SIP # 62: Congenital Uterine Anomalies — Reproductive Implications & Management

This blog post is the summary of Scientific Impact Paper #62 “Reproductive Implications and Management of Congenital Uterine Anomalies” published in November 2019.

This paper provides important information regarding this topic. I found this SIP quite extensive and had to really dig in to make this summary. I have tried my best to extract main points but it is suggested to read through the original document to make sure nothing is missed.

You can download the SIP # 62 by clicking: Scientific Impact Paper Links or Direct Download by clicking Here

Kindly let me know if this post was helpful and suggestions to improve future posts are welcome.

Thanks

SIP # 62 Reproductive Implications and Management of Congenital Uterine Anomalies (CUA)

Background

• CUA → embryological maldevelopment of Müllerian ducts
• Most CUAs → asymptomatic & normal reproductive outcomes
• 3D USG → non-invasive, reproducible & provides visible evidence of internal/external contours of uterus
• Recent Meta-analysis
• Overall prevalence CUA → 5.5% in unselected women
• 8% in Infertile 
• 13.3% in women with h/o Miscarriage
• 24.5% in women with h/o Miscarriage plus Infertility
• Presentation of anomalies is variable (from asymptomatic to very complex)
• Four main reason of being difficult counselling about CUAs
• Several classifications in literature
• Several different diagnostic modalities still being used
• Each CUA’s Reproductive Impact is different
• No single RCT for surgical management of CUAs

The aim of this Scientific Impact Paper is to address these four issues and make recommendations.

NICE 123: Pelvic Organ Prolapse — Management

This is the part 2 of summary of the NICE guideline “Urinary Incontinence & Pelvic Organ Prolapse in Women: Management” published in April 2019. As this is a long guideline, so it was decided to cover it in two posts. To access the part 1 of summary please Click Here

• This post #2 mainly focuses on the management of pelvic organ prolapse. It covers assessing pelvic organ prolapse (POP), non-surgical/surgical management of POP, surgery for women with both SUI & POP, assessing & managing complications associated with mesh surgery
• The post #1 of summary covered organization of specialist services, data collection on surgery, assessing urinary incontinence (UI), non-surgical management of UI and surgical management of stress urinary incontinence (SUI). Summary Part 1
• It is advised to read the original guideline to grasp the topic and to make sure no important point is missed
• The full guideline can be downloaded by clicking here: NG 123 Urinary Incontinence & POP in women: Management
• Some other relevant links of this topic are also provided at the end of this post

Kindly let me know if this post was helpful and suggestions to improve future posts are welcome.

Thanks

NICE 123 Pelvic Organ Prolapse in women: Management

Assessing Pelvic Organ Prolapse

• In Primary Care: women with symptoms or incidental findings of vaginal prolapse
• Take history → including prolapse symptoms, urinary, bowel & sexual function
• Examination → to rule out pelvic mass or other pathology / document presence of prolapse
• Discuss → woman’s treatment preferences & refer if needed 
• In secondary Care: If referred due to unrelated condition with incidental symptoms /findings → Consider referral to prolapse expert clinician
• Women referred for specialist evaluation of vaginal prolapse → perform an examination to:
• Assess/ record presence & degree of prolapse of anterior, central & posterior vaginal compartments of pelvic floor, using POP-Q system
• Assess pelvic floor muscle activity
• Assess for vaginal atrophy
• Rule out pelvic mass or other pathology
• Consider using validated pelvic floor symptom questionnaire to aid assessment & decision making

NICE 123: Urinary Incontinence in women: Management

This is the part 1 of summary of the NICE guideline “Urinary Incontinence & Pelvic Organ Prolapse in Women: Management” published in April 2019. As this is a long guideline, so I decided to cover it in two posts.

• There are some changes in this guideline. This guideline provides information about management of women having urinary incontinence and pelvic organ prolapse, outline of the service organization and how the services should be provided (which are relevant for the health professionals working in UK)
• This post #1 of summary covers organization of specialist services, data collection on surgery, assessing urinary incontinence (UI), non-surgical management of UI and surgical management of stress urinary incontinence (SUI)
• This rest of the topics will covered in next post
• It is advised to read the original guideline to grasp the topic and to make sure no important point is missed
• The guideline can be downloaded by clicking here: NG 123 Urinary Incontinence & POP in women: Management
• Some other relevant links of this topic are also provided at the end of this post

Kindly let me know if this post was helpful and suggestions to improve future posts are welcome.

