Acute pelvic pain Flashcards
gynae causes of pain in pregnancy
Torsion of ovarian cyst
Degeneration of fibroids
Flare up of PID
DD of medical and surgical causes of pelvic pain
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
how might ovarian cyst present
pelvic pain
bloating and early satiety
palpable adnexal mass
scoring system for the identification of women with adnexal torsion
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)
common symptoms of adnexal torsion
Pelvic or abdominal pain,
fluctuating, radiating to loin or thigh
Nausea
Vomiting
what is adnexal torsion
twisting of the ovary and sometimes the fallopian tube, interrupting the arterial supply and causing ischemia.
signs of adnexal torsion
sign seen on US
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
features of appendicitis
Typically<40years old
Migratory pain, anorexia, vomiting
features of functional ovarian cyst
natural cycles
sudden onset
sharp stabbing pain
types of ovarian cyst
functional
pathological
what are functional cysts and how are they formed
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.
what are pathological cysts and how are they formed
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.
in what medical conditions can you see cysts in
endometriosis
PCOS
If ovarian cyst is found in menopause women then what happens and why
US scans and blood tests every 4 months for a year as they have a higher chance of ovarian cancer
what is OHSS
ovarian hyperstimulation syndrome
serious complication of fertility treatment especially IVF
Mild OHSS featrues
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
moderate Sx of OHSS
swelling is worse because of fluid build-up
in the abdomen.
abdominal pain
vomiting.
severe Sx of OHSS
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
Mx of OHSS
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
features of fibroid torsion
constant, severe pain
what are fibroids
Fibroids are non-cancerous growths that develop in or around the womb (uterus).
features of fibroids
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
RFs of fibroids
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
what are the types of fibroids
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
What is fibroid degeneration and the most common
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
Sx of fibroid degeneration
constant dull pain in abdomen
Ix and Mx of fibroid degeneration
palpable mass
inflammatory markers are raised
US
endometrial biopsy
when is emergency surgery for fibroid degeneration required
pedunculated fibroid torsion
what if u suspect sarcoma
hysterectomy
what is PID
ascending infection from the endocervix
microorganisms causing pID and tubo-ovarian abscesses
chlamydia trachomatis -STD
Neisseria gonorrhoea -STD
mycoplasma genitalium
gardnerella vaginalis anaerobes
insertion of IUD
complications of PID
Tubal infertility. Ectopic pregnancy. Chronic pelvic pain. Tubo-ovarian abscess. Fitz-Hugh-Curtis syndrome
appendicitis
diverticulitis
pyelonephritis
haematogenous spread of infection
RFs of PID
- 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
PID presentation
- 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
O/E of PID
- lower abdominal tenderness
- cervical motion tenderness, adnexal tenderness
- Pyrexia
- vaginal discharge
cervical excitation - fever >38
- adnexal mass
- contact bleeding from cervix
Ix for PID
- 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
Mx of PID
mycoplasma genitalum
- analgesia
- 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
- abstinence from intercourse for duration of Mx
- encourage partner notification and Mx
- Pt education about safe sex
- follow up
removing an intrauterine contraceptive device in women presenting with PID, especially if symptoms have not resolved within 72 hours.
if initial Mx of PID does not work what do u do
when do we admit PID pt in
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
future complications of PID
- 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)
advantages of laparoscopy
Quicker recovery
Smaller incisions
Less postoperative pain
advantages of laparotomy
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
when would you do laparoscopy in pregnancy
Appendicitis
Cholecystitis
Torsion of ovarian cyst
what is haematocolpos
Cyclical pain
No bleeding
Examination bluish membrane at introitus
I&D, cruciate incision
common causes of pelvic pain
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
Mx when discharging pt
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
Ix for ovarian torsion
- FBC - leukocytosis
- Pregnancy test
- transvaginal or w doppler flow US - WHIRLPOOL
abdominal US for children
urinary analysis
Diagnostic -> surgical visualisation
Mx of adnexal torsion
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
Mx of fibroids fertility desired
not desired
medical
mifepristone
mirena LNGIUS
myomectomy
not desired
uterine artery embolisation or myomectomy
RFs of ovarian cyst
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
Ix for ovarian cyst
esp pre menopausal women with complex ovarian cysts
transvaginal US
serum CA125 aFP BHCG
Mx of acute ovarian cyst
1st line - laparoscopy or laparotomy
IV access
adjunct - ABx - cefotxitin 2g every 6 hrs
Mx of ovarian cyst in premenopausal women
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
Mx of ovarian cyst in postmenopausal women
<5cm normal CA125 -> conservative 4-6 months, discharge after a year
increasing in size/malignant???
laparoscopy/laparotomu
gynae oncology referral
pelvic infection causes
post miscarriage
post termination of pregnancy
puerperal spsis
intrauterine contraceptive device
