Gynae: Ectopic Pregnancy, PID, Miscarriage & Ovarian Cyst Flashcards
1
Q
In women, what is the most common cause of pelvic pain?
A
1ary dysmenorrhoea
2
Q
What is mittelschmerz?
A
When some experience transient pain in the middle of their cycle 2ary to ovulation.
3
Q
Give 6 acute causes of pelvic pain
A
1) Ectopic pregnancy
2) Ovarian torsion
3) Pelvic inflammatory disease
4) Appendicitis
5) UTI
6) Miscarriage
4
Q
Give 4 chronic causes of pelvic pain
A
1) Endometriosis
2) Ovarian cyst
3) IBS
4) Urogenital prolapse
5
Q
What is cervical excitation?
A
Cervical motion tenderness (during bimanual exam).
6
Q
What 2 conditions does cervical excitation indicate?
A
1) PID
2) Ectopic pregnancy
7
Q
What is typically seen in the history of a patient with an ectopic pregnancy?
A
a female with a history of 6-8 weeks amenorrhoea
8
Q
What is ectopic pregnancy?
A
a life-threatening obstetric emergency, in which the fertilised ovum implants outside the uterine cavity
9
Q
Most common site in ectopic pregnancy?
A
Fallopian tube (97%)
10
Q
Clinical presentation of ectopic pregnancy?
A
1) lower abdo pain (typically 1st symptom)
2) vaginal bleeding
3) history of amenorrhoea
4) may have shoulder tip pain
5) 50% may be asymptomatic
11
Q
What can cause shoulder tip pain in ectopic pregnancy?
A
Peritoneal bleeding
12
Q
Give some risk factors for ectopic pregnancy
A
1) Fallopian tube abnormalities e.g. scarring, adhesions, or congenital anomalies
2) Pelvic inflammatory disease
3) Previous ectopic pregnancy
4) Tubal surgery e.g. salpingectomy, tubal ligation
5) Assisted reproductive technology (ART) e.g. IVF
6) IUD use (decrease the overall risk of pregnancy, but if pregnancy occurs, the likelihood of it being ectopic is increased )
7) Endometriosis
8) Smoking
13
Q
Why is PID a signficiant risk factor for an ectopic?
A
As it leads to tubal inflammation, damage, and impaired motility.
14
Q
What 2 bacteria is PID commonly caused by?
A
1) Chlamydia trachomatis
2) Neisseria gonorrhoeae
15
Q
Why is IVF associated with an increased risk of an ectopic?
A
due to embryo misplacement during transfer.
16
Q
Why is endometriosis a risk factor for an ectopic?
A
The presence of endometrial tissue outside the uterine cavity can cause tubal obstruction and inflammation, increasing the risk of ectopic implantation.
17
Q
Why is smoking a risk factor for an ectopic?
A
Tobacco use is linked to impaired tubal function and ciliary beat frequency, which may increase ectopic pregnancy risk.
18
Q
2 key investigations in an ectopic?
A
1) hCG levels –> useful for assessing the viability of a pregnancy.
2) Transvaginal ultrasonography (TVUS –> 1st line imaging for suspected ectopic
19
Q
What is the minimum hCG level at which an intrauterine pregnancy should be visible on transvaginal ultrasonography?
A
1,500-2,000 mIU/mL
20
Q
What is the 1st line imaging modality for evaluating suspected ectopic pregnancy?
A
TVUS
21
Q
Findings on TVUS that are suggestive of an ectopic pregnancy?
A
1) adnexal mass
2) extrauterine gestational sac
3) complex adnexal fluid collection
4) empty uterine cavity and absence of an intrauterine gestational sac in the presence of an elevated hCG level
22
Q
What imaging can be done in a suspected ectopic if TVUS is contraindicated or not feasible?
A
Abdominal ultrasonography
23
Q
Purpose of a doppler US in an ectopic?
A
Can supplement TVUS in detecting blood flow in the trophoblastic tissue of ectopic pregnancies, improving diagnostic accuracy.
24
Q
Give the 5 criteria for ‘expectant’ management of an ectopic?
A
1) size <35 mm
2) unruptured
3) asymptomatic
4) no foetal heartbeat
5) hCG <1000 IU/L
25
What is involved in 'expectant' management of an ectopic?
1) closely monitoring the patient over 48 hours
2) if B-hCG levels rise again or symptoms manifest intervention is performed.
26
Give the 5 criteria for 'medical' management of an ectopic?
1) size <35 mm
2) unruptured
3) no significant pain
4) no fetal heartbeat
5) hCG <1,500 IU/L
27
What are the 3 management routes for an ectopic?
1) expectant
2) medical
3) surgical
28
1st line medical management of an ectopic?
Methotrexate --> can only be done if the patient is willing to attend follow-up.
29
Give the 5 criteria in which 'surgical' management of an ectopic would be considered?
1) size >35 mm
2) can be ruptured
3) pain
4) visible foetal heartbeat
5) hCG >5,000 IU/L
30
What are the 2 options for surgical management of an ectopic?
When would each be used?
1) Salpingectomy --> 1st line for women with no other risk factors for infertility
2) Salpingotomy --> considered for women with risk factors for infertility (e.g. contralateral tube damage)
31
what is a salpingectomy?
a surgical procedure where one or both of a woman's fallopian tubes are removed
32
What is a salpingotomy?
The creation of an opening into the fallopian tube, but the tube itself is not removed in this procedur
33
What % of women who undergo a salpingotomy for an ectopic require further treatment (methotrexate and/or a salpingectomy)?
20%
34
What are the 2 main complications of an ectopic?
1) tubal rupture
2) haemoperitoneum
35
What is the most severe and life-threatening complication of ectopic pregnancy?
tubal rupture
36
When does tubal rupture occur in an ectopic?
Occurs when the growing conceptus causes the fallopian tube to burst, leading to severe intraperitoneal haemorrhage.
37
At how many weeks gestation does tubal rupture in an ectopic usually occur?
6-10 weeks gestation
38
Clinical features of tubal rupture as a consequence of an ectopic?
1) sudden, severe abdo pain
2) signs of hypovolaemic shock (tachycardia, hypotension, pallor)
3) peritoneal irritation
39
Management of tubal rupture as a consequence of an ectopic?
Surgery
40
What is haemoperitoneum as a result of an ectopic?
Bleeding into the abdominal cavity from trophoblast invasion.
This internal bleeding can ead to a significant accumulation of blood in the peritoneal cavity, causing hemodynamic instability and potential hypovolemic shock.
41
Give 2 intermediate complications of an ectopic?
1) Persistent trophoblastic tissue
2) Infection: e.g. post-surgical, undiagnosed tubo-ovarian abscess
42
What occurs in persistent trophoblastic tissue as a result of an ectopic?
Following treatment with methotrexate or surgical management, residual trophoblastic tissue may remain and continue to produce hCG.
his can necessitate further medical or surgical intervention to ensure complete removal of the ectopic pregnancy.
43
What are 3 longer term complications of an ectopic?
1) damage to reproductive organs can impact future fertility e.g. due to surgical intervention
2) psychological sequelae --> appropriate counselling and support
3) Rh sensitisation --> In Rh-negative women with an ectopic pregnancy, there is a risk of developing Rh isoimmunization.
44
Does ectopic pregnancy itself increase the risk of subsequent ectopic pregnancies?
Yes
45
What is PID?
A term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum.
It is usually the result of ascending infection from the endocervix.
46
What is the most common bacterial cause of PID?
Chlamydia trachomatis
47
What are the 4 most common causative organisms of PID?
1) Chlamydia trachomatis
2) Neisseria gonorrhoeae
3) Mycoplasma genitalium
4) Mycoplasma hominis
48
Clinical features of PID?
