Dr Sarah Cox Senior OampG Registrar Vaginas are SCARY Gynaecology in the ED httpsyoutube3HwJ0BSN8k Acute pelvic pain In the emergency assessment of women of reproductive age it is important to exclude ID: 930853
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Slide1
Gynaecology HMO Teaching April 2018
Dr Sarah CoxSenior O&G Registrar
Vaginas are SCARY …
Slide2Gynaecology in the ED
https://youtu.be/3HwJ_0BSN8k
Slide3Acute 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
Slide4Investigation 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
Slide5PID
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
Slide6What 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
Slide7Two 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)
Slide8Causes 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
Slide9PID 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)
Slide10PID
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
Slide11Fitz-Hugh-Curtis
SyndomePerihepatic inflammation & adhesionsOccurs with 1 – 10% acute PID
Causes RUQ and pleuritic pain
May be confused with cholecystitis or pneumonia
Slide12Ovarian 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
Slide13Functional 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
Slide14Ovarian 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
Slide15Endometriosis
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
Slide16Endometriosis 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
Slide17Primary 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
Slide18Bleeding 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
Slide19Cervical 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
Slide20Miscarriage
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
Slide21bHCG
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
Slide22Slide23Assessment 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
Slide24Cervical 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
Slide25? 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
Slide26Slide27Ectopic 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
)
Slide28Treatment 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
Slide29DUB
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)