Gynaecology HMO Teaching April 2018 - PowerPoint Presentation

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Gynaecology HMO Teaching April 2018

Dr Sarah CoxSenior O&G Registrar

Vaginas are SCARY …

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Gynaecology in the ED

https://youtu.be/3HwJ_0BSN8k

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Acute pelvic pain

In the emergency assessment of women of reproductive age it is important to exclude:Ectopic pregnancyAcute PIDOvarian cystEndometriosis

And you may be left with a diagnosis of Primary Dysmenorrhoea

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Investigation with USS

Unless you are suspecting appendicitis, intermittent ovarian torsion or a tubo-ovarian abcess, there is VERY LITTLE role for URGENT ED investigation for pelvic pain in non-pregnant, fertile femalesIf the bHCG is NEGATIVE, it is NOT an ectopic pregnancy

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PID

Diagnosis requires a patient at riskUsually younger patient (15 – 25 years)New partner or multiple partnersOr a partner at risk e.g. one that travels

It is a bilateral disease

Pelvic peritoneal tenderness is a subtle sign

WCC & ESR or C-reactive protein can be useful

Requires careful microbiology

Test for all STD’s simultaneously

A role for laparoscopy in diagnosis

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What is PID?

Inflammation of female pelvic structuresAscending spread of infection from the the

cervix

through the uterus, to

fallopian tubes

,

ovaries

and

adjacent peritoneum

Upper genital tract infection

It is

not

infection in the vagina or vulva

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Two types of PID

AcutePatient has generalised symptomsLasts a few daysMay recur in episodes

Very infectious in this stage

Chronic

Patient may have no symptoms

Occurs over months and years

Progressive organ damage & change

May burn out (arrest)

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Causes of PID

85 – 95% is due to specific sexually transmitted organismsNeisseria gonorrhoeaChlamydia trachomatisOthers e.g. Mycoplasma species

5 – 15% begins after reproductive tract damage

From pregnancy

From surgical procedures e.g. D&C

Includes insertion of IUCD

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PID Risk Factors

Age of 1st intercourseNumber of sexual partners

Number of sexual contacts by the sexual partner

Cultural practices

Polygamy,

Sex workers

Attitudes to menstruation and pregnancy

Frequency of intercourse (Age)

IUCD design

Poor health resources

Antibiotic exposure (resistance)

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PID

Requires a high index of suspicion in a patient “at risk” when there is:Lower abdominal pain (90%)

Fever (sometimes with malaise, vomiting)

Mucopurulent discharge from cervix

Pelvic tenderness

Tests

Raised WCC

Endocervical

swab for organisms or PCR

Ultrasound evidence of pelvic fluid collections

Laparoscopy

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Fitz-Hugh-Curtis

SyndomePerihepatic inflammation & adhesionsOccurs with 1 – 10% acute PID

Causes RUQ and pleuritic pain

May be confused with cholecystitis or pneumonia

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Ovarian cysts

Very commonBut not always the source of painPain can be due to:Rapid enlargementRupture

Haemorrhage

- typical of the corpus luteum

Torsion (rare)

Ultrasound is both a boon and a bane because

Paraovarian

cysts

Mesenetric

cysts & Adhesive collections

Hydrosalpinx

, Bladder or even Ureter

May be imaged but do not cause acute pain

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Functional Ovarian cysts

Not uncommon with MirenaIgnore alarming reports from the radiologistIf the patient is <50 then it is usually benignAnalgesia, observation and reassurance is best

Repeat scan in 3 – 4 months

Can use COC to suppress the ovaries and prevent confounding “cysts” appearing

Laparoscopy, drainage and biopsy rarely required

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Ovarian Torsion

Almost always associated with ovarian pathologyPresents as “reverse renal colic” (groin to loin)May

present with acute abdomen

Pulls

cervix to the side of the torsion

Usually

requires

ovarian cystectomy or unilateral

salpingo

-

oophorectomy

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Endometriosis

CommonAs many as 1:4 women if your diagnostic criteria are liberalThe “At Risk” IndividualHas delayed pregnancies

Family history common

Cardinal symptoms are:

Dysmenorrhoea

Dyspareunia

Infertility

Premenstrual staining

Pain with

defaecation

during menstruation

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Endometriosis Investigations

