily life. I want to be able to normalize what they’re feeling and offer them a viable solution to a given problem.

4. The opportunity for continuity of care. When women are pregnant especially if they are deemed high risk they have to see their doctor several times over the course of their pregnancy. I love this aspect simply because I get to keep up with these women, with their families and their lives. I also love to talk and this is perfect for that.

5. This is the only specialty where you go in with one patient and come out with two. Plus the challenge of caring for two people at the same time is a unique one as the actions of one party fully and completely affect the other.

Being an OBGYN means high risk and high reward, it means intense job satisfaction, it means being at the hospital at 3AM, it means fielding questions about whether you can eat your placenta, it means holding a nervous soon to be father’s hand, but at the end of the day it means being present both intellectually and emotionally during life altering moments.

 

 

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Reflection: OBGYN Observership

By Ameera Khan

I spent a few weeks in an OBGYN department in Oman to learn more about the doctor-patient relationship and the dedication required in this field. This specialty is fascinating to me because of the immense responsibility one undertakes during a woman and her family’s most significant moments. Having a baby changes your whole life and to be trusted with helping that process is truly a privilege.

On my first day I saw a vaginal delivery, there were minor complications and an episiotomy was needed. A baby boy was born. No matter how much I had learnt about deliveries and heard stories about them, nothing could have prepared me for what I actually saw. It was intense. It was long. The woman was in a completely different state with the mixture of emotions, nitrous oxide and nausea. But after the wait and the struggle, the delivery was truly miraculous. And what was even more miraculous, are the women who decide to have a second child- but we can thank hormones for that.

As the week progressed, I saw my first surgery, a C-section for a breech baby. Patients always assume surgeries are cutting and exposing the insides of the body and leaving a huge scar. However I learnt how surgery is more of a gentle process with the smallest incision possible. We started from the lower abdomen working layer by layer until we reached the baby. If the woman on the table knew how gentle yet persistent her surgeon was, she would not have been half as scared to have gone into the OR. The surgeon closed up layer by layer, taking her time even after the nurses and interns left. As you would imagine there is limited patient interaction in surgeries, however there is patient consideration at every step. The surgeons act in the patient’s best interest. The patient was pleasantly surprised that the surgery just left a small, hidden scar.

In the clinics, I met various other patients, some from rural areas, some from the city. One was a staff member with appendicitis after pregnancy; she only came in because of the persistent fever! I saw an ultrasound of a baby’s ribs, head and heart for the first time with a new mother. It was a beautiful moment for all of us in the room. I met one lady with six children; she previously had nine abortions and is currently pregnant with another baby. In the rural areas of Oman, having several children is quite common, but this was not the case for this patient due to her recurring abortions. Meeting all these women and listening to their stories was fascinating and I slowly began to understand how easy it is to lose track of time with them. There is just too much to squeeze into one appointment.

My second week at the OBGYN department was a bit more intense. I was seeing at least three live births per day. The exhaustion from each of them was getting to me and I wasn’t even the patient! One day we had three major events: a vaginal haematoma requiring a haematoma evacuation, a primary postpartum haemorrhage and an unknown case of an assisted pregnancy. In the last case, there was the need for a neonatologist.

 

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The neonatologist, the obstetricians/gynaecologists, the midwives and the nurses were all working together in such a crucial moment of this woman’s life, her baby’s life, and her family’s life. It was literally a fight against death and the healthcare professionals handled the crisis beautifully. They did it as a team, not just by the specialty they were assigned to.

My time in the OBGYN department was a blur of never ending cervix dilation checks and rushing to live deliveries. It is not the most glamorous specialty in the hospital. However I saw the selfless attitude and the immense dedication emanating from each individual there. The surgeons in the department are passionate and eager to teach. The doctors, nurses and midwives always do more than what could be done for their patients and strive to go beyond. However sometimes the situation is not always in their control. They deal with hepatitis B, chicken pox, and obese patients among others. Sometimes there are unnecessary hospital errors and unexpected circumstances. Things are out of our control and that is just how life is in the OBGYN department; it is chaotic. However,

it is the chaos that makes the job glamorous.

Image 1,2,3: http://timothykurek.com/uploads/2017

 

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“Seeing my first C-section”

By Traveen Singh

Image 4: https://i.ytimg.com/vi/rgS9N5OldBM/hqdefault.jpg

I was scrubbed in, waiting in the operating room for the obstetrician to arrive. The assisting physician, the anaesthetist and the nurses were all in good humour, telling jokes, and meanwhile, there I was sitting on a stool in the corner of the room internally freaking out. I had never even witnessed a natural delivery, let alone an emergency C-section, like the one I was mentally preparing myself to observe. I was scoping out the doors in the theatre thinking “which way should I go if I feel like I am going to pass out?” Before I could come to a decision, the OB strolled in, along with the patient on a stretcher. Everyone quickly moved to where they were supposed to be, while I timidly approached the table. The obstetrician asked me to stand directly beside him, and I was equal parts excited and nervous. The nurse handed over a scalpel, and in a few short minutes, the initial incisions were made and all the anxiety that had just been bubbling up inside me was long forgotten. All of the diagrams and pictures that I had only ever seen in Gray’s Anatomy or in a cadaver, were suddenly right in front of me, various structures pulsing, oozing and contracting. A discarded glove covered in blood and who knows what else was dropped on my bootie-clad shoe and I could not have cared less. The surgeon grabbed my hand excitedly and essentially thrust it into the incision he had made and said “guess what you’re feeling! The baby’s head!” I’m not sure that I could even come up with a response. And then, before I knew it, the assist was pressing down on the patient’s belly, the obstetrician was pulling Baby out with – to my horror – the umbilical cord wrapped around his neck. The surgeon quickly unwrapped the cord and freed the baby. The newborn was then passed off to a nurse and we were back to focusing on the mother. In what seemed like no time at all, she was sutured up and the operation was successfully completed.

This was one of my first experiences in a situation where there was a direct threat to a person’s life. But despite the potential high stresses of the situation, none of the individuals involved in the procedure showed even a modicum of panic, and the operation was therefore efficient and successful. Observing this operation showed me how rewarding obstetrics can be, and also the confidence and efficiency that comes with having experience in a given medical field. It also gives me hope that even though the trials and tribulations of a medical career seem very daunting to me now, it will undoubtedly be worth it in the end.

 

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An Overview of Premenstrual Syndrome

By Bunmi Adesanya

“Talk to me after your period is over” and my personal favourite “Calm down, have some chocolate you’ll feel better”. I’m sure we’ve all heard this at some point in our lives, maybe we’ve even said this to someone as a joke or with all seriousness. These statements are associated with the enigmatic premenstrual syndrome (PMS). This group of symptoms has been a controversial subject for several years, the big questions being around its legitimacy, the severity and treatment options. Being a female myself, I can fully testify that PMS is alive and well.