1) lower abdo pain
2) fever
3) deep dyspareunia
4) dysuria & menstrual irregularities (e.g. intermenstrual, postcoital) may occur
5) abnormal vaginal or cervical discharge
49
Investigations in PID?
1) pregnancy test: exclude ectopic
2) high vaginal swab: these are often negative
3) screen for Chlamydia and Gonorrhoea: NAAT swabs
4) STI screen: HIV test, syphilis test, NAAT swabs for Mycoplasma genitalium if available
5) Inflammatory markers: raised
50
Examination findings in PID?
1) pelvic tenderness
2) cervical motion tenderness (cervical excitation)
3) inflamed cervix (cervicitis)
4) purulent discharge
Patients may have a fever and other signs of sepsis.
51
What does a high vaginal swab look for in suspected PID?
1) bacterial vaginosis
2) candidiasis
3) trichmoniasis
52
A microscope can be used to look for pus cells on swabs from the vagina or endocervix in PID.
What result would assist in diagnosis?
The ABSENCE of pus cells is useful for EXCLUDING PID.
53
Risk factors for PID?
Same as any other STIs:
1) not using barrier contraception
2) multiple sexual partners
3) younger age
4) existing STIs
5) previous PID
6) IUD e.g. copper coil
54
Define the following terms:
a) endometritis
b) salpingitis
c) oophoritis
d) parametritis
e) peritonitis
a) inflammation of the endometrium
b) inflammation of the fallopian tubes
c) inflammation of the ovaries
4) inflammation of the parametrium (connective tissue around the uterus)
5) inflammation of the peritoneal membrane
55
Management of PID?
Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment.
1) oral ofloxacin + oral metronidazole OR intramuscular ceftriaxone + oral doxycycline + oral metronidazole
2) consider removal of IUD
3) where appropriate patients should be referred to a genitourinary medicine (GUM) specialist service for management and contact tracing.
4) More severe cases, particularly where there are signs of sepsis or the patient is pregnant, require admission to hospital for IV antibiotics.
56
When are Abx started in PID?
Antibiotics are started empirically, before swab results are obtained, to avoid a delay and complications.
57
One suggested Abx regime for PID is:
1) single dose of IM ceftriaxone
+
2) doxycycline 100mg twice daily for 14 days
+
3) Metronidazole 400mg twice daily for 14 days
What is the purpose of each Abx?
1) Ceftriaxone: to gover gonorrhoea
2) Doxycycline: to cover chlamydia and Mycoplasma genitalium
3) Metronidazole: to cover anaerobes such as Gardnerella vaginalis
N.B. Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
58
Complications of PID?
1) ectopic pregnancy
2) chronic pelvic pain
3) infertility: risk may be as high as 10-20% after a single episode
4) perihepatitis (Fitz-Hugh Curtis Syndrome)
5) sepsis/abscess
59
What is Fitz-Hugh-Curtis syndrome?
A complication of PID that is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum.
Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
60
Presentation of Fitz-Hugh-Curtis syndrome?
1) Right upper quadrant pain (may be confused with cholecystitis).
2) Pain can be referred to the right shoulder tip if there is diaphragmatic irritation
61
Management of Fitz-Hugh-Curtis syndrome?
Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
62
What other features may be seen alongside abdo pain in PID?
- Pelvic pain
- fever
- deep dyspareunia
- vaginal discharge
- dysuria
- menstrual irregularities
63
Describe the pain in ovarian torsion
Usually SUDDEN onset unilateral lower abdo pain.
64
What does onset of pain in ovarian torsion often coicincide with?
Exercise
65
Clinical features of ovarian torsion?
1) sudden onset unilateral lower abdominal pain
2) N&V
3) unilateral, tender adnexal mass on examination
66
Describe pain typically seen in an ovarian cyst
Unilateral DULL ACHE which may be intermittent or only occur during intercourse.
Torsion or rupture may lead to severe abdominal pain
67
Clinical features of LARGE ovarian cysts?
Large cysts may cause abdominal swelling or pressure effects on the bladder
68
Benign ovarian cysts are extremely common and can be divided into what 3 groups?
1) physiological (functional) cysts
2) benign germ cell tumours
3) benign epithelial sex cord stromal tumours
69
What should you ALWAYS do with complex (i.e. multi-loculated) ovarian cysts?
Biopsy to exclude malignancy
70
What is the most common type of ovarian cyst?
Follicular cysts (this is a type of physiological/functional cyst)
71
What are the 2 types of physiological cysts?
1) follicular
2) corpus luteum cyst
72
What causes a follicular cyst?
Due to the non-rupture of the dominant follicle or failure of atresia in a non-dominant follicle.
73
When do follicular cysts typically regress?
commonly regress after several menstrual cycles
74
What causes a corpus luteum cyst?
During the menstrual cycle if pregnancy doesn't occur the corpus luteum usually breaks down and disappears. If this doesn't occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst.
75
What type of physiological is more likely to present with intraperitoneal bleeding?
Corpus luteum cyst
76
What is a benign germ cell tumour ovarian cyst also known as?
Dermoid cyst OR mature cystic teratomas
77
What is a dermoid ovarian cyst?
Usually lined with epithelial tissue and hence may contain skin appendages, hair and teeth
78
What is the most common benign ovarian tumour in woman under the age of 30 years?
Dermoid cyst
79
Median age of diagnosis of a dermoid cyst?
30 y/o
80
What % are dermoid cysts bilateral?
10-20%
81
What type of ovarian cyst is ovarian torsion most likely?
Dermoid cyst
82
What are the 2 types of benign epithelial tumour ovarian cysts?
1) serous cystadenoma
2) Mucinous cystadenoma
83
What is the most common benign epithelial tumour ovarian cyst?
Serous cystadenoma
84
Which type of ovarian cyst bears a resemblance to the most common type of ovarian cancer (serous carcinoma)?
Serous cystadenoma
85
What type of ovarian cyst are typically large and may become massive?
Mucinous cystadenoma
86
If a mucinous cystadenoma ruptures, it can cause pseudomyxoma peritonei.
What is this?
a rare tumour that grows slowly and causes a build-up of mucin (a jelly-like substance) in the abdomen and pelvis, giving rise to the name “jelly belly”.
87
Ruptured ovarian cysts are a common gynae emergency.
What are the most common symptoms?
1) sudden onset severe lower abdo pain
- usually sharp and localised to one side
- can be diffuse and generalised
2) N&V
3) fever
4) can result in haemodynamic instability in cases where significant intraperitoneal bleeding occurs (due to the rupture of a vascularized cyst)
5) can have urinary symptoms (f there is inflammation or compression of the urinary tract structures)
88
Examination findings in a ruptured ovarian cyst?
Peritoneal signs:
1) tenderness
2) guarding
3) rebound tenderness in the lower abdomen.
89
When do ruptured ovarian cysts typically occur?
Can occur spontaneously or after physical activities such as vigorous exercise, sexual intercourse, or trauma to the abdomen.
The rupture may be due to increased intra-abdominal pressure, torsion of the cyst's pedicle, or vascular compromise
90
What 3 examinations may you want to do in a ruptured ovarian cyst?
1) abdo exam: tenderness, guarding, and rebound tenderness
2) pelvic exam: unilateral adnexal tenderness and fullness
3) speculum exam: vaginal discharge or bleeding may be observed if there is communication between the ruptured cyst and vagina or if there is concurrent cervical pathology.
91
Define a miscarriage
The spontaneous loss of pregnancy <24 weeks gestation.
92
When do the majority of miscarriages tend to occur?
1st trimester
93
How do miscarriages commonly present?
Lower abdo pain + vaginal bleeding
94
What is a major cause of 1st trimester miscarriages?
Chromosomal abnormalities.
95
Give some causes of miscarriages
1) In most cases, there is no identifiable cause for the miscarriage.
