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Acute pelvic pain Flashcards

1
Q

gynae causes of pain in pregnancy

A

Torsion of ovarian cyst
Degeneration of fibroids
Flare up of PID

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2
Q

DD of medical and surgical causes of pelvic pain

A 
Constipation
UTI
Diverticulitis
IBS
Interstitial cystitis
Sickle cell crisis
Porphyria
Acute appendicitis
Ureteric calculi
Cholecystitis
Peptic ulcer
Pancreatitis
Intestinal obstruction
Ruptured liver/spleen
GI cancers
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3
Q

how might ovarian cyst present

A

pelvic pain
bloating and early satiety
palpable adnexal mass

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4
Q

scoring system for the identification of women with adnexal torsion

A


Criteria
Adjusted odds ratio (95%CI)

1
Unilateral lumbar or abdominal pain
4.1 (1.2–14)

2
Pain duration>8 hours
8.0 (1.7–37.5)

3
Vomiting
7.9 (2.3–27)

4
Absence of leucorrhoea/metrorrhagia
12.6 (2.3–67.6)

5
Ovarian cyst>5cm by ultrasound
10.6 (2.9–38.8)

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5
Q

common symptoms of adnexal torsion

A

Pelvic or abdominal pain,
fluctuating, radiating to loin or thigh
Nausea
Vomiting

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6
Q

what is adnexal torsion

A

twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia.

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7
Q

signs of adnexal torsion

sign seen on US

A

pyrexia
tachycardia

due to increased inflammatory markers or due to dehydrations due to N/V

Abdominal examination
Generalised abdominal tenderness, localised guarding, rebound

Vaginal examination
Cervical excitation, adnexal tenderness, adnexal mass

WHIRLPOOL SIGN ON US

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8
Q

features of appendicitis

A

Typically<40years old

Migratory pain, anorexia, vomiting

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9
Q

features of functional ovarian cyst

A

natural cycles

sudden onset

sharp stabbing pain

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10
Q

types of ovarian cyst

A

functional

pathological

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11
Q

what are functional cysts and how are they formed

A

linked to the menstrual cycle

does not release an egg, or does not discharge its fluid and shrink after the egg is released. If this happens, the follicle can swell and become a cyst.

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12
Q

what are pathological cysts and how are they formed

A

abnormal cell growth and are not related to the menstrual cycle. They can develop before and after the menopause.

Pathological cysts develop from either the cells used to create eggs or the cells that cover the outer part of the ovary.

They can sometimes burst or grow very large and block the blood supply to the ovaries.

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13
Q

in what medical conditions can you see cysts in

A

endometriosis

PCOS

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14
Q

If ovarian cyst is found in menopause women then what happens and why

A

US scans and blood tests every 4 months for a year as they have a higher chance of ovarian cancer

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15
Q

what is OHSS

A

ovarian hyperstimulation syndrome

serious complication of fertility treatment especially IVF

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16
Q

Mild OHSS featrues

A

mild
abdominal swelling
discomfort
nausea

moderate
swelling is worse because of fluid build-up
in the abdomen.
abdominal pain
vomiting.

severe
extreme thirst and
dehydration.
- small amounts of urine which is dark in colour
- difficulty breathing because of a build-up of fluid
in your chest.
DVT

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17
Q

moderate Sx of OHSS

A

swelling is worse because of fluid build-up
in the abdomen.

abdominal pain

vomiting.

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18
Q

severe Sx of OHSS

A

extreme thirst and
dehydration.
- small amounts of urine which is dark in colour
- difficulty breathing because of a build-up of fluid
in your chest.
DVT

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19
Q

Mx of OHSS

A

it will usually get better in 7-10 days

if u get pregnant it may persist and get worse

not pregnant when next period it gets better

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20
Q

features of fibroid torsion

A

constant, severe pain

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21
Q

what are fibroids

A

Fibroids are non-cancerous growths that develop in or around the womb (uterus).