Physical examinationThere may be tender nodules in the uterosacral ligamentsUltrasoundOf little value unless there are

endometriomas

Menstrual phase Ca125 may be used

But has poor sensitivity

Laparoscopy required for diagnosis

There is a poor correlation between findings and symptoms

Debate as to the role of biopsy in diagnosis

Treatment

Medical for pain but surgery for infertility

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Primary dysmenorrhoea

Is not associated with any pelvic pathologyAlso called “spasmodic dysmenorrhoea”

Typically a teenager but can occur in the 40's too

Worse before and on the day of first flow

Accompanied by pallor, prostration &

diarrhoea

Relieved by NSAIDs in effective doses

Best managed with combined OC

Which can be given for up to 3m continuously

But the

Mirena

IUS and sometimes Depot Provera has a role

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Bleeding in Early Pregnancy

Early pregnancy; is defined as a pregnancy of less than 20 weeks gestation. It is sometimes referred to as 'nonviable', however this term is not acceptable to patients as their baby is alive. Speculum examination in early pregnancy is ED investigation and management for bleeding

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Cervical shock

Patient has PV bleeding and is hypotensive - suspect cervical shock Vasovagal syncope produced by acute stimulation of the cervical canal during dilatation POC, instrumentation of

cervix

etc

With

removal of stimulus rapid recovery usually follows

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Miscarriage

25% pregnancies <24/40ThreatenedClosed os

Viable

pregnancy on USS

Inevitable

Bleeding

and open

os

Incomplete

POC

seen in uterus on USS

Early foetal

or embryonic demise

Complete

POC

, witnessed and not seen in uterus on USS

Bleeding

and pain have

ceased or are setting

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bHCG

Threshold βHCG – level at which intrauterine gestational sac can be seen with TVUS 1000-2000IU/L (6500IU/L for TAUS) β-HCG – First 60 days (weeks 4-8) doubles every 1.4 to 2.1 days

Taking

two β-HCG 48 hours apart can be helpful

<

20% increase

or

a reduction it is 100% sensitive for foetal demise or

ectopic

If

β-HCG >50,000 ectopic pregnancy very unlikely

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Assessment of Early Pregnancy

Quantative pregnancy test (useful if uterine pregnancy prev. confirmed on USS but suspected fetal

demise or

heterotopic HOWEVER USS is preferred in this instance)

LMP

and menstrual history

Bleeding

- amount, compared to usual period, any clots/tissue

Previous

ectopic, PID, operation on fallopian tube, pregnancy whilst using IUD

Pain

- severity and site

Establish

physiological status, examine abdomen

Keep

fasting

Analgesia

Group and hold

esp

Rh status for ? Anti-D

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Cervical shock

Call for help & move to resus/monitored bay. IV access and bloods if not already taken. 500mL

– 1L saline stat.

Speculum

examination ASAP - if products in cervical

os

remove

If

tissue small sweep

os

with gauze in sponge holding forceps. If large: insert forceps closed, open, grasp tissues, rotate and remove.

If unable to remove,

conside

Atropine 600mcg (

rpt

to 3mg) if

persistantly

bradycardic and hypotensive

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? To exam PV or not

PV exam is controversial Used to determine if cervical os open v closed, pain in adnexae, palpable masses

Largely

replaced with BHCG and ultrasound in cases of spotting / very light bleeding

If

any concerns regarding products within cervix then a speculum exam must be performed

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Ectopic pregnancy

PV bleeding esp. 6-8 weeks LMPabdominal/pelvic pain, shoulder tip pain (large amount of bleeding)Lightheaded or postural symptomsExamination

unilateral

pelvic tenderness (+/- PV state of cervix, adnexal tenderness +/- masses

)

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Treatment of Ectopic

Surgery Unstable fluid resucitation, Large lines bilaterally, Massive transfusion protocol as req.

Urgent Gynaecology review,

anaethetics

, theatres

Large

>3.5cm

peritonitis

Medical

(Methotrexate) or conservative

no

peritonitis

<

3.5cm

no

free fluid on USS

ability

to closely monitor as an outpatient

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DUB

Norethisterone (Primolut) 5mg tabletsWeaning schedule

10mg QID => 10mg TDS => 10mg BD => 5mg BD

TXA 1g QID for 4-5 days

NSAIDs

esp

if pain => reduction in blood loss by 30-40%

Consider COCP

Treat anaemia (? PRBC vs iron infusion vs oral Fe)