Thanks

NICE 123 Urinary Incontinence and Pelvic Organ Prolapse in women: Management

Organisation of specialist services

Local / Regional Multidisciplinary Teams

NICE 140: Abortion Care

This is the summary of the NICE guideline “Abortion Care” published in September 2019.

There are some changes in this guideline. This guideline provides information about management of women undergoing abortion at different gestations, outline of the service organization and how the abortion services should be provided (which are relevant for the health professionals working in UK). In this summary, only main points are extracted.

It is advised to read the original guideline to grasp the topic and to make sure, no important point is missed.

The guideline can be downloaded by clicking here: NG140 Abortion Care

Some other relevant links of this topic are also provided at the end of this post.

Thanks

NICE 140: ABORTION CARE 

Service Organization

Making it easier to access services

• Commissioner & providers should work together to:
• Make information about abortion services widely available
• Ensure → prompt referral onwards if service cant provide abortion
• Avoid → need for women to repeat key steps (like GP return/referral, repeated assessments/investigations)
• Allow women to self-refer to abortion services
• Ensure → abortion services have capacity/ resources to deliver range of services with minimum delay
• Health Professionals → should NOT allow their personal believes to delay services access 
• Commissioners → should consider upfront funding for travel/ accommodation for women who:
• are eligible for NHS Healthcare Travel costs Scheme and/or
• need to travel to service not available locally 

Waiting Times

• Ensure minimal delay & ideally provide
• Assessment within → 1 wk of request

NICE 121: Intrapartum Care for women with Medical Conditions — Part 1

Post #1
This blogpost is Post #1 of Summary of NICE guideline “NG 121: Intrapartum Care for Women with Existing Medical Conditions or Obstetric Complications and their Babies” released in March 2019. As this is an extensive and lengthy guideline, so I will be covering it in two posts. 

This post covers intrapartum care in Heart Disease, Asthma, Long-term Systemic Steroids, Bleeding Disorders, SAH / AV Malformation of Brain, Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) and Obesity

I have extracted the main points only. You must read the original guideline to have complete understanding. Original guideline can be downloaded here: NG 121

This guideline should be read along with NICE intrapartum Care for Healthy Women CG190 (N.B: In this summary when it is written “to manage as low risk /like normal/follow routine intrapartum care” refers to CG 190)

Kindly let me know in comments below if anything needs to be modified in this post and suggestions to improve future posts are welcome.

Thanks

NICE 121: INTRAPARTUM CARE FOR WOMEN WITH EXISTING MEDICAL CONDITIONS

Information for women with existing medical conditions

• Clarify with women whether and how they would like their birth companions(s) involved in discussions about care during labour/birth
• Offer information about Intrapartum care including
• General information
• How medical condition affect care
• How labour & delivery affect medical condition 
• How medical condition and its management affect baby
• Offer this information in pre-conception consultations or as early as possible during pregnancy & Allow extra time to discuss
• Information delivered by a member of multidisciplinary team (MDT)

Planning for intrapartum care with women with existing medical conditions – involving a multidisciplinary team

• MDT led by named healthcare professional to prepare individualized plan involving woman
• Plan should be:
• Based on → shared decision making principles
• Reviewed with woman and her birth companions(s) → as soon as possible  throughout pregnancy & on admission for birth
• Updated → if change in medical condition
• Shared with → GP & teams providing Antenatal/ Intrapartum care
• MDT may include:
• Midwife, Obstetrician, Obstetric Anesthetist, Obstetric Physician or Clinician with Expertise in care of pregnant women with medical condition, Clinician with Expertise in Medical Condition, Speciality Surgeon, Critical Care Specialist, Neonatologist, woman’s GP, Allied Health Professionals 

