Gynae: Ectopic Pregnancy, PID, Miscarriage & Ovarian Cyst Flashcards
In women, what is the most common cause of pelvic pain?
1ary dysmenorrhoea
What is mittelschmerz?
When some experience transient pain in the middle of their cycle 2ary to ovulation.
Give 6 acute causes of pelvic pain
1) Ectopic pregnancy
2) Ovarian torsion
3) Pelvic inflammatory disease
4) Appendicitis
5) UTI
6) Miscarriage
Give 4 chronic causes of pelvic pain
1) Endometriosis
2) Ovarian cyst
3) IBS
4) Urogenital prolapse
What is cervical excitation?
Cervical motion tenderness (during bimanual exam).
What 2 conditions does cervical excitation indicate?
1) PID
2) Ectopic pregnancy
What is typically seen in the history of a patient with an ectopic pregnancy?
a female with a history of 6-8 weeks amenorrhoea
What is ectopic pregnancy?
a life-threatening obstetric emergency, in which the fertilised ovum implants outside the uterine cavity
Most common site in ectopic pregnancy?
Fallopian tube (97%)
Clinical presentation of ectopic pregnancy?
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
What can cause shoulder tip pain in ectopic pregnancy?
Peritoneal bleeding
Give some risk factors for ectopic pregnancy
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
Why is PID a signficiant risk factor for an ectopic?
As it leads to tubal inflammation, damage, and impaired motility.
What 2 bacteria is PID commonly caused by?
1) Chlamydia trachomatis
2) Neisseria gonorrhoeae
Why is IVF associated with an increased risk of an ectopic?
due to embryo misplacement during transfer.
Why is endometriosis a risk factor for an ectopic?
The presence of endometrial tissue outside the uterine cavity can cause tubal obstruction and inflammation, increasing the risk of ectopic implantation.
Why is smoking a risk factor for an ectopic?
Tobacco use is linked to impaired tubal function and ciliary beat frequency, which may increase ectopic pregnancy risk.
2 key investigations in an ectopic?
1) hCG levels –> useful for assessing the viability of a pregnancy.
2) Transvaginal ultrasonography (TVUS –> 1st line imaging for suspected ectopic
What is the minimum hCG level at which an intrauterine pregnancy should be visible on transvaginal ultrasonography?
1,500-2,000 mIU/mL
What is the 1st line imaging modality for evaluating suspected ectopic pregnancy?
TVUS
Findings on TVUS that are suggestive of an ectopic pregnancy?
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
What imaging can be done in a suspected ectopic if TVUS is contraindicated or not feasible?
Abdominal ultrasonography
Purpose of a doppler US in an ectopic?
Can supplement TVUS in detecting blood flow in the trophoblastic tissue of ectopic pregnancies, improving diagnostic accuracy.
Give the 5 criteria for ‘expectant’ management of an ectopic?
1) size <35 mm
2) unruptured
3) asymptomatic
4) no foetal heartbeat
5) hCG <1000 IU/L
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.
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
What are the 3 management routes for an ectopic?
1) expectant
2) medical
3) surgical
1st line medical management of an ectopic?
Methotrexate –> can only be done if the patient is willing to attend follow-up.
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
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)
what is a salpingectomy?
a surgical procedure where one or both of a woman’s fallopian tubes are removed
What is a salpingotomy?
The creation of an opening into the fallopian tube, but the tube itself is not removed in this procedur
What % of women who undergo a salpingotomy for an ectopic require further treatment (methotrexate and/or a salpingectomy)?
20%
What are the 2 main complications of an ectopic?
1) tubal rupture
2) haemoperitoneum
What is the most severe and life-threatening complication of ectopic pregnancy?
tubal rupture
When does tubal rupture occur in an ectopic?
Occurs when the growing conceptus causes the fallopian tube to burst, leading to severe intraperitoneal haemorrhage.
At how many weeks gestation does tubal rupture in an ectopic usually occur?
6-10 weeks gestation
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
Management of tubal rupture as a consequence of an ectopic?
Surgery
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.
Give 2 intermediate complications of an ectopic?
1) Persistent trophoblastic tissue
2) Infection: e.g. post-surgical, undiagnosed tubo-ovarian abscess
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.
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.
Does ectopic pregnancy itself increase the risk of subsequent ectopic pregnancies?
Yes
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.
What is the most common bacterial cause of PID?
Chlamydia trachomatis
What are the 4 most common causative organisms of PID?
1) Chlamydia trachomatis
2) Neisseria gonorrhoeae
3) Mycoplasma genitalium
4) Mycoplasma hominis