Pelvic pain Flashcards
Mnemonic for causes of acute pelvic pain in women.
- ECTOPIC
E ctopic pregnancy C ystic disease/rupture T orsion of ovaries O vulation (Mittleschmerz) P ID/pyelonephritis I ncomplete abortion C ystitis
A 21 year old nulliparous student presents via emergency admissions complaining of severe left iliac fossa pain. She is normally fit and well with no allergies and taking no regular medication. She had an IUCD fitted five days prior to admission for emergency contraception.
Examination reveals a tender left iliac fossa with guarding, no rebound tenderness, and no masses.
a) What is the differential diagnosis?
b) What other features in the history would support this?
c) How would you manage this case?
a) Ectopic, threatened miscarriage, PID, ovarian torsion/rupture
b) PV bleed, pregnancy test positive/period missed
c) - Admit urgently to EPAU
- A-E assessment
- Bedside: pregnancy test, urine dip (+MSU)
- General bloods: FBC, CRP, lactate, group/save, clotting, cross-match, ?amylase
- Specific bloods: serum b-HCG and progesterone
- Imaging: TVUS
- Decide on further management (expectant, medical or surgical)
Ectopic pregnancy.
a) Define
b) Risk factors
c) Triad of features (3 Ps)
d) Other possible features
e) Investigations
f) beta-hCG levels in ectopic
g) TVUS findings
a) Pregnancy occurring outside the uterus; most commonly in the Fallopian tubes
b) IVF, adhesions (eg. endometriosis), PID, previous tubal surgery (eg. salpingotomy), previous ectopic, IUCD
c) - Pain (pelvic, abdominal, shoulder tip)
- PV bleed (+/- passage of tissue)
- Period missed / Pregnancy test positive
d) - Haemodynamic instability: dizziness, syncope, tachycardia, hypotension, SHOCK
- GI symptoms: diarrhoea, nausea, vomiting
e) - Do NOT do an internal examination (risk of rupture); if done, possible signs: adnexal tenderness/mass
- Bedside: pregnancy test, urine dip (+MSU)
- General bloods: FBC, CRP, lactate, group/save, clotting, cross-match, ?amylase
- Specific bloods: serum b-HCG and progesterone
- Imaging: TVUS (gold standard)
f) Change over 48 hours of a 50% decline to a 63% rise (suggestive of ectopic - refer to EPAU)
g) - Empty uterus
- If tubal pregnancy - adnexal mass moving separate to the ovary
- If no pregnancy is found but ectopic suspected, this is termed pregnancy of unknown location (PUL)
Ectopic pregnancy: management
a) Initial management
b) Indications for expectant vs medical vs surgical Mx
c) Further monitoring
d) Side effects of medical management
e) salpingotomy vs salpingectomy
a) - Refer to EPAU urgently
- A-E: oxygen, IV access, bloods (FBC, clotting, group/save, X-match, rhesus status), fluids
- Anti-D to all rhesus-negative women
b) - Expectant: beta-hCG levels falling and patient clinically well and stable
- Medical (single-dose IM methotrexate): no pain, hCG < 1500, unruptured adnexal mass < 35 mm
- Surgical: pain, rupture, mass > 35 mm, hCG > 5000, foetal heartbeat on TVUS; or unable to return for follow-up following methotrexate treatment
c) - Bloods: b-hCG (ensure levels are dropping), LFTs (if methotrexate given)
- Vital signs, pain, etc.
d) - Abdominal pain, nausea, vomiting, diarrhoea, abnormal LFTs
- TERATOGEN - must use contraception for 6 months
e) - Salpingectomy preferred
- Salpingotomy: if other tube non-viable (endometriosis, etc.); however, risk of further ectopic at this site
PID.
a) What is it?
b) Main causes and risk factors
c) Presentation (PELVIC)
d) Investigations and findings
e) Management
f) Further management
g) Complications (acute and chronic)
h) What is Fitz-Hugh Curtis syndrome? How does it present?