HEART DISEASE

Risk Assessment

• Follow principles of MDT working
• Include a Cardiologist
• Heart disease diagnosed intrapartum→ urgent multidisciplinary discussions & take woman’s preferences into account
• Some women may be low risk→ follow routine intrapartum care 

Module 9: Maternal Medicine

This blogpost is the outline of Module 9: Maternal Medicine. It is one of the most important and lengthy module. There is an extensive list of topics to cover and a lot of facts to memorize. To make it simple, this module can be outlined according to the Systems e.g. Neurology, Endocrinology etc

• The first step is to have a look in to details of core module on the RCOG website which provides a mental road map to cover it under appropriate headings
• One of a very important and standard resource for this module is “Handbook of Obstetrics Medicine” by Catherine Nelson Piercy. The module is well covered in this book. It is recommended to at least go through the differential diagnosis tables given at the end of the book
• Remember that management of patient starts from pre-conception period and it is important to make sure that she enters pregnancy in optimal health condition
• Most of the Medical Disorders are chronic conditions and a woman may have to live with it for the rest of her life, which can be frustrating 
• There is need of Multidisciplinary Team and involvement of Specialists
• As the pregnancy may become high risk, so patient needs Close Monitoring, Extra Antenatal Visits and Consultant-led Care
• Once she delivers, there should be appropriate postpartum care, contraception plan and advice regarding next pregnancy
• The following tables may be used to organise the study material in one place

Module 10-11: Labour & Delivery - Module 12: The Puerperium

This blogpost provides the outline of three (3) Modules in obstetrics “Module 10 & 11: Management of Labour & Delivery” AND “Module 12: Postpartum Problems (The Puerperium)”. I decided to cover these in a single post as all these modules are closely interlinked

• It is important to develop understanding of a particular problem as it may start in antenatal period and has to be dealt till the postpartum period (and may even effect the management of next pregnancy)
• Kindly have a look at the details of modules on RCOG website which will clarify what are you expected to demonstrate under these modules
• Module 10 & 11 are covered under a Single Main Heading as it is difficult to clearly distinguish it in a given scenario
• Some of the topics to be covered in these modules are already outlined in posts covering Module 8: Antenatal Care Click Here: Post#1 Post#2
• Specially in the postpartum module, you may notice that there is repetition of some topics which were already outlined under antenatal care module. The main purpose to repeat these is to give a clear idea how all these modules are connected. Some of the problems are more relevant in postpartum period e.g. mental health issue, Sepsis or VTE to name a few
• Following tables may help you to collect and organize your study material in one place
• If you use gadgets (iPad/Laptop/Smartphone) its easier to arrange but if you prefer hard copies, you can get the printouts and arrange it according to your convenience

Module 8: Antenatal Care — Part 2

This post is the second part of outline of “Module 8: Antenatal Care” and it covers the remaining topics in this module. As this is a lengthy module so, it was decided to cover the reading resources and outline in two posts. 

• The first part of this module can be accessed by clicking here: Module 8: Antenatal Care—Part 1
• The first post of this module included the topics of “the routine antenatal care” along with preterm labour and stillbirth
• This post mainly covers topics which are NOT routine care and they require additional care
• Study outline for two main topics of obstetrics (Infections in Pregnancy and Obstetrical Emergencies) is added which may occur in antenatal period and effect the intrapartum/ postpartum care
• Again it is evident that it is not possible to prepare any module separately
• We need to develop the deep understanding of the topic and apply it on a given scenario
• Following tables provide an outline of the module which might be helpful to collect and organize your study material
• You can make a BIG folder “Antenatal Care” and add subfolders based on the following tables
• Make your own NOTES and keep adding points as you come along new ones

Module 8: Antenatal Care — Part 1

This post is Part #1 of the outline of “Module 8: Antenatal Care”. As this is a lengthy module so I decided to cover it in more than one post. This module can be organized well by dividing it into different sub-headings. 