PMS is clinically defined as the cyclic recurrence of life impacting symptoms during the luteal phase of the menstrual cycle (a week before the period) leading to the experience of both somatic and psychological symptoms.1,2 These symptoms should recede at the onset of a period.1

PMS can be divided into 2 categories: PMS and PMDD or pre-menstrual dysphoric disorder.1 PMDD is a more severe form of PMS and its effects can be severely debilitating. PMDD includes feelings of hopelessness or self-deprecating thoughts, increased anxiety, sudden shifts to feelings of sadness and anger, increased sensitivity to rejection, decreased interest in daily activities, feeling overwhelmed and out of control as well as the physical symptoms already associated with PMS.1-3 PMDD diagnoses focus more on the psychological aspects of PMS. The diagnostic criteria differs for both disorders, including number and type of symptoms needed to be present and certain length of time in order to be diagnosed.1-3

All of this being said, the etiology of PMS is unclear, adding to the mystery behind the whole thing – no one knows its origin story.3 The word hysteria has long been associated with women’s bodies, in fact Plato described the uterus as an animal, and once this animal did not bear children after puberty it becomes very irritated causing respiration and a myriad of diseases.4 While I do not think your uterus will rebel against you if you don’t have children this “explanation” provides an example of the link between hysteria and women’s health. Looking at present day, the explanations behind PMS are still very murky. There have been several theories such as differences in receptors that bind to estrogen and progesterone. The levels of these substances were normal in women with and without PMS so sensitivity level has been examined, however at various points during the ovulation cycle progesterone and estrogen levels are not equal. Symptoms are more likely to appear when progesterone levels are higher than estrogen levels.2, 5 Serotonin is heavily implicated in theories concerning PMS because of

 

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the ability of serotonin reuptake inhibitors (SSRIs), serotonin releasing drugs6, serotonin precursors7 and serotonin receptor agonists8 to ameliorate the psychological effects of PMS. Furthermore, impairment of serotonin production (such as a tryptophan free diet – tryptophan being an essential amino acid needed to produce serotonin) induces PMS symptoms.9 PMDD is also said to have a genetic link with single nucleotide polymorphisms in the genes that code for the serotonin 1A receptor translating to a homozygous phenotype.10 This homozygous state results in a decline in serotonergic effects because of reduction in neurotransmission manifested as working memory impairment and reduced impulse control during the premenstrual period.10 Meanwhile, other theories cite that PMS is an evolutionary tool needed in order to maximize reproductive chances by allowing women to drive away infertile mates and increase male enthusiasm and passion and induce the zeal of reproduction.11 Needless to say this was met with a significant amount of skepticism and backlash, to put it lightly.12

While the scientific research for PMS leaves more questions than answers, PMS has also been defined as a social and cultural construct. A woman’s societal gender role is centered around the expected gentle, loving, submissive personality.13 Women are not to have strong emotions or feelings as these would detract and shatter the culturally created role.13 PMS is seen as a deviation from this role, academics pointing out that mood change is often a symptom of PMS.13 However the medicalization of these mood swings, displays of strong behaviours and emotions, gives society the license to dismiss the reasons that may cause such reactions and attribute them to biology. The use of PMS as a murder defense further medicalizes PMS.13 This can be seen either as an increase in the syndrome’s legitimacy from a strictly biomedical point of view or a detraction in feminism and trying to dispel the myth that women are irrational and unstable during the premenstrual period.

There are no standardized treatments for PMS or PMDD.14 The general goal is to relieve core symptoms such as depression, irritability and anxiety and somatic symptoms like breast pain, bloating and swelling and headache.15 To treat mild symptoms patients are often told to exercise and try various relaxation techniques.15 Moderate to severe symptoms especially those classified under the PMDD diagnosis can be treated with selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors.15 These are first line treatments for PMDD. They are either taken continuously or only in the luteal phase (on day 14 of the cycle), stopping once menses begins.15 Side effects of SSRIs are dose dependent and include nausea, headache, insomnia and decreased libido.15 Oral contraceptives are also used in attempts to treat PMS and PMDD, however evidence of their effectiveness is inconsistent.1, 15 Contraceptives containing the progestin drospirenone were found to be effective using placebo controlled trials and meta-analysis but are prescribed with caution because of their higher risk of venous thromboembolism.15-18 Other oral contraceptives showed little to no improvement in psychological symptoms and were more effective for physical symptoms, the variants being drug, dose, number of placebo days.1, 15 Vitamins B6 and E, calcium and magnesium, are all considered ineffective due to inconsistent evidence.14, 15 For women unresponsive to SSRIs or oral contraceptives, gonadotropin releasing hormone agonists work to suppress gonadotropin releasing hormone translating to a decrease in ovarian function.15

PMS is a disease with many faces, whether it’s being examined under a social and cultural lens or biomedical lens. There are several opinions around why PMS occurs in the first place. The inconsistent evidence concerning etiology translates to non-standardized treatment options.

 

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PMS continues to be somewhat of a mystery and while it helps to be more informed about the disease in general, I will still continue to eat chocolate at least once a month (like I needed a reason anyway) and hope my uterus does not implode if I don’t have children by the age of 25.

References

1. Biggs S. W, Demuth R.H. Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician. 2011; 84: 918- 924

2. Yonkers K, O’Brien M P Shaughn, Eriksson E. Premenstrual syndrome. The Lancet. 2008; 371: 1200 – 1210

3. Dickerson L, Mazyck, P, Hunter M. Premenstrual syndrome. American Family Physician. 2003; 67: 1743 to 1752

4. Chadwick, R. Pathological wombs and raging hormones: psychology, reproduction and the female body in Shefer T, Boozaaier, Kiguwa P. The gender of psychology. Cape Town. UCT Press; 2006. 1 – 45

5. Schmidt PJ, Neiman L, Danaceau M, Adams L, Rubinow D. Differential behavioral effects of gonadal steroids in women with and in those with premenstrual syndrome. The New England Journal of Medicine. 1998; 338: 209 – 216

6. Brzezinksi A, Wurtman J, Wurtman R, Gleason R, Greenfield J, Nader T. d-Fenfluramine suppresses the increased calorie and carbohydrate intakes and improves the mood of women with premenstrual depression. Obstetrics and Gynacology. 1990; 76: 296 – 300

7. Steinberg S, Annable L, Young S, Liyanage N. A placebo controlled clinical trial of L – tryptophan in premenstrual dysphoria. Biol Pyschiatry. 1999; 45: 313 – 320

8. Landen M, Eriksson O, Sundblad C, Andersch B, Naessen T, Eriksson E. Compounds with affinity for serotonergic receptors in the treatment of premenstrual dysphoria: a comparison of buspirone, nefazodone and placebo. Psychopharmacology. 2001; 155: 292 – 298

9. Menkes D, Coates D, Fawcett J. Acute tryptophan depletion aggravates premenstrual syndrome. Journal of Affective Disorders. 1994; 32: 37 – 44

10. Yen J, Hung-Pin T, Cheng-Sheng C, Cheng-Fang Y, Cheng-Yu L, Chih-Hung K. The effect of serotonin 1A receptor polymorphism of the cognitive function of premenstrual dysphoric disorder. European Archives of Psychiatry and Clinical Neuroscience. 2014; 264: 729 – 739

11. Gillings M. Were there evolutionary advantages to premenstrual syndrome?. Evolutionary Applications. 2014; 7: 897 – 904

12. Brookshire, Bethany. [webpage]. Hypothesis on evolution of PMS attracts hostility. Science News. [cited Dec 2017]. Available from https://www.sciencenews.org

13. Lorber J, Moore L. if a situation is defined as real: premenstrual syndrome and menopause in Lorber J, Moore L. Gender and the social construction of illness. Maryland. AltaMira Press; 2002. 71 – 79.

