Gynaecological Emergencies Flashcards
What is the ultrasound criteria for silent miscarriage?
Diagnosed if on transvaginal ultrasound
* CRL <7mm with no visible heartbeat, and no interval change on rescan at least 7 days later
* CRL >7mm with no visible heartbeat, confirmed by second opinion or rescan at least 7 days later
* Intrauterine gestational sac with mean sac diameter <25mm and no visible fetal pole, and no interval growth on rescan at least 7 days later
* Intrauterine gestational sac with mean sac diameter >25mm, confirmed by 2nd opinion or rescan at least 7 days later
Rescan should be performed at least 14 days later if transabd scan is used
Private scans with reports done by radiologists or gynaecologists can be accepted as 2nd opinion
If there is doubt about the dx and/or a woman requests a repeat scan, this should be performed at an interval of at least 1 week from the initial scan before treatment
Fever – history
- Pregnant (infection is very rare, bring temperature down so it doesn’t affect foetus)
- Sexually active
- Surgical condition
- Medical condition
Bleeding - Hx taking
- Pregnant
- Sexually active
- Contraception
- Menstrual-related
- Trauma – kids, adult
- Haematological disorder
Pain – history
- Site, duration, radiation, nature
- ?Pregnant
- ?Sexually active
- ?menstrual related
- ?trauma
- ?surgical condition
- ?medical condition
Urinary and bowel
Past obstetric history
Predisposing risk factors
Social history
What is the management of miscarriage?
- Offer expectant management for 7-14 days as the 1st line manageent strategy for women with a confirmed dx of miscarriage because it is the most cost effective
Explore manamgent options if the women
* is at increased risk of hemorrhage
* Has previous adverse or traumatic experience associated with pregnancy (stillbirth, miscarriage or antepartum hemorrhage)
* is at increased risk from the effects of hemorrhage (coagulopathies or is unable to have a blood transfusion)
* evidence of infection
If expectant management is not acceptable to the women offer medical management because it is the next most cost effective treatment. Single dose 800mg misoprostol.
Thirdly is offer surgical treatment
What is classical triad of ectopic pregnancy?
History and PE?
- Missed period, pain and bleeding
History: pregnant, risk factors (PID, tubal surgery, previous ectopic pregnancy), IUCD
Examination: abd signs (if +ve, use surgical treatment), uterus bulky, adnexal mass (be gentle, danger of rupture), tenderness
What Ix done for ectopic pregnancy?
- Ix: CBP, type and screen
- Suspected: pregnancy test, serial hCG, ultrasound
- Laparoscopy
What are USG features suggestive of ectopic pregnancy?
- Sliding sign #
- Bagel sign # or a complex, inhomogeneous adnexal
mass move separately to the ovary - Empty uterus or pseudo-sac #
- Moderate to large amount of free fluid in POD
suggestive of haemoperitoneum
When is suitable and unsuitable for expectant management for ectopic pregnancy?
If hCG <5000IU/L ectopic pregnancy what is the medical vs surgical management?
What is medical treatment of ectopic pregnancy?
- Methotrexate (for low hCG levels) and absence of cardiac activity in the fetal pole
- Associated with saving in treatment costs
What is surgical treatment of ectopic pregnancy?
2 approaches: laparoscopy, laparotomy
2 types: classical (total salpingectomy, i.e. if in shock), conservative (salpingotomy)
What is the algorithm for suspected ectopic pregnancy with uncertain dx from USG?
ddx for ectopic pregnancy?
- Miscarriage complications
- Bleeding corpus luteal cyst
- Ovarian cyst complications
- Pelvic inflammatory disease
- Appendicitis
What is treatment of torsion of ovarian cyst?
Complete torsion, venous thrombosis, ovarian infarction –> treatment used to be salpingooophorectomy. Now it is detorsion and cystectomy –> can preserve ovarian function.
What do these patterns of bleeding indicate?
- ‘Extremes of reproductive age’
- ‘Pubertal DUB’
- ‘Perimenopausal DUB’
What are organic causes of bleeding?
Need some form of endometrial sampling before we start hormones. We don’t want to give hormones in the presence of Ca corpus.
What are the methods to control acute bleeding in patients with DUB?
tds = 3 times a day
What are the DDx of primary dysmenorrhoea and secondary dysmenorrhoea?
Circumstances that may indicate secondary dysmenorrhea
- In the first 6 months from the start of menarche, in anovulatory patients
- Appear after many years of painless menses
- Pelvic abnormality on examination
- Infertiliy, menorrhagia, irregular cycles
- Not responding to standard treatment
What are ovarian cyst complications
- Pain
- Torsion
- Rupture/leak
- Bleeding into or from cyst
- Infection (rare)
Can the patient be having a tubo-ovarian abscess? This is far more common than ovarian cyst
S/S of torsion of ovarian cyst
- Acute or subacute pain
- Sudden onset
- Recurrent, intermittent, progressive
- Nausea and vomitting, fever
- Acute abdomen, pelvic mass
- Uncertain – U/S, laparascopic
Treatment of torsion of ovarian cyst
- Incomplete torsion with no evidence of tissue damage, desire to preserve fertility, benign-looking
- Complete torsion, venous thrombosis, ovarian infarction
How would a patient with pelvic inflammatory disease present?
What Ix should be done for PID? What are the DDx?
- Culture
- In doubt: laparoscopy
- DDx: ectopic pregnancy, appendicitis
Why is there a low threshold of empiral treatment for PID? Which antibiotics should be used?
Outpatient treatment:
- Ceftriaxone 500mg IM followed by oral Doxycycline 100mg bd + Metronidazole 400mg bd for 14 days
- (Oral Levofloxacin 500mg qd + oral Metronidazole 400mg bd for 14 days)
As most PID can be given outpatient treatment, which patients require in patient treatment?
Inpatient treatment:
- Surgical emergency cannot be excluded
- Clinically severe disease
- Tubo-ovarian abscess
- PID in pregnancy
- Lack of response to oral therapy
- Intolerance to oral therapy
What is the inpatient regimen for patients with PID?
Should there be contact tracing for PID?
Yes.
What are some post-treatment complications which may be seen?
- Ovarian hyperstimulation syndrome
- Secondary haemorrhage following LEEP
- Wound complications – infection, hernia
- Vault haematoma
- Bowel/urinary tract injuries
What is incarcerated prolapse?
Third degree uterine prolapse
- Incarcerated with oedema, ulcer and infection
- Bed-rest, reduce prolapse, vaginal douching, oestrogen cream
- Definitive surgery
What are some pathologies we must keep in mind for urinary retention?
Must exclude pelvic mass:
- Gravid uterus
- Fibroid
- Ovarian mass
- Prolapse
Watch out for atonic bladder, overflow incontinence
What are surgical conditions which may mimic gynaecological conditions?
- Appendicitis
- Haematuria or haemorrhoidal bleeding mistaken as PMB
- Renal stones
- Bowel obstruction/volvulus
- Gallstone complications
What are medical conditions which may be mistaken for gynaecological conditions?
- Bleeding disorders, e.g. von Willebrand’s disease
- Acute UTI
- Acute gastroenteritis