a) Infection of the upper female genital tract, including the uterus, Fallopian tubes, and ovaries
b) Usually from ascending cervical infection. Most common: chlamydia, gonorrhoea
- Risk factors: new sexual partner, multiple sexual partners, lack of barrier contraception, young (20 - 29), recent IUCD fitted, recent TOP
c) Pain (pelvic, dyspareunia), Elevated temperature, Laparoscopic findings, Vaginal bleed/discharge, Inflammatory markers, Cervical motion tenderness
d) - Examination: cervical motion tenderness
- Pregnancy test - exclude ectopic
- Bloods: FBC, CRP
- endocervical swabs for chlam/gono
- TVUS: Tubo-ovarian abscess
- Laparoscopy best test but rarely used
e) - A-E assessment
- Analgesia
- ABx: Cef (IM, single dose), met + doxy (oral, 14 days)
- If severe PID (pyrexia above 38°C, clinical signs of tubo-ovarian abscess, signs of pelvic peritonitis or pregnancy), give IV
- Fail to respond: laparoscopy
f) - No unprotected sex until treatment finished
- Screen for STIs (GUM clinic follow-up)
- Sexual partner notification, screening and empirical treatment for chlamydia (single-dose azithromycin 1g)
g) - Acute: sepsis, abscess
- Chronic: Infertility, ectopic pregnancy, abscess formation and chronic pelvic pain.
h) Perihepatitis that causes liver capsular infection without infecting the hepatic parenchyma or pelvis: acute RUQ pain, fever, unwell, nausea, violin string adhesions (note: no jaundice, normal LFTs)
Acute pelvic pain assessment
a) Initial tests and management
b) Red flags
a) - Bedside: pregnancy test, swabs (EC/VV), urine dip +/- MSU
- Bloods: FBC, CRP, serum Beta-hCG, progesterone, etc.
- Imaging: TVUS, ?CT abdo (Acute abdomen - surgical review), laparoscopy if required
- Send to EPAU if in early pregnancy /suspected ectopic or miscarriage
b) - Severe pain
- Shock
- PV bleed in pregnancy
- Pregnancy test positive
Ovarian cysts (benign tumours)
a) Most common types
b) Risk factors
c) Presentation
d) Investigations
e) Use and flaws of CA-125
a) - Functional (physiological cysts; cyclical)
- Serous cystadenoma (more common in 40 - 50 yrs)
- Mucinous cystadenoma (more common in 20 - 30 yrs)
- Malignant (5%)
b) Obesity, infertility, early menarche, tamoxifen, FHx
c) - Asymptomatic;
- Pain (pelvic/back), dyspareunia, distended abdomen/ mass, pressure effects (urinary frequency, leg swelling)
- Torsion (severe sudden pain; may be intermittent)
- Rupture or haemorrhage (severe sudden pain; possible peritonism and shock if large rupture)
d) - Bedside: pregnancy test, urine dip, ?swabs
- Bloods: FBC, CRP/ESR
- Tumour markers: CA-125*, AFP/hCG (germ cell tumour)
- Imaging: TVUS
- Special tests: diagnostic lap, FNA + biopsy
e) - Not reliable in Pre-menopausal women (false negative rate high)
False positives:
- Gynae: endometriosis, menstruation, pregnancy, ovarian cysts, fibroids
- Non-gynae: diverticulitis, liver cirrhosis, other malignancy (pancreatic, bladder, breast, liver, lung)
Ovarian cyst: management
a) Uncomplicated cysts
b) Larger cysts/ symptomatic
c) Torsion
d) Rupture
a) Expectant - often physiological and resolve
b) Surgical removal: cystectomy preferable to preserve fertility in younger females
c) Untwisting and oopheropexy (or if vascular compromise - oophorectomy)
d) Oophorectomy
Miscarriage.
a) Define
b) Risk factors
c) Presentation
d) Differentials - serious and benign
a) - Loss of a pregnancy before 24 weeks* gestation
- It is either early (≤12 weeks) or late (13-24 weeks)
*Bleeding after 24 weeks = APH
Foetal death after 24 weeks = stillbirth
b) - Foetal - chromosomal, genetic, twins, TORCH
- Maternal: Age > 35, smoking, uterine abnormality, submucosal fibroids, incompetent cervix (2nd trimester), PCOS, APLS, thrombophilia, uncontrolled diabetes or thyroid disease
c) - PV bleed (+/- products of conception), pain
- Note: continuing pregnancy-associated vomiting is a GOOD sign (lower risk of miscarriage)
- Cervical os open (indicates inevitable miscarriage)
- Small for dates uterus
d) - Serious: ECTOPIC, molar pregnancy (GTD), cancer
- Implