Gynaecology emergencies Flashcards
What is an ectopic pregnancy
Pregnancy that occurs when the fertilised egg implants outside of the uterus
Where is the most common location of an ectopic pregnancy
fallopian tube - 90%
Give 5 RFs for an ectopic pregnancy
- Previous ectopic
- previous STI/ PID
- endometriosis
- age >35
- IUD (coils etc)
What investigations would you do when suspecting ectopic pregnancy
- Urine pregnancy test (hcg)
- BHCG
- transvaginal ultrasound
Give 5 ways an ectopic pregnancy may present
- PV bleeding
- unilateral low abdominal pain
- shoulder tip pain (peritonitis)
- dizziness
- missed period
- cervical excitation
What are the possible findings of an ectopic pregnancy on an ultrasound
- adnexal mass moving separately to the ovary comprising of gestational sac +/- fetal pole
- free fluid may be seen
State the 3 options for terminating an ectopic pregnancy
- Expectant management - natural termination
- Medical management
- Surgical management
Describe expectant management for an ectopic pregnancy
- Repeat BHCG on day 2,4 and 7
- If BHCG reduced by 15% each 48h then can repeat weekly until <20iu
What is the criteria for expectant management of an ectopic pregnancy
- clinically stable pt w no significant pain
- unruptured ectopic
- adnexal mass < 35mm with no fetal pole
- BHCG < 1000iu
- pt able to return for follow up
What drug is used in the medical management of an ectopic pregnancy
IM methotrexate
What is the criteria for medical management of an ectopic pregnancy
- no significant pain + clinically stable
- unruptured ectopic <35mm
- confirmed absence of intrauterine pregnancy
- can return for follow up
- BHCG < 1500iu
What are the two options for surgical management of ectopic pregnancy
- laparoscopic salpingectomy (1st line) - whole tube w ectopic
- laparoscopic salpingostomy - just ectopic removed
When is surgical management first line for an ectopic pregnancy
- significant pain
- adnexal mass > 35mm
- live/ ruptured ectopic
- HCG >5000iu
- haemodynamically unstable
When should salpingostomy be considered over salpingectomy for removing an ectopic and why
Salpingostomy should be considered for women with contralateral tube damage, as this is a risk factor for infertility
What is a miscarriage
Involuntary, spontaneous loss of a fetus before 24 weeks
Describe a complete miscarriage (presentation, cervical Os, USS findings)
- PV bleeding and passing of products of conception
- Open/ closed cervical Os depending on stage
- USS: empty uterus
Describe an incomplete miscarriage (presentation, cervical Os, USS findings)
- Heavy bleeding inc some passing of products
- Os: open
- USS: retained tissues
Describe a threatened miscarriage (presentation, cervical Os, USS findings)
- mild PV bleeding, some abdo pain, intact membranes
- Os: closed
- USS: viable intrauterine pregnancy detected
Describe a missed miscarriage (presentation, cervical Os, USS findings)
- asymptomatic
- Os: closed
- USS: nonviable pregnancy, retained products with no fetal heartbeat or empty gestational sac
Describe an inevitable miscarriage (presentation, cervical Os, USS findings)
- Pv bleeding and abdo pain +/- intact membranes
- Os: open
- USS: gestational sac in the uterus without fetal HB or other signs of a non-viable pregnancy.
How is a miscarriage managed conservatively
- allow miscarriage to occur spontaneously
- bHCG - decrease of >50% in 48h indicates early pregnancy loss
- repeat UPT in 3 weeks to confirm miscarriage is complete
- follow up USS (1w) for threatened/ inevitable miscarriages
Describe the medical management of a miscarriage
- Mifepristone followed by misoprostol 48h later for missed miscarriage
- single dose oral/ vaginal misoprostol for others
- analgesia
- anti-emetics
- UPT after 3w to confirm
What are the two types of surgical management for a miscarriage
- Manual vacuum aspiration under local anaesthetic
- Electric vacuum aspiration under general anaesthetic
Why is infection more common in an incomplete miscarriage
retained products of conception create a risk of infection
treat with abx
What are molar pregnancies
- chromosomally abnormal pregnancies that have the potential to become malignant (gestational trophoblastic neoplasia)
What is a complete mole
occurs when a single sperm (90%) or two sperm cells fertilise an egg that has lost its DNA (“empty ovum”)
What is a partial mole
- occurs when two sperm cells fertilise a normal ovum (has DNA) at the same time
- new cell now has three sets of chromosomes
How is a molar pregnancy diagnosed, give findings
- Pelvic ultrasound - irregular echobright area containing multiple cysts (snowstorm appearance)
- serum hCG - significantly elevated for gestational age
How does a molar pregnancy typically present
- vaginal bleeding
- uterus size greater than expected for gestational age
How is a molar pregnancy managed
- send POC for histology urgently to confirm
- surgery - suction evacuation of uterus to remove mole
Molar pregnancies are at an increased risk of developing into which cancer
choriocarcinoma - part of the gestational trophoblastic tumours
What is ovarian torsion
Twisting of the ovary and/ or fallopian tube on its vascular and ligamentous supports
Why is ovarian torsion an issue
It can block adequate blood flow to the ovary
Give 3 ways ovarian torsion may present
- severe pelvic/ abdo pain
- N+V
- diarrhoea
(non- specific)
What imaging should be done for a suspected ovarian torsion
- urgent transvaginal ultrasound - enlarged ovary, free fluid, whirlpool sign
- abdo/ transrectal USS for children/ pt who haven’t been sexually active
How is ovarian torsion managed
laproscopic surgery
* immediate surgical detorsion
* salpingo-oophrectomy if ovary is non-viable
What is the definitive diagnostic tool for ovarian torsion
Surgical visualisation
What is pelvic inflammatory disease
Infection within the female reproductive system
* inc: endometrium, fallopian tubes, ovaries, uterus
How might PID present
- abnormal cervical/ vaginal discharge
- lower abdo pain
- dyspareunia
PID can be diagnosed by clinical exam. Give 3 findings on pelvic examination.
- uterine tenderness
- cervical motion tenderness
- adnexal tenderness (endometritis)
Give 4 RFs of PID
- unprotected sex
- previous chlamydia, gonorrhoea or PID
- Multiple sexual partners
- IUD use
How is PID investigated
- STI screen
- pregnancy test - exclude ectopic
- CRP/ ESR - raised = support diagnosis
What typically causes PID
Bacterial infection - mc STI
* Gonorrhoea
* chlamydia (mc)
How is PID managed
- Swabs to confirm causative agent
- single dose IM ceftriaxone + PO doxycycline and metronidazole for 14 days
- contact tracing
- advice: avoid sex until patient and partner complete treatment
What bacteria does each antibiotic cover in the treatment of PID
- Ceftriaxone - gonorrhoea
- doxycycline - chlamydia and mycoplasma genitalium
- metronidazole - anaerobes eg. gardnerella vaginalis (bv)
