Gynae emergencies

Question 1

What is pelvic inflammatory disease? (PID)

Answer 1

Caused by infections ascending from the cervix or vagina to upper genital tract eg endometritis, salphingitis, abscess, peritonitis

Question 2

What can cause PID?

Answer 2

Usually caused by STIs, instruments eg IUCD, hysterectomy or TOP, post-partum or spread of other infection

Question 3

What is the presentation of PID?

Answer 3

lower abdominal pain, deep dyspareunia, discharge PV, IMB, PCB, dysmenorrhea, fever, cervical and adnexal tenderness on bimanual

Question 4

What are the investigations for PID?

Answer 4

swabs for STIs, do slide of cervix for pus cells, MCS, if acutely unwell do FBC, CRP(inflamm) and blood cultures for sepsis and appendicitis.

Question 5

What is the management for PID?

Answer 5

treat before results with abx - OPD use ceftriaxone/ azithromycin plus doxycycline and metronidazole.

Question 6

What are the main differentials for acute pelvic pain in a young woman?

Answer 6

ectopic, UTI, appendicitis, PID, cyst or fibroid torsion

Question 7

What is a miscarriage?

Answer 7

Loss before 24 weeks (post 24 works it is a stillbirth)

Question 8

What are the different types of miscarriage?

Answer 8

Incomplete – passage of some but not all tissue

Complete – all tissue passed

Silent/missed- no symptoms

Recurrent- three or more

Question 9

What are possible causes of a miscarriage?

Answer 9

Fetal chromosomal abnormalities  
Antiphospholipid syndrome 
PCOS 
Pollutants 
Infection

Question 10

What investigations and findings are there for miscarriage?

Answer 10

TVS – gestational sac empty >25mm if <25mm and unsure repeat scan in 1 week.
Fetal heart beat- absent
Beta hCG double normally between 36 and 48 hours of pregnancy but will not in miscarriage – so falling/ levels staying the same is a worrying sign

Question 11

What is the presentation for miscarriage?

Answer 11

PV bleed- can vary from very heavy to light brown spotting

No symptoms if missed

Question 12

What is the management for miscarriage?

Answer 12

mifepristone then misoprostol 36-48 hours later. Misoprostol only if less than 12 weeks pregnant

Vaccum surgery (small risk perforation uterus)

watchful waiting if no majoy PV bleed and fetus may pass spontaenously

Repeat pregnancy test after treatment – if still positive ?ectopic ?Retained pregnancy tissue ?molar pregnancy

Anti – D injection

If think cervical weakness is to blame can do cervical suture

Question 13

What is an ectopic pregnancy?

Answer 13

A pregnancy outside the uterus. Most commonly occurs in the fallopian tube but can be outside

Question 14

How may an ectopic pregnancy present?

Answer 14

PV bleed
Abdo/ shoulder tip pain
Bowel upset

Question 15

What investigations do you do for ectopic preg?

Answer 15

Pregnancy test- may be negative but if there will have a lower rise compared to its usual rapid rise
US transvaginal - empty uterus

Question 16

What is the management for an ectopic pregnancy?

Answer 16

Laparoscopy if unstable, >35mm adnexal mass, positive heart beat or >5000 hCG
methotrexate (can only do if beta-hCG is less than 3000 and LFTs and U+Es are normal)

Question 17

What is hyperemesis gravidarum?

Answer 17

5% pre-pregnancy weight loss
dehydration
electrolyte imbalance

Question 18

What is a risk factor for hyperemesis gravidarum?

Answer 18

Associated with higher levels of beta-hCG eg multiple pregnancies, molar pregnancy

Question 19

What is the presentation for hyperemesis gravidarum?

Answer 19

hypovolaemic and dehydrated, tachycardic, hypokalaemia, hyponatraemic, Mallory Weiss tears

Question 20

What investigations do you do for hyperemesis gravidarum?

Answer 20

urine drip for ketones and UTI, U&Es for low K or Na. US for multiple pregnancy and molar pregnancy

Question 21

What is the management for hyperemesis gravidarum?

Answer 21

first line anti-emetic: promethazine or cyclizine (anti-histamines)

second line: ondansetron and metoclopramide.

Give fluids, U+Es, thromobprophylaxis if in hospital for long time.