Gynaecological emergencies

Question 1

What is an ectopic pregnancy

Answer 1

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

Question 2

What are the risk factors for ectopic pregnancy?

Answer 2

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

Question 3

What are the symptoms of ectopic pregnancy?

Answer 3

PV bleeding​

Abdominal pain, typically to one side​

Shoulder tip pain​

Dizziness​

Sometimes none at all

Question 4

How do we diagnose ectopic pregnancy ?

Answer 4

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)

Question 5

What are the sites of implantation of ectopic pregnancy?

Answer 5

Ampulatory - 70&
Isthmic - 12%
Fimbrial - 11%
Interstitial - 2-4%
Ovarian - 3%
Abdominal - 1%

Question 6

What is a tubal ectopic in ectopic pregnancy?

Answer 6

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

Question 7

which implantation site has the highest risk of rupture

Answer 7

isthmic

Question 8

What are the 3 options for ectopic pregnancy management?

Answer 8

Conservative​
Medical​
Surgical

Question 9

What is the conservative management for ectopic pregnancy?

Answer 9

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.

Question 10

What is the medical management for ectopic pregnancy?

Answer 10

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

Question 11

Issues with medical management of ectopic pregnancy?

Answer 11

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

Question 12

Who is surgical management first line in for ectopic pregnancy?

Answer 12

• Have significant pain​
• Adnexal mass >35mm​
• Live ectopic​
• HCG >5000​
• Signs of rupture​
• Haemodynamic instability

Question 13

What happens in surgical management of ectopic pregnancy?

Answer 13

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

Question 14

What happens in a complete miscarriage?

Answer 14

• 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

Question 15

What happens in an incomplete miscarriage?

Answer 15

• 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.

Question 16

What happens in delayed miscarriage?

Answer 16

• 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

Question 17

expectant, medical and surgical management of miscarriage

Answer 17

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 .

Question 18

What is molar pregnancy?

Answer 18

• 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)

Question 19

what does misoprostol do

Answer 19

softens cervix and stimulates uterine contractions

Question 20

What is the management of molar pregnancy?

Answer 20

• 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

Question 21

What happens in ovarian torsion?

Answer 21

• 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

Question 22

What is the management of ovarian torsion?

Answer 22

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.

Question 23

What is a cyst accident

Answer 23

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.

Question 24

What is pelvic inflammatory disease?

Answer 24

Infection of the female reproductive system:
Uterus
Fallopian tubes
ovaries

Question 25

What are the symptoms of pelvic inflammatory disease?

Answer 25

Often asymptomatic, but symptoms can include:
pelvic pain
Dyspareunia
Dysuria
IMB/PCB
Change to vaginal discharge

Question 26

Risk factors,causes and treatment of PID

Answer 26

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

Question 27

most common causing organisms of pid

Answer 27

CHYLAMIDIA
Neisseria gonorrhoeae
Mycoplasma genitalium
Mycoplasma hominis

Question 28

features of PID

Answer 28

lower abdominal pain
fever
deep dyspareunia
dysuria and menstrual irregularities may occur
vaginal or cervical discharge
cervical excitation

Question 29

A large-for-dates uterus is highly indicative

Answer 29

MOLAR PREGNANCY