14. Douglas S. Premenstrual syndrome: evidence – base treatment in family practice. Canadian Family Physician. 2002; 48: 1789 – 1797

15. Casper R, Yonkers K. Treatment of premenstrual syndrome and premenstrual dysphoric disorder. UptoDate [updated Jun 8 2016, cited 15 Dec 2017]. Available from http://uptodate.com

16. Yonkers K, Brown C, Pearlstein T, Foegh M, Sampson-Landers C, Rapkin K. Efficacy of a new low dose-oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstetrics and Gynecology. 2005; 106: 492 - 501

17. Pearlstein T, Bachmann G, Zacur H, Yonkers K. Treatment of premenstrual dysphoric disorder with a new drospirenone-containing oral contraceptive formulation. Contraception. 2005; 72: 414 -421

18. Lopez L, Kaptein A. Helmerhorst F. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database of Systematic Reviews. 2012.

 

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Oral Contraceptive Options—Choosing the ‘pill’ that is right for you

By: Angela Joannou

Image 6. https://media.glamour.com/photos/58b465d209e96e7fe3be7414/master/pass/birth-control-pills.jpg

Oral contraceptives, more commonly known as “birth control pills”, are one of the most frequently used forms of contraception available to women. While there are a plethora of contraceptive options including condoms, diaphragms, injections, and IUDs, oral contraceptive pills are very popular. This is due to their high efficacy rate of 99.9% if used correctly, and their easy oral administration.1 Furthermore, many women take them for reasons other than contraception, such as menstrual cycle regulation, acne control, and dysmenorrhea.2,4 With so many different types of oral contraception it can be confusing as to what type is best to take. There is really no ‘correct’ option per se, as individual people will respond differently to the medication, with a varying range of side effects. Therefore, many women may need to try different formulations to find what works best for them1.

The combined pill contains both estrogen and a progestogen, such as, ethinylestradiol and norethisterone or levonorgestrel.2 Ethinylestradiol, which is derived from 17β-estradiol is the predominant type of estrogen used in contraceptive pills because of its high oral bioavailability.Combined pills are taken for either 21 days with 7 hormone-free days or 24 days with 4 hormone-free days. The estrogen inhibits the release of Follicle Stimulating Hormone (FSH), and therefore, the development of the ovarian follicle. The progestogen inhibits the release of Luteinizing Hormone (LH), preventing ovulation and making the cervical mucus inhospitable to sperm. Therefore when taken together, this alters the endometrium and discourages implantation from occuring, resulting in contraception. After either 21 or 24 days, progestogen withdrawal allows for menstruation to occur.2

There are many types of combined pills with varying concentrations of hormones, and they can be mono-, bi- or tri-phasic. Monophasic pills have the same amount of hormone throughout the cycle2,3. Some side effects include weight gain, nausea, breast tenderness, mood changes, spotting, skin pigmentation, hypertension, breast cancer and thromboembolism.3

The lower dose combined pills are a popular choice as they contain less estrogen, typically 35 micrograms or less. Higher dose combined pills have a greater risk of developing breast tenderness, nausea, thromboembolisms and breast cancer due to the increased amounts of

 

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estrogen being consumed. Comparatively, the lower dose combined pills have fewer side effects, and are therefore safer to be taken for more prolonged periods of time.5 However, lower dose combined pills may not work for everyone as they have other side effects such as spotting, and mood changes/irritability.3

Furthermore, the specific type of estrogen or progestogen used in the pill can provide different benefits. For instance, a pill containing ethinylestradiol and drospirenone is recommended for those wanting to reduce their acne. Acne develops as a result of excessive sebum production. Androgens, including testosterone, stimulate the production of sebum. Drospirenone, a type of progestogen, has anti-androgenic effects, thereby reducing the formation of acne6. Patients should consult with their doctor as to what they are looking for specifically, as different types of oral contraceptives have a range of uses.

There are also progestogen-only pills or ‘mini-pills’, containing for example norethisterone or levonorgestrel. Progestogen-only pills are taken daily with no hormone-free days. The progestogen-only pills make the cervical mucus inhospitable to sperm, hinder implantations, inhibit LH release and prevent ovulation.2 Progestogen-only pills are used when taking estrogen is contraindicated in the patient. For instance, estrogen is contraindicated if women get hypertension from taking estrogen, are breastfeeding, have a history of a venous thromboembolism, or have smoked for over 35 years. These patients should not take the combined pill but instead should instead choose to take the progestogen-only pills.7

Therefore, as there is a wide variety of options available, it is important that physicians take a thorough history from their patients in order to select the best oral contraceptive for their patients.7

Cari Rice, G. (2006). Selecting and Monitoring Hormonal Contraceptives: An Overview of Available Products. [online] Stage.uspharmacist.com

 

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References

1. Mayo Clinic. Choosing a birth control pill. Mayo Clinic. 2018 [cited 20 December 2017]. Available from: https://www.mayoclinic.org/healthy-lifestyle/birth-control/in-depth/best-birth-control-pill/art-20044807

2. Morgan M, Reproductive Pharmacology. [Lecture] Renal, Endocrine, Genitourinary and Breast, Royal College of Surgeons in Ireland, 15 March 2017.

3. Stewart M, Choosing a combined oral contraceptive pill, PubMed-NCBI, 2015 [cited 23 December 2017], Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4654044/

4. Bernardi M et al., Dysmenorrhea and related disorders. PubMed-NCBI, 2017 [cited 2 December 2017], https://www.ncbi.nlm.nih.gov/pubmed/28944048

5. Low-Dose and Ultra-Low-Dose Birth Control Pills. WebMD. 2018 [cited 4 January 2018], Available from: https://www.webmd.com/sex/birth-control/low-dose-birth-control-pills#1

6. Endly DC et al., Oily Skin: A review of treatment options. PubMed, Journal of Aesthetic Dermatology, 2017 [cited 8 January 2018], Available from: https://www.ncbi.nlm.nih.gov/pubmed/28979664

7. Cooper DB et al., Oral Contraceptive Pills, PubMed, 2017 [cited 10 January 2018], Available from: https://www.ncbi.nlm.nih.gov/pubmed/2861363

 

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A Case Review: Antepartum hemorrhage

By Rachel Tan

A 38 years old ,Para 2+1, Gravida 4, currently 31 weeks gestation, was admitted to Rotunda Hospital presenting with vaginal bleeding at 24 weeks gestation on a background history of fibroid and history of placenta accreta from previous pregnancy.

History of Presenting Complaint

● Admitted to Wexford hospital due to painless PV bleed but was transferred to Rotunda Hospital after 2 days.

○ Painless bleed progress to painful abdominal painful bleeding as the quantity increase. Pain described as crampy but not contractions.

● Previously she has 2 episodes of painless PV bleed. ● 1st episode of bleeding @ 16 weeks gestation when she was on holiday in Croatia. Fresh,

bright red blood is observed. Quantity of blood is similar to pad around day 2 to 3 during period.

● Diagnosis with low lying placenta by the doctor she saw in Croatia. She did an ultrasound scan and it showed that the placenta is low lying at the os, almost covering the cervical os.