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22
Q

features of fibroids

A

usually its asymptomatic but some women may experience certain Sx

  • heavy periods or painful periods
  • tummy (abdominal) pain
  • lower back pain
  • a frequent need to urinate
    constipation
  • pain or discomfort during sex
23
Q

RFs of fibroids

A

African-Carribean women

overweight or obese women as its associated with higher levels of oestrogen

more children you have the lower the risk

-ncreased patient weight
	•	age in the 40s
	•	hypovitaminosis of vitamin D
	•	hypertension
	•	early menarche (under 10 years)
	•	use of oral contraceptives (if started before age 16 years)
	•	nulliparity
	•	younger age at first birth
	•	poor vitamin A intake
	•	dietary intake high in beef and other red meat
	•	sex hormone exposure
	•	menstrual history
	•	smoking
	•	alcohol consumption
24
Q

what are the types of fibroids

A

intramural fibroids – the most common type of fibroid, which develop in the muscle wall of the womb

subserosal fibroids – fibroids that develop outside the wall of the womb into the pelvis and can become very large

submucosal fibroids – fibroids that develop in the muscle layer beneath the womb’s inner lining and grow into the cavity of the womb

25
Q

What is fibroid degeneration and the most common

A

degeneration due to excessive growth that outmatches blood supply or mechanical compression of feeder arteries

more common in pregnant woman as they have more oestrogen and it increases the growth of fibroids

hyaline most common
mycomatous
calcification

26
Q

Sx of fibroid degeneration

A

constant dull pain in abdomen

27
Q

Ix and Mx of fibroid degeneration

A

palpable mass

inflammatory markers are raised
US
endometrial biopsy

28
Q

when is emergency surgery for fibroid degeneration required

A

pedunculated fibroid torsion

29
Q

what if u suspect sarcoma

A

hysterectomy

30
Q

what is PID

A

ascending infection from the endocervix

31
Q

microorganisms causing pID and tubo-ovarian abscesses

A

chlamydia trachomatis -STD
Neisseria gonorrhoea -STD

mycoplasma genitalium

gardnerella vaginalis anaerobes

insertion of IUD

32
Q

complications of PID

A 
Tubal infertility.
Ectopic pregnancy.
Chronic pelvic pain.
Tubo-ovarian abscess.
Fitz-Hugh-Curtis syndrome

appendicitis
diverticulitis
pyelonephritis
haematogenous spread of infection

33
Q

RFs of PID

A
  • Young age (younger than 25 years).
  • Early age of first coitus.
  • Multiple sexual partners.
  • Recent new partner (within the previous 3 months).
  • History of STI in the woman or her partner.
  • instrumentation of uterus
  • TOP
  • Insertion of an IUD (within the past 4–6 weeks, especially in women with pre-existing gonorrhoea or C. trachomatis infection).
  • low socioeconomic status
  • low educational attainment
  • appendicitis
  • Hysterosalpingography.
  • IVF and intrauterine insemination.
  • Non use of barrier contraception
  • Previous episodes of PID
  • Multiple sexual partners
  • Diabetes
  • Immunocompromised
  • Co-existing endometriosis
  • Reported in not sexually active women
34
Q

PID presentation

A
  • Asymptomatic
  • Lower abdominal pain
  • Pyrexia
  • Vaginal discharge-yellow or green
  • Dyspareunia
  • IMB AND PCB
  • irregular bleeding
  • change to bowel habit
  • blood in stools
  • urinary Sx

Non‐migratory pain, bilateral tenderness, no nausea or vomiting

history as sexually active

35
Q

O/E of PID

A
  • lower abdominal tenderness
  • cervical motion tenderness, adnexal tenderness
  • Pyrexia
  • vaginal discharge
    cervical excitation
  • fever >38
  • adnexal mass
  • contact bleeding from cervix
36
Q

Ix for PID

A
  • Pregnancy Test
  • FBC,CRP, U&E
  • high vaginal urethral and endocervical swab -> exclude bacterial vaginosis, candidiasis test for chlamydia & gonorrhoea via NAAT
  • microscopy
  • MSU
  • Triple swabs
  • USG-Pelvis/Abdomen
  • X ray
  • Diagnostic Laparoscopy GOLD STANDARD
  • under 25 chlamydia screening
37
Q

Mx of PID

mycoplasma genitalum

A
  1. analgesia
  2. ABx
    OUTPATIENT
Ceftriaxone 500mg IM stat
\+
Doxycycline 100mg PO BD for 14 days
\+
Metronidazole 400mg PO BD for 14 days
Inpatient
IV Ceftriaxone 2g daily 
\+
IV doxycycline 100mg bd (oral if tolerated)
Oral metronidazole 400mg bd for 14 days
\+
Oral doxycycline 100mg bd for 14 days
  1. abstinence from intercourse for duration of Mx
  2. encourage partner notification and Mx
  3. Pt education about safe sex
  4. follow up
    removing an intrauterine contraceptive device in women presenting with PID, especially if symptoms have not resolved within 72 hours.
38
Q

if initial Mx of PID does not work what do u do

when do we admit PID pt in

A

Ceftriaxone 1 g as a single IM dose, followed by oral azithromycin 1 g per week for 2 weeks.

  • Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
  • Complicated PID with pelvic abscess (including tubo-ovarian abscess)
  • Possible need for invasive diagnostic evaluation for alternate aetiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
  • Inability to take oral medications due to nausea and vomiting
  • Pregnancy
  • Lack of response or tolerance to oral medications
  • Concern for nonadherence to therapy
39
Q

future complications of PID

A
  • risk of ectopic
  • subfertility
  • chronic pelvic pain
  • tubo-ovarian abscess
  • Fitz-Hugh Curtis syndrome
    1. RUQ pain
    2. perihepatitis
I FACE PID 
Infertility
Fitz-hugh curtis syndrome
Abscess
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruciotn
Disseminated infection (sepsis, endocarditis, arthritis, meningitis)
40
Q

advantages of laparoscopy

A

Quicker recovery
Smaller incisions
Less postoperative pain

41
Q

advantages of laparotomy

A

More thorough exploration of the pelvis and loops of bowel (ability to palpate rather than just visualise tissues)
Thorough wash out of pelvis and abdomen, with possible reduction in pus remnants
Advanced laparoscopic skills not required

42
Q

when would you do laparoscopy in pregnancy

A

Appendicitis
Cholecystitis
Torsion of ovarian cyst

43
Q

what is haematocolpos

A

Cyclical pain
No bleeding

Examination bluish membrane at introitus

I&D, cruciate incision

44
Q

common causes of pelvic pain

A 
pelvic inflammatory disease (PID)
urinary tract infection (UTI)
miscarriage
ectopic pregnancy
torsion or rupture of ovarian cysts.
ovulation (mid-cycle, may be severe pain), dysmenorrhoea
 degenerative changes in a fibroid
45
Q

Mx when discharging pt

A

PARTNER NOTIFICAITON
offer screening for chlamydia and gonorrhoea

start doxycycline 100mg twice daily for 1 week.
If chlamydia or gonorrhoea is diagnosed in the partner(s), treat both the partner(s) and the woman appropriately.

  • advise sexual abstinence until both the woman with PID and her partner(s) have completed the course of treatment after one week though
  • Advise that a barrier method of contraception (such as condoms, diaphragms, or caps) should be used if sexual intercourse cannot be avoided.

FOLLOW
UP 48-72hrs then 2-4 weeks

SAFETY NETTING

  • high fever and rigors (uncontrollable shakes)
  • severe abdo pain
  • uncontrollable vomiting, unable to tolerate food/fluid/medications
46
Q

Ix for ovarian torsion

A
  • FBC - leukocytosis
  • Pregnancy test
  • transvaginal or w doppler flow US - WHIRLPOOL
    abdominal US for children
    urinary analysis

Diagnostic -> surgical visualisation

47
Q

Mx of adnexal torsion

A

1st line surgical detorsion or salpingo-oopherectomy

laparoscopy better than larparotmy because reduces hospital stay, reduced drugs, lower febrile morbidity

adjunct - oophoropexy - prevent recurrence

adjunct - ovarian cystectomy

secondary prevention ORAL Contraceptives

48
Q

Mx of fibroids fertility desired

not desired

A

medical
mifepristone
mirena LNGIUS

myomectomy

not desired
uterine artery embolisation or myomectomy

49
Q

RFs of ovarian cyst

A

pre-menopausal age group
early menarche
first trimester of pregnancy
personal history of infertility or polycystic ovary syndrome
increased intrinsic or extrinsic gonadotrophins
• tamoxifen therapy
• personal or family history of endometriosis
• smoking

50
Q

Ix for ovarian cyst

esp pre menopausal women with complex ovarian cysts

A

transvaginal US

serum CA125 aFP BHCG

51
Q

Mx of acute ovarian cyst

A

1st line - laparoscopy or laparotomy
IV access

adjunct - ABx - cefotxitin 2g every 6 hrs

52
Q

Mx of ovarian cyst in premenopausal women

A

conservative - 5-7cm above follow up 2-6 for character or 6-12 for growth

+ laparoscopy

suspicious of malignancy
laparotomy

confirms malignancy -> gynae oncology referral

53
Q

Mx of ovarian cyst in postmenopausal women

A

<5cm normal CA125 -> conservative 4-6 months, discharge after a year

increasing in size/malignant???
laparoscopy/laparotomu
gynae oncology referral

54
Q

pelvic infection causes

A

post miscarriage
post termination of pregnancy
puerperal spsis
intrauterine contraceptive device

repro (28 decks)

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