2) Abnormal fetal development:
- chromosomal abnormalities
- structural abnormalities
3) Maternal conditions
4) Uterine conditions
5) Maternal age
96
What are some materan pre-existing conditions that can increase the risk of a a miscarriage?
1) infections e.g. BV
2) antiphospholipid syndrome (present in 15% of women who experience recurrent miscarriages)
3) thrombophilia e.g. factor V Leiden, prothrombin gene mutation
4) endocrine problems e.g. PCOS, thyroid disease, diabetes mellitus, and hyperprolactinaemia
5) genetic abnormalities
97
What uterine conditons can cause a miscarriage?
Uterine abnormalities including septate, bicornuate, or arcuate uterus can affect the development of the growing fetus, making it incompatible for a viable pregnancy.
98
Can fibroids cause a miscarriage?
Fibroids typically do not affect pregnancies, but a uterus may be distorted by fibroids to the extent that it is unable to accommodate the development of a healthy fetus.
99
What are the 2 identified risk factors for having ANOTHER miscarriage?
1) increased maternal age
2) previous miscarriage
100
What is the risk of miscarriage in women aged 45 and older?
93%
101
Other examples of risk factors for miscarriage:
1) environmental:
- high dose radiation
- heavy metals exposure
2) paternal factors:
- tight clothing (bottom) in males
- sperm abnormalities
- old paternal age
3) lifestyle:
- stress
- smoking
- obesity
102
What is an incomplete miscarriage?
When is it more likely to occur?
What: the gestation sac ruptures and the fetus is then expelled while parts of the placenta remain in the uterus.
When: between 12-24 weeks,
103
When is a complete miscarriage more likely to occur?
<12 weks: as the placenta is unlikely to have been independently developed, thus being expelled together with the fetus.
104
Define an 'early' miscarriage
<13 weeks
105
Define a 'late' miscarriage
13-24 weeks
106
Define a complete miscarriage:
- Both fetus and all pregnancy tissue have been expelled from the uterus
- Bleeding stops and further treatment is not needed
107
Define an incomplete miscarriage
- Fetus and parts of the membranes are expelled from the uterus
- Placenta is not fully expelled and bleeding persists
- Surgical management is often needed to remove the remaining products of conception
108
What is a threatened miscarriage?
Viable pregnancy with symptoms (such as vaginal bleeding) and a closed cervical os.
75% of threatened miscarriages will settle
109
Associated risks of a threatened miscarriage?
Carry a higher risk of preterm delivery and preterm rupture of membranes
110
What is an inevitable miscarriage?
Non-viable pregnancy with vaginal bleeding and an open cervical os that progresses to an incomplete or complete miscarriage.
111
Define 'recurrent' miscarriage
3 or more
112
Clinical features of a miscarriage?
1) vaginal bleeding
2) lower abdo cramping pain
3) vaginal fluid discharge/tissue discharge
4) loss of pregnancy symptoms (e.g. no more nausea/breast tenderness)
5) lower back pain
113
If the patient presents with bleeding but no pain and is < 6 weeks pregnant, what is management?
1) Often expectant management.
2) Repeat pregnancy test after 7-10 days:
a) if negative: miscarriage
b) if positive with persistent symptoms: referred to an EPAU or out-of-hours gynaecology unit
114
What is typically the 1st line investigation in a miscarriage?
transvaginal ultrasound scan: to determine the location and viability of the pregnancy.
115
3 management routes in a miscarriage?
1) Expectant
2) Medical
3) Surgical
116
Most miscarriages are managed expectantly.
Give some indications for surgical or medical management.
1) increased risk of haemorrhage e.g. late in 1st trimester, has coagulopathies or is unable to have transfusion
2) previous adverse and/or traumatic experience associated with pregnancy e.g. stillbirth, miscarriage
3) evidence of infection
117
1st line medical management of miscarriage?
Vaginal misoprostol
118
What is misoprostol?
Prostaglandin analogue --> binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
119