● 2nd episode of bleeding at 24 weeks gestation. Fresh bright red blood observed, however quantity increase to about a glass full accompanied with some blood clot.

● Current episode is the 3rd PV bleed. She has been bleeding everyday. The longest period she has not bleed is 1 week. There will be occasion of times where there is brown blood and occurs about 4-5 days. Her condition improved a lot since her admission.

● There is no trauma involved, most bleeding occurred spontaneously. ● No fever ● Fetal movement is normal ● Movement can occasionally exacerbate bleeding and pain.

History of Index Pregnancy:

● LMP: 13/4/2017 ● Date of Conception: unsure. It was an unplanned pregnancy ● Date of positive pregnancy test: 2nd week of May ● EDD: 18/1/2018 ● Booking visit and scans done regularly since 5 weeks gestation. Previously, she was

having her scans in Germany until 18 weeks gestation, and then she has her scan in Rotunda (when she relocate back to Ireland over the summer). All the fetal scan results are normal.

 

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● At 26 weeks scan, fibroids were found in the uterus ● She had two booking blood test done before (one in Germany and one is done in

rotunda) for serology test for varicella, rubella, Hep B, HIV and results are negative. ● Fetal anomaly scan at 20 weeks is normal ● Blood group: B+

Past obstetric history:

● 1st pregnancy (2011): one baby boy, 39 weeks gestation, 3.4kg ○ Elective C-section – due to embolization and myomectomy procedure for fibroid

removal in 2007 ○ Pregnancy is unremarkable ● 2nd pregnancy (2014) : one baby girl, 38+4 weeks, 3.5kg ○ She suffered from placenta accreta during pregnancy. ○ A healthy baby girl was born via elective c section with no complication perinatally.

Past Gynaecology history:

● Menarche: 12 year old ● Menstrual cycle regular (~28 day) , period last for 5 days ● In 2007: She had an episode intermenstrual bleeding on day 10th and day 24th of

menstrual cycle and went to see a gynaecologist. Fibroids were found in her uterus and she had an myomectomy.

● Ectopic pregnancy in Oct 2016 – had a laparoscopy salpingectomy ● No contraception. ● Last smear done in Feb 2017 and is normal

Past medical history:

● Epilepsy – in her early 20s and was treated for 4 to 5 years. She has been seizure-free for more than 10 years.

Past surgical history:

● 2007: Myomectomy ● 2011: 2014: Elective Caesarean section ● 2016: Laparoscopic salpingectomy

Medication:

● She is currently on Iron and Folic acid

Allergy:

● No Known Drug Allergy

 

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Family history:

● Her sister has endometriosis ● Grandmother has endometrial cancer

Social history:

● Living with her husband and children in Wexford ● Occupation: Freelance acupuncturist ● She and her family was living in Germany for 8 years and only relocated back last year. ● Non smoker. She does not drink alcohol. ● She plan to breastfeed her baby

System review:

● Her mood is good ● Appetite has been great ● Bowel and bladder movement is normal

Physical examination:

Patient is alert and well.

● No sign of pallor of the palmar crease or conjunctiva pallor (no indication of anemia) ● Capillary refill less than 3s.

Vital signs:

● Blood pressure: 120/80 mmhg ● Pulse: 80 bpm ● SpO2: 98% ● Respiratory Rate: 16 breath per min

Inspection of the abdomen:

● Abdomen is distended consistent with pregnancy ● Pfannenstiel incision scar was present. ● Mild striae gravidarum present

Symphyseal fundal height (SFH): 35cm

* SFH indicates large of dates. It is due to the presence of the fibroid in the uterus, apart from fetus.

Abdominal Palpation:

● Transverse lie ● No presentation ● No engagement.

 

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Auscultation using pinnard for 15s: ideally 100-160 bpm

Summary:

This is a 38 years old, G4 P2+1, currently 31 weeks gestation, presented to the hospital with PV bleeding at 24 weeks gestation with a background history of fibroids and past medical history of placenta accreta and surgical history of myomectomy. She is currently stable and monitored in the hospital until the delivery of her baby.

Antepartum Haemorrhage (APH)

● Vaginal bleeding from 24 weeks until the onset of labour ● Prevalence: 5%

Main causes of Antepartum hemorrhage

Placental causes Local causes

Placenta Previa: a placenta that is partially or completely located in the lower uterine segment

Vasa Previa: occurs when vessels of umbilical cord runs in the fetal membrane across the cervical os

Placental Abruption: premature separation of normally sited placenta

Uterine rupture

Cervical or vaginal laceration (trauma)

Cervical or vaginal cancer

Cervicitis or vaginitis (infections)

Unknown

The management of antepartum hemorrhage depends on the cause of bleeding, severity of bleeding and patient presentation. For this patient, a focused history is taking followed by a thorough physical examination.

 

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Expectant management

Emergent management

Things to consider:

· Is the mother stable?

· Depend on whether the bleeding has stopped, if the amount decreased.

· Is it a fetal non-reassuring CTG?

· What is the gestational age of the fetus?

Immediate delivery is indicated if mother experienced life threatening maternal haemorrhage regardless of gestational age and if fetus shows non reassuring CTG.

· The major risk of placenta previa is that patient may have a sudden unpredictable life threatening hemorrhage; therefore they are advised to be stay in the hospital until delivery of the baby.

· Outpatient management are only allowed to woman with stable circumstances.

· If <35 weeks gestation, steroid should be given for fetal lung maturation.

· Mode of delivery: Vaginal delivery is preferred unless there are clear indication for caesarean section such as placenta previa, multiple c-section, previous uterine surgery etc)

· Admit the patient immediately

· Establish IV lines via 2 bore cannula

· Hematological investigation: Full blood count, coagulation screen, group and cross match (4 unit) blood if transfusion is required

· Ultrasound: impt to visualize diagnosis such placenta previa and vasa previa.

· Continuous Fetal cardiotocography

· Call senior for help and notify Neonatal intensive care unit

· If patient is rhesus negative, they are required to have anti D injection after an episode of antepartum hemorrhage

Reference:

● SC1 Obgyn notes ● Norwitz, E. R., & Park, J. S, (2017). Overview of the etiology and evaluation of vaginal bleeding in

pregnant women ● Oxford handbook of obstetrics and gynaecology 3rd edition

 

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A Surgical Case: Vaginal Hysterectomy for Uterine Prolapse

By:Jonavan Tan

PC:

A 56 year old lady, P4+1, admitted for elective vaginal hysterectomy and pelvic floor repair for a 2 year history of uterine prolapse, associated with urinary and faecal incontinence as well as lower abdominal and back pain.

HPC:

Referred by her GP to the gynae clinic in 2015 due to uterine prolapse causing urinary and faecal incontinence. Conservative management with a ring pessary and pelvic floor training was unsuccessful, and thus she was eager for surgical intervention for symptomatic relief due to significant impact on her daily life.

She experiences a chronic “dragging” sensation, as well as “pressure” in her pelvis. She complains of urine leaking when coughing, consistent with stress urinary incontinence, as well as nocturia (2-3x per night). This progressed to faecal incontinence, with incomplete emptying of both urine and faces and leaking of urine on the way to the toilet. CD denies other urinary/bowel symptoms (e.g. dysuria, haematuria, haematochezia). She also experiences “crampy” suprapubic and lower back (L4/5) pain (severity 2-3/10), extending to her iliac fossae bilaterally, exacerbated by coughing and standing for long periods of time, and relieved by sitting.

She also notices a visible protrusion out of her vagina, increasing in size, currently roughly 2cm. It occasionally becomes irritated and painful with friction on clothes, and rarely may bleed.

Past Gynaecological History:

Menarche at age 14; periods were regular (28-31 days) + 4-5 days “normal” bleeding. Rarely experienced “period cramps”, but never severe pain. No inter-menstrual bleeding, post-coital bleeding, dyspareunia. Currently post-menopausal – last menstrual period 4 years ago; experienced hot flushes. Not on HRT.

Smears regularly, most recently 2 years ago, all normal. No history of UTIs, STIs.

Past Obstetric History:

Gravida 5 Para 4+1

1986: Induced SVD, 6.11lb girl

1989: Miscarriage

 

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1992: Caesarean section under GA; Indication – IUGR, 5.11lb boy

1994: SVD, 7.4lb boy

1996: SVD, 6.11lb girl

All pregnancies and deliveries were otherwise uneventful – longitudinal lie, cephalic presentation, no instrumentation. Children all healthy and well.

Past Medical History:

Moderate asthma (Dx 2009) – chronic cough, and recurrent respiratory tract infections requiring admission

Seropositive rheumatoid arthritis (Dx 2015) – affecting hands, wrists and knees. Well-controlled.

Previously on methotrexate, currently on sulfasalazine

Hypertension

Dyslipidemia

Hemorrhoids

Depression

Past Surgical History:

Caesarean section 1992

Excision of cystic lesion on neck 2013

Meds:

Monteleukast 10mg PO OD

Xyzal (levocetirizine) 5mg PO OD

Ventolin (albuterol) 20mcg Inhaled PRN

Symbicort (budesonide/formoterol) 100/12mcg Inhaled BD

Spiriva (tiotropium) 2-5mcg Inhaled OD

Zoton 30mg PO OD

Sertraline 10mg PO OD

Sulfasalazine 1g PO BD

 

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Folic Acid 10mg PO once weekly

Amlodipine 5mg PO OD

Allergies: NKDA

Family History:

COPD – mother

Rheumatoid arthritis – Aunt, Daughter

Social History:

Ex-smoker 20 years ago, 10 pack years; Drinks alcohol on occasion, 3-4 units

Currently retired. Previously worked as a machinist in 1980’s – occasionally heavy lifting of raw materials. Lives in family home with 2 sons and 1 daughter; Partner left years ago.

Systems Review:

Productive cough – ?unresolved pneumonia, despite treatment with amoxicillin 500mg PO TDS x 10/7 and prednisolone 30mg PO OD x 5/7 one week ago. Yellow-green sputum. Mild dyspnea and wheeze. No chest pain, hemoptysis.

Physical Examination:

Not performed as patient was being transferred to theatre. Previous pelvic exam in clinic 4 months ago showed positive cough impulse for grade 2 prolapse, leaking urine, cystocele and rectocele.

Summary:

This is a 56 year old lady, G5 P4+1, admitted for elective vaginal hysterectomy and pelvic floor repair for a 2 year history of uterine prolapse, associated with urinary and faecal incontinence as well as lower abdominal and back pain, following failed conservative management; with risk factors of: multiparity, menopausal, chronic cough, occupational heavy lifting.

Differential Diagnosis:

Second degree uterine prolapse; cystocele, rectocele, enterocele.

(risk factors: multiparity, menopausal, chronic cough, ex-smoker, occupational heavy lifting)

Large cervical Polyp.

Pedunculated subserosal fibroid extending through external cervical os.

 

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Management:

Clinical examination to confirm diagnosis – abdominal (?masses, tenderness) + pelvic in left lateral position with sims speculum (?location, size of mass, cough reflex, reducible, signs of incontinence, ulceration, vaginal atrophy)

Investigations:

Bloods: FBC – Hb ?anemia, platelets, WCC, Coagulation,

LFTs (?liver impairment for medication),

U&E Cr, (?hydration, renal impairment), Type & Crossmatch, Blood Glucose

USS uterus

MSU (?UTI secondary to incontinence/prolapse)

Urodynamics – evaluate incontinence

ECG; Anaesthetic assessment – asthma, concurrent upper respiratory tract infection.

Consent for surgery

Preoperative antibiotic prophylaxis – Cefuroxime + Metronidazole

Surgical management: Vaginal hysterectomy + Pelvic floor repair,

under spinal anesthesia with sedation

Send specimen for histology

Post-hysterectomy:

Routine obs; monitor vitals (?fever, tachycardia) and bloods (Hb, WCC, ESR/CRP), surgical site for signs of infection

Vaginal packing 24 hrs for hemostasis.

Monitor fluid balance/urine output; IV fluid replacement, urinary catheter in situ 72hrs.

Monitor bowel motions/passing wind; ?signs of bladder/bowel injury

Analgesia – Paracetamol 1g PO/IV QDS, Ibuprofen 300mg PO TDS, Oxynorm 10mg PO QDS

Antiemetic – Ondansetron 4mg IV TDS

Laxative – movicol 2 sachets PO TDS

DVT prophylaxis – Innohep (tinziparin) 4500IU SC OD; TED stockings, encourage early ambulation

 

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Plan for discharge ?POD3-4 on same; GP review at 2 weeks, Gynae outpatient clinic review at 6 weeks

Physio referral, continue pelvic floor exercises; advise to avoid heavy lifting, cough control, avoid intercourse and swimming for 6 months.

Instruct patient on wound care/hygiene. Return if any symptoms of soreness, redness (infection), bleeding

 

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An Obstetric Case: Antepartum Haemorrhage

By: Vanessa Nguyen

PC:

A 35 year old lady, G4 P2+1, presented to A&E at 30+6 weeks gestation with PV bleeding, with a history of asymptomatic subchorionic hematoma diagnosed at 12 weeks gestation.

HPC:

She walked in to A&E 2 days ago at 30+6 weeks gestation, complaining of PV bleeding since morning, which she noticed as she woke up with blood-soaked sheets; patient estimated 150ml blood loss. She denied any pelvic/abdominal pain, contractions, headache/visual disturbance, dizziness, or bladder/bowel symptoms. No other PV fluid/gushing. No history of vaginal trauma/intercourse. Fetal movements present.

Previous incidental finding of subchorionic hematoma on transabdominal ultrasound at 12 weeks, which spontaneously resolved. Patient was asymptomatic, no PV bleeding or abdominal/pelvic pain.

History of current pregnancy:

EDD: 2nd May 2016 LMP: 26th July 2016

Rh(D)-Positive, Serology negative, GBS negative

She has had no other complications thus far during the pregnancy; no previous admissions.

Patient was taking folic acid preconception and 12 weeks into pregnancy

Most recent transabdominal ultrasound: longitudinal lie, cephalic presentation.

Patient unsure of placenta location, ?low lying

Patient receives combined GP + consultant care

Past Obstetric History:

G4 P2+1

2009 – Vaginal delivery assisted with ventouse, at term. Prolonged labour, induced with syntocinon.

GBS Dx at 28 weeks. Pregnancy otherwise uneventful, livebirth baby boy, 3.75kg; healthy.

2012 – Caesarean-section under epidural anesthesia at term, for non-reassuring CTG. IUGR, livebirth baby boy 2.6kg, admitted to NICU. Diagnosed with Russell-silver syndrome.

2014 – Incomplete miscarriage – pregnant while on Mirena coil. Received ERPC.

 

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Past Gynecological History:

Menarche at age 14. Menstrual cycles regular, 31 days + 3 heavy and 3-4 light days bleeding. No inter-menstrual/post-coital bleeding, dysmenorrhea or dyspareunia. No history of STIs/PID, vaginal discharge.

Previously on Mirena coil – incomplete miscarriage, presenting with mild pelvic discomfort and PV bleeding. Managed surgically – ERPC.

Patient’s most recent cervical smear in 2012, all smears normal; intends on receiving one 3 months after index pregnancy.

Past Medical History: Nil

Past Surgical History: ERPC 2014 miscarriage

Meds: Nil

Allergies: NKDA

Family History:

Russell-silver syndrome in 5 year old son

Social History:

Non-smoker, no alcohol. Works as nurse, intends on taking 6 months maternity leave. Lives at home with partner and 2 children; all well. Mother in law currently taking care of children while patient admitted. Currently undecided on breast or bottle-feeding. She and partner either plan on her having tubal ligation or partner having vasectomy following this pregnancy.

Physical Examination:

Patient declined. Given the chance, I would perform a general inspection and abdominal exam, in addition to a vaginal exam (as listed below).

Summary:

A 35 year old lady, G4 P2+1, presented to A&E at 30+6 weeks gestation with PV bleeding, without pain/contractions, PV fluid/discharge; with previous resolved asymptomatic subchorionic hematoma at 12 weeks.

Differential Diagnosis:

· Bloody Show

· Placenta Previa (Painless bleed; Risk factor of previous uterine surgery – C-section in 2012, miscarriage D&C 2014, increased parity)

· Vasa Previa

 

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· Cervical bleeding e.g. cervicitis, polyp, neoplastic, ectropion

· Vaginal bleeding e.g. trauma, neoplastic

· Placental abruption (risk factor: subchorionic hematoma, though unlikely as non-painful)

· Uterine rupture

· UTI, GI Bleed (e.g. hemorrhoids)

Management:

Admit patient

Clinical exam – Abdominal and vaginal speculum, after placenta previa ruled out by USS (see below)

?onset of labor – cervical dilation, effacement

?ruptured membranes

?local vaginal/cervical bleeding

?urinary or GI bleed

Ultrasound – Transabdominal and transvaginal (confirm placental location – placenta previa ?distance from placental edge to internal cervical os)

Fetal monitoring – Continuous CTG ?contractions – onset of labor

Transabdominal ultrasound – BPP, Fetal biometry

Uterine artery Doppler

Bloods – FBC Hb ?anemia, platelets, WCC, ESR/CRP; Coagulation (?thrombophilia, coagulopathy), LFTs (?liver impairment for medication); U&E Cr (?hydration, renal impairment)

Crossmatch 4-6 units. (Kleihauer-Betke test, Anti-D not necessary as patient Rh-positive)

Corticosteroids – Betamethasone 12.5mg IM x2 24 hours apart for fetal lung maturation

Magnesium sulfate for neuroprotection

IV fluids ± blood products if massive hemorrhage – activation of massive transfusion protocol

Close monitoring as inpatient, especially if develops pain (?abruption) or ongoing bleeding. Management of placenta previa – immediate delivery vs expectant, depending on bleed.

May require emergency cesarean section if fetal/maternal compromise or if placenta abruption - Arrangements with NICU in event of emergency delivery.

 

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Consider discharge if bleeding stops, examination and investigation findings reassuring. Close follow-up; high risk patient. Weekly BPP and CTG; two-weekly fetal biometry.

If placenta previa, aim for delivery at 37 weeks if possible, likely by cesarean section, with close monitoring, continuous CTG prior; Anticipation of PPH as high risk in placenta previa and abruption.

 

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A Gynaecology Case: Laparoscopic Surgery for Hydrosalpinx

By: Danielle Wuebbolt

A 45 year old woman

Gravida 2, Para 0+2

Presenting Complaint:

A 45 year old woman, para 0+2, presented to hospital on November 6th for an elective left salpingectomy due to fluid accumulation and damage, on a background history of multiple ectopic pregnancies and a previous right tube removal.

History Presenting Complaint:

She conceived in 2004 with an ectopic pregnancy in the right fallopian tube. She was treated with a right salpingectomy. During the laparoscopic procedure they found that her left fallopian tube was “damaged”. In 2006 she underwent a left tubal reconstruction (salpingostomy) in order to repair the tube in hopes of conceiving again. Later in 2006 she conceived again with left tubal ectopic pregnancy. She was treated with methotrexate in hopes of preserving the fallopian tube for further pregnancies. She was diagnosed with left hydro-salpinx at this time. In both 2008 and 2012 she underwent two hysterosalpingograms to visualize the left fallopian tube hydro-salpinx, during this time she was trying to conceive. She underwent an elective left salpingectomy due to the left hydro-salpinx. She explained that during the laparoscopic operation her left ovary was damaged and had to be removed via oophorectomy.

Post-operatively she denied feeling or experiencing any signs or symptoms of infection, like fever, increased pain, discoloured wound discharge or erythema around the incision sites.

Gynaecological and Menstrual History:

She was not using any forms of contraception prior to her elective left salpingectomy as she was trying to conceive. As of November 6th she had a Mirena coil inserted.

Her last cervical smear was in September 2017 and came back normal. She has not had any previous abnormal cervical smears.

Her last menstrual period (LMP) was on the 28th of October 2017.

Her menarche began at 12 years old. In regards to menstruation she says her cycles are irregular varying from 3-5 weeks. She describes them as heavy, bleeding for 5 days and changing her sanitary napkin 6 times/day, but varies from “month to month”. She describes the

 

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pain associated with her menstruation as a “tugging” and “pulling” pain. She reports bleeding between cycles with slight discomfort. She has no post-coital bleeding.

Previous Medical History:

She has hypercholesterolaemia and hypertension, she does not take medication for either. She has iron deficiency anaemia for which she takes oral iron supplements.

She has no history of urinary tract infections or sexually transmitted infections.

Previous Surgical History:

She underwent a right salpingectomy in 2004 due to an ectopic pregnancy. She had a left salpingostomy in 2006 to reconstruct the damaged fallopian increases her chances of conceiving.

Medications:

She is not currently on any medications and is not taking any analgesia for the incision site pain. She takes oral iron supplements.

Allergies:

She is allergic to Pethidine.

Family History:

She did not feel comfortable disclosing any family history regarding gynaecological related medical issues (ie. Infertility, ectopic pregnancies, etc). She has a positive family history of hypertension in both parents.

Social History:

She lives at home with her husband and does not have any children. She is currently a non-smoker, she quite 20 years ago, and she occasionally consumes alcohol. She mentioned that she has been trying to conceive for a “long time” and is overall in good spirits.

