Gynaecological emergencies Flashcards
What is an ectopic pregnancy
Ectopic pregnancy occurs when a fertilised egg implants outsideof the uterus, most commonly within the fallopian tube.
In the UK, approximately 1 in 90 pregnancies are ectopic
What are the risk factors for ectopic pregnancy?
Previous ectopic pregnancy
Tubal damage – e.g. PID, previous STI, sterilisation
History of infertility or assisted reproductive techniques
Smoker
Age over 35
Use of IUD/IUS or POP
What are the symptoms of ectopic pregnancy?
PV bleeding
Abdominal pain, typically to one side
Shoulder tip pain
Dizziness
Sometimes none at all
How do we diagnose ectopic pregnancy ?
Usually diagnosed by USS +/-bHCG
1/3 of those with an ectopic pregnancy will have no risk factors
Scan signs of tubal ectopic:
Adnexal mass moving separately to the ovary (sliding sign)comprising a gestational sac containing a yolk sac
OR
Adnexal mass moving separately to the ovary comprising agestational sac andfetalpole (with or without a heartbeat)
What are the sites of implantation of ectopic pregnancy?
Ampulatory - 70&
Isthmic - 12%
Fimbrial - 11%
Interstitial - 2-4%
Ovarian - 3%
Abdominal - 1%
What is a tubal ectopic in ectopic pregnancy?
Accounts for approximately 90% of all ectopic pregnancies
Usually diagnosed on USS – adnexal mass that moves separatelyto the ovary. Sensitivity of 87-99%.
In 20% of cases apseudosacmay be seen within the uterine cavity
Free fluid may be seen but is not diagnostic of an ectopicpregnancy
Serum b-hCGshould be performed
which implantation site has the highest risk of rupture
isthmic
What are the 3 options for ectopic pregnancy management?
Conservative
Medical
Surgical
What is the conservative management for ectopic pregnancy?
Patient must be clinically stable and pain free
AND
Have a tubal ectopic pregnancy <35mm with no visible heartbeat
AND
SerumhCG<1000iu/l
AND
Patient is able to return for follow-up
RepeathCGon day 2,4 and 7
IfhCGlevels by 15% or more from previous value then followingday 7 repeathCGweekly until result is <20iu/l.
What is the medical management for ectopic pregnancy?
Offer systemic methotrexate in women who:
= Have no significant pain and be clinically well
AND
- Unruptured tubal ectopic with an adnexal mass <35mm with novisible FH
AND
- SerumhCG<1500
AND
- Do not have an intrauterine pregnancy
AND
- Can return for follow-up
Issues with medical management of ectopic pregnancy?
Can offer the choice of medical and surgical with a serumbhCGbetween 1500 and 5000
For women who have methotrexate,bhCGmust be monitored ondays 4 and 7, and then weekly untilhCGis negative. If fall is <15%between day 4-7 repeat USS should be performed, andconsideration of repeat MTX following discussion with consultant
Patients should be informed NOT to get pregnant for 3 monthsfollowing methotrexate
Contraindications include thrombocytopaenia, hepatic or renaldysfunction, immunocompromised, breastfeeding and pepticulcer disease
Who is surgical management first line in for ectopic pregnancy?
- Have significant pain
- Adnexal mass >35mm
- Live ectopic
- HCG >5000
- Signs of rupture
- Haemodynamic instability
What happens in surgical management of ectopic pregnancy?
Should be performed laparoscopically wherever possible
Salpingectomy first line unless they have other risk factors forinfertility
Salpingotomy is an alternative for women with risk factors forinfertility such as contralateral tubal damage (1in5 will needfurther treatment) - should performhCGday 7 and then weeklyuntil negative
What happens in a complete miscarriage?
- Usually present following an episode of PV bleeding
- May remove products of conceptions on examination
- USS will show an empty uterus
- Usually will require follow-up with bHCG monitoring (if no IUP confirmed on USS).
- A decrease of >50% a minimum of 48 hours apart is indicative of early pregnancy loss.
- Patients should perform UPT 3 weeks after to confirm
What happens in an incomplete miscarriage?
- partially expelled products of conception
- Diagnosed on USS – usually see mixed echoes within the uterine cavity
- If no previous IUP seen on USS, will require serial bHCG monitoring to ensure failing IUP.
What happens in delayed miscarriage?
- Diagnosed on transvaginal scan
- Requires visualisation of a gestation sac, yolk sac and foetal pole, with a CRL >7mm with no foetal heart activity
- This should be conformed by a second sonographer.
- If there is any doubt regarding diagnosis then arrange a repeat USS in 1 week to confirm
expectant, medical and surgical management of miscarriage
E -allow 1-2 weeks for spontaneous delivery and repeat hcg 3 weeks after
M- misoprostol
S- manual or electric vacccum aspiration under GA if risk of infection or haemorrhage .
What is molar pregnancy?
- Type of gestational trophoblastic disease
- Complete mole caused by a single (90%) or two (10%) sperm fertilising an egg which has lost its DNA
- Complete moles have a 2-4% risk of developing in to choriocarcinoma
- Partial molar pregnancy occurs when the father supplies 2 sets of chromosomes, but mothers chromosomes are also present (e.g. 2 sperm fertilising an egg)
what does misoprostol do
softens cervix and stimulates uterine contractions
What is the management of molar pregnancy?
- Diagnosed on USS by visualisation of an irregular echobright area containing multiple cysts – bunch of grapes sign.
- Management is surgical only
- Increased risk of bleeding
- Send POC for urgent histology
What happens in ovarian torsion?
- Occurs when the ovary, and sometimes the fallopian tube twists on its vascular and ligamentous supports
- This blocks adequate blood flow to the ovary
- Surgical emergency – much like testicular torsion
- Most commonly seen in women of reproductive age, and it can occur in pregnancy
What is the management of ovarian torsion?
Commonly presents with:
Severe abdominal pain
Nausea and vomiting
Often non-specific
May note an enlarged ovary on USS
Definitive management is surgical – may require oophrectomy if ovary necrotic. Detorsion is preferred.
What is a cyst accident
Includes rupture, haemorrhage and torsion
Cyst rupture and haemorrhage usually occur with functional cysts, and are generally self-limiting.
Occasionally laparoscopy may be required if the diagnosis is uncertain, or if the patient is haemodynamically unstable.
What is pelvic inflammatory disease?
Infection of the female reproductive system:
Uterus
Fallopian tubes
ovaries
What are the symptoms of pelvic inflammatory disease?
Often asymptomatic, but symptoms can include:
pelvic pain
Dyspareunia
Dysuria
IMB/PCB
Change to vaginal discharge
Risk factors,causes and treatment of PID
Risk Factors
UPSI
IUS/IUD
Multiple sexual partners
Causes
Bacterial infection, usually sexually transmitted e.g. chlamydia, gonorrhoea or mycoplasma
Treatment
14 day course of antibiotics – IM ceftriaxone single dose plus PO metronidazole and doxycycline
Avoid SI until patient and partner completed treatment
most common causing organisms of pid
CHYLAMIDIA
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis
features of PID
lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation
A large-for-dates uterus is highly indicative
MOLAR PREGNANCY