• If you have a look at details of this module on the RCOG website, it will be evident that we should prepare it systematically starting from the Pre-conception period, Routine Antenatal Care which includes booking visits, screenings, anomaly scans and follow-up visits till the time a woman goes into labour
• A pregnancy may start as low risk but could have a bad outcome. So, Main Aim of providing antenatal care is to prevent risk, identify if it becomes a high risk and manage it accordingly
• This module is a classic example that “none of the modules can be prepared in isolation” as we have to apply certain principles from other modules also
• All these topics need to be understood in depth
• Always have the full picture in mind and read carefully each & every word in the given question
• It is essential to develop critical thinking and apply it to a given scenario in order to reach the correct answer
• Following tables provide an outline of the module which might be helpful in collecting and organizing your study material

Module 5: Core Surgical Skills - Module 6: Post-op Care - Module 7: Surgical Procedures

This blogpost covers the outline of Three Modules (5: Core Surgical Skills - 6: Postoperative Care - 7: Surgical Procedures) which can be collectively labeled as “Surgery in Obstetrics and Gynaecology.” I have compiled it in one post as all these modules are interlinked and follow same basic principles.

• Any Surgical procedure requires certain level of surgical skills. There is pre-operative assessment including anaesthesia evaluation, informed consent and preparation of patient for surgery
• Then comes the Intra-operative period where certain ethical/ legal issues as well as decision-making skills are applicable in addition to surgical skills
• Post-operative period is a critical period where it is important to ensure appropriate care along with managing certain complications
• RCOG Consent Advice (CA) papers are must to cover and there are different numbers which should be on your fingertips (as these are straight forward  questions)
• The topics in these modules are easy to cover if you keep a mental track of sequence of any surgical procedure
• You can make one main folder with heading of “Surgery in Obs & Gynae” and add subfolders based on following tables. It will help to collect and organize the study material in one place
• Reading resources for different Surgical Procedures are also provided which are essential to prepare for MRCOG exam

Module 13: General Gynaecology

This blog post is an outline of Module 13: General Gynaecology. It is an extensive module which needs in-depth study and a good grip on the subject. This module can be tested in a variety of ways along with other modules like contraception, urogynaecology, subfertility etc

• An important point to keep in mind while preparing for the MRCOG exam is that “None of the modules can be clearly distinguished”
• All we need is to learn how to apply the knowledge collected from different resources in a given question/scenario
• In this module, some topics can be covered which do not fit in any other module (Misc)
• If you have a look at the module on the RCOG website, you will find that this module can be divided into various portions
• It would be easy to study if followed in the chronology of age starting from pre-pubertal, puberty, adolescence, reproductive period and way up to climacteric
• The following tables are to give an outline of the module which might be helpful to collect and organize the reading materials
• You can make a BIG folder “General Gynaecology” and add subfolders based on the following tables
• Make your own NOTES and keep adding points as you come along

Module 15: Sexual & Reproductive Health

This post is an outline of “Module 15: Sexual and Reproductive Health”. This is a very important module where many ethical and legal issues are to be considered. For exam purposes, it is mandatory to be aware of UK laws and practices. Sexual and reproductive health is an important aspect of a person’s life which needs to be dealt with sensitively.

• When you look at the details of this module RCOG website, you will find that this module can be broadly divided as follows:
• Fertility control which includes contraception and termination of pregnancy (TOP)
• Psychosexual Disorders
• Sexually Transmitted Infections including HIV/AIDS

Few Tips

• For contraception, the main source of study is the Faculty of Sexual and Reproductive Health (FSRH) guidelines. At first, you may find it difficult to even think of going through so many guidelines. So it is strongly recommended to MAKE YOUR OWN NOTES after extracting important points from these documents. It will be time-saving while revising and help you to retain information easily
• Main things to focus on:
• UKMEC especially relative/absolute contraindications (UKMEC 3/4)
• Efficacy of a method
• Failure rate (typical/perfect use)
• Non-contraceptive benefits (e.g condoms are used for the prevention of STIs)
• It is important to be familiar with UK systems of STI screenings and referral pathways (GUM clinics, contact tracing etc) 
• For relevant UK Laws, it is suggested to go through a previous blog post: Medical Law & Ethics
• To organize the study, you can make a big folder with the name of the module “Sexual & Reproductive Health” and subfolders as outlined below in the tables & collect reading materials