Examination: Abdominal

On general inspection she appeared well, alert and excited to be going home. She was not in any obvious discomfort and had no signs of tachypnea or increased work of breathing.

Her vitals are as follows:

· Temperature: 36.6 degrees (obtained from IMEWS card)

· Heart rate: 78 beats/min

 

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· Respiratory rate: 16 breaths/min

· O2 saturation: 97 (obtained from IMEWS card)

· Blood pressure: 132/76

On closer inspection of her abdomen there were no signs of erythema, abdominal distension, hernias, striae or bruising. She has three scars from her laparoscopic procedures. Patient reported that there was no erythema or discoloured discharge from the wound sites, as they were bandaged at the time of examination. She had no concerns in regards to their immediate healing. She has one incisional wound by the umbilical area (10mm), one located in the mid suprapubic region (5mm) and one in the left iliac fossa (5mm).

When palpating all nine quadrants both superficially and deep the patient reported tenderness around the wound sites. Her abdomen was soft and not rigid. Her liver, spleen and kidneys were non-palpable. On percussion there were no signs of shifting dullness and both the liver and spleen were of normal size. On auscultation bowel sounds were present and renal bruits were not heard.

Summary Line:

In summary, this is a 45 year old, para 0+2 woman who presented to hospital for an elective unilateral salpingo-oophorectomy on a background history of two tubal ectopic pregnancies, a right salpingectomy and left hydro-salpinx. She is recovering well and has no signs or symptoms of infection.

Management:

Preoperative care would firstly entail explaining all aspects of the procedure and potential risks involved. Examples include infection, haemorrhage and potential need for blood transfusion, ovary removal if indicated and infection. I would gain consent for the procedure and ensure that she understands all the risks involved and the preoperative and postoperative care needed. After gaining consent I would proceed with a preoperative workup consisting of a urine dipstick sample to out rule a potential undiagnosed urinary tract infection and to pregnancy. I would insert 2 large IV cannulas (14g) from which I would take blood for a full blood count including ESR/CRP and white cell count to out rule any preoperative signs of infection. I would do a blood group, coagulation screen, and cross match 4 units of blood in case complications arise operatively requiring a blood transfusion. I would check her urea and electrolytes, and creatinine for kidney function and her liver function tests for drug metabolism pre and post operatively.

Postoperative counselling and care would be essential in regards to her. I would prescribe a simple analgesia for her incision pain. I would counsel her on the signs and symptoms of

 

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infection and encourage her to return to hospital if she experienced any. These would include yellow or green discharge, change in odour on dressing, change in size of incision wounds, redness or hardening, increase in temperature, fever, increase or unusual amount of pain, and excessive bleeding that has soaked through the dressing. Adhesive strips should fall off on their own and sutures should be kept clean. I would provide her with contact details in case she has any concerns and ensure a follow-up appointment is booked with both her GP and the OPG clinic.

I would remind her of the importance of keeping the wound site clean with warm water and soap. The importance of hand hygiene, gentle care and no vigorous scrubbing or picking at the scabs when handling the wound. After cleaning she should air dry the wound or pat down with a towel before reapplying a dressing. Do not use any lotions or powders on the incision, and do not expose to direct sunlight. I would encourage her not to not pursue any strenuous activity during the healing period. Lastly, I would remind her that some soreness, tenderness, itching and mild oozing from the wound sites is normal and should not cause alarm. Prior to discharge I would inquire about her fluid intake and ensure that she is passing urine. I would make sure that she is mobilising well and has been using her TED stockings to reduce the risk of a deep vein thrombosis.

If returned with concerns and signs of infection an antibiotic would be considered for prescription. Investigation wise, a full blood count should be performed looking for an increase in white cells, and inflammatory markers (CRP and ESR). A swab from the wound should be taken for culture and sensitivity ensuring that the correct antibiotic is prescribed. If further concerns for systemic infection, a blood culture should be taken as well.

Lastly, I would provide counselling support for the patient and put her in contact with a support group in the event that she was struggling with her now infertility.

 

 

 

 

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OBGYN Winning Essay:

“GO FORTH AND MULTIPLY: AT WHAT COST?”

By:TISHELLE BOODOO

I traced a line in the layer of dust coating the dining table set for five which my seven siblings and I once merrily crowded around. Nostalgia overwhelmed me as I inspected the now quiet, quaint features of my humble abode which in my childhood, was once filled with incessant noise, love and laughter from dusk till dawn.

My family had fitted the frame for the typical poor family living in Trinidad. We lived in a rural area. My mother tended to a small garden and my father was a maxi driver and they gladly contributed to the popular culture of poor households having many children. We had only enough money to get by. Every one of my childhood outfits were either “hand me downs” or the dresses my mother would sew for me when there was a noteworthy event. Until I left for University I had no idea what sleeping alone on my own bed, much less sleeping alone in a room felt like.

I avidly recall the day, October 27th 2002, the day my other’s eyes conveyed the message of just how proud she was of me when her words were choked by her endless crying. October 27th 2002- the day I was awarded a National Additional Science Scholarship by the Government of Trinidad and Tobago. From the day I was born, my mother had big dreams for me, as she did for all her children. Growing up I recognized and appreciated the endless sacrifices she made for my siblings and I, all in the name of education. However, none of my elder siblings ever made the mark and entered into the world of work straight after obtaining acceptable grades in the O level examinations. I, the youngest of seven siblings, was the first to receive meritorious results, gaining me a scholarship and affording me the opportunity to pursue tertiary education.

In a society and era where members of the “poor” community rarely made such strides in education, you’d think making it to higher level studies would be enough, despite the field of study. However this was not the case. Medicine, Law and Engineering, the “Holy Trinity” of careers were regarded as the only esteemed choices.

Swayed by popular culture, my mother’s dreams for me and my own yearning for success to alleviate myself from the cycle of poverty while benefitting society, I chose to pursue Medicine at the University of the West Indies, the largest and most accredited University in my country.

I distinctly remember feeling like a celebrity as I walked through the front door on weekends after returning from a week of a school. I was greeted with my favourite dishes hot off the stove and a plethora of questions as everyone wanted to know what studying to be a doctor was like. I graduated from the pampering which being the youngest earned me to the pampering which being the family’s first future doctor earned me.

As the weekends passed, I’d return to a home with one less sibling. By the time my final year of school rolled around, all my siblings were married and moved out. I was no longer the only

 

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visitor on weekends. In fact, nieces and nephews became the new apple of my parent’s eyes. Through all the changes my family remained close knit.

Upon completion of the MBBS Programme which spanned five years, I was then required to undergo a 12-month internship. During this year, I married my first love and fellow classmate, Dr. Arun Maharaj, who I met and began dating since my second year of Medical School. I moved out of my parents’ home, but religiously visited every weekend accompanied by my husband.

Today, a further seven years later, I am standing alone in my childhood living room as a Doctor of Medicine in the department of Obstetrics and Gynaecology, looking around reminiscing on the various paths I travelled which brought me to this moment. “Why am I standing alone?” you might question. Traditional values of our ancestors all the way in India which have been passed down have been upheld and practiced. There are many great sins which are looked down upon, which dam your reputation, for instance engaging in sexual intercourse before marriage. However, it feels as though the greatest, most unforgivable of them all is infertility. The plight of infertility wrecked my marriage which lead to me committing another “deadly sin” – divorce. The impacts of infertility on my own health was grave. I succumbed to depression which stemmed from a lack of self-esteem due to my inadequacy to bring forth a child. This culmination of factors, mixed with my own desire to have a child being the most prominent, drove me to the edge. Now living once again with my parents, I was at an all-time low. Days were long and empty and my once optimistic attitude faded away, leaving me disgruntled and upset as I dwelled on the unfairness of life.

***

“See you tonight!” I kissed my mom goodbye as I hurried out the front door. It was a beautiful morning with pleasantly surprising, light traffic. I parked my Honda CRV in my regular parking spot and made my way to my locker at the Gulf View General Hospital.

Teary-eyed, a long time patient of mine, Rebecca Almanzar, smiled at me as she exited the hospital doors.

“What’s the matter Becky?” I grabbed her hand and asked.

“Doc-c” she stammered, as her words were staggered by her crying, “today I held my newborn nephew for the first time. While I only felt pure love for that child, my heart ached knowing I can never hold my own.”

I froze. A million thoughts raced through my mind in that moment as I recalled once facing the same devastation as Rebecca. “Sorry to hear that” was all that I could mutter and I quickly rushed off. In that moment, I was so bombarded by emotions that I could not properly reflect what I really felt or even offer her comfort. Afterward, this scenario replayed in my head all day long. I felt a rush of emotions that I once supressed- mainly hurt and rage. I was angry at the world once again that there are millions of unwanted pregnancies a year yet there are also millions who would give anything for that chance. However, this time around, I was not only overwhelmed by a sea of negative emotions, but also, an overwhelming desire to help. I pulled

 

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Rebecca’s patient records and scribbled down her contact number. That evening I made a call that would change my life forever.

Rebecca was raised very similarly to me. We both grew up in households that were classified as below “average” income households and followed traditional values of our ancestors, a lot of which we believe are ordained by God. Knowing Rebecca’s medical condition and history, I knew she would be a viable candidate for in-vitro fertilization. However, when I previously diagnosed her infertility she shot down the suggestion of in-vitro fertilization immediately. At the time, I had no desire to persuade her otherwise. In a society in which there is a widespread lack of knowledge concerning the procedure, there was a lot of controversy surrounding it. Many contested that it was unnatural and it was not a popular option among the masses. That night, I mustered the courage to call Rebecca and I did everything in my power to convince her to consider in-vitro fertilization. It was almost an hour long conversation of back and forth arguing which ended with her saying “I will sleep on it.” I was not hopeful.

***

“I’ll get it” I shouted as I ran to pick up the landline telephone.

“I’m having a baby boy. He’s expected to be born tomorrow. The IVF clinic had me working with their doctor but I’ve decided I want you to deliver my baby.”

At first I was confused, forgetting the phone call I had a year and three months prior to this one. Then it clicked. My heart raced. Overjoyed, I responded, “I’d be delighted to.”

***

“Just one more push,” I coached Rebecca. Moments later the piercing cry of a new-born baby boy filled the room. I gazed at him- a seven pound miracle! I’ve been Rebecca’s gynaecologist for 4 years. I was there at the start of her fertility treatments and there at the end of her second miscarriage, the day which she gave up trying. My heart felt full as I watched her hold onto that baby like he was life itself. From the beginning of my medical career to this moment, I’ve been in a delivery room hundreds of times, but I’d never felt quite like this. When I delivered a healthy or stillborn baby, it brought me joy or pain respectively. However, this baby brought me hope- hope on behalf of all the women out there that gave up their dream of being a mother. I got excited once more about the profession I was in. I had a sudden craving to do more. At a stage of monotony in my life, I developed a new zeal. I suddenly became very interested in in-vitro fertilization and as it reminded me of the passion I once had for the life-changing advances in medicine. After having my own misfortunes blindside me from the beauty of new life which I was faced with for years, I vowed to take up a new challenge.

***

Four years after delivering Rebecca Almanzar’s beautiful baby boy, I now sat at a new desk, with the quote “whether your pregnancy was meticulously planned, medically coaxed, or happened by surprise, one thing is certain—your life will never be the same” plastered on the wall behind me. My new profession, performing in-vitro fertilization brought me sheer joy and the deepest pain possible when another’s hope was either regained or lost forever, respectively.

 

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I never had the opportunity to bring forth my own child but assisting others in their journey of bringing new life into the world sufficed. Go forth and multiply- at what cost? To me, the cost of the pure bliss of success and the extreme agony of failure in an attempt at changing someone else's world forever.

 

Congratulations to everyone who took part in the competition!

Please watch for our next Essay Competition, 2018-2019 :)

 

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OBGYN Conferences

Health Research Board Summer Student Scholarships

December - February 2017/2018

The HRB grants are very competitive and offer similar funding opportunities as other scholarships. The Summer Student Scholarships provide €250 per week over 8 weeks. However, the application is a lot more intensive and requires collaboration with your supervisor to complete.

The Pregnancy Meeting

January 29 - February 3 2018

The Pregnancy Meeting is an international event that houses one of the largest collections of OBGYN research..

ICHAMS International Conference for Healthcare and Medical Students

February 15 - 17 2018

RCSI’s own student run conference is always a massive success and guaranteed fun experience with interactive workshops and talks from guest specialists. Successful abstracts are also published online in BioMed Central so not only can you gain invaluable presenting skills, you can gain a publication credit too.

Expert Fetal Medicine

March 1 - 2, 2018

This conference held in London is presented by Imperial College London brings professionals from all over the world to discuss new frontiers in this field. While the topics are very specific, there’s a wide range being discussed allowing them to appeal to every specialty in OBGYN.

RCSI Research Summer School

March 7, 2018

The RCSI RSS is a fantastic opportunity for all undergraduate students. The programme provides €2000 for 8 weeks of research. The student must arrange for themselves with a supervisor in an area they have an interest . Applications open in February, so start thinking about what areas of medicine or specific areas in obstetrics or gynaecology that captivate you and possible supervisors.

 

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BMFMS British Maternal Fetal Medicine Society Annual Conference

April 19 – 20, 2018

The BMFMS Annual Conference takes place late April every year in different cities - In 2018 it falls in Brighton (UK). While participation is open to various career levels, what makes this conference stand out for prospective obstetricians/gynaecologists is the addition of the Medical Student Prizes. Abstract submission opens in late August and runs through to early December with successful applicants notified in late January. It truly is a great opportunity for all, but prospective SC2 students bear in mind that dates may clash with exams and at least one registered author needs to be present. Once your abstract is accepted, it will be then be published in BJOG: An International Journal of Obstetrics and Gynaecology.

 

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Tips for Success 

 

 

We would like to extend a big thank you!  

The editing team would like to thank each and every individual, that has submitted an article for publication. Without you, we would not have such as incredibly diverse and insightful newsletter. The obstetrics and gynaecology committee takes great pride in providing students and staff alike with an informative newsletter. This year we would like to recognize the entire society and OBGYN faculty at RCSI for their efforts, and commitment to you the students.

Amy Pawson, Traveen Singh and Bunmi Adesanya 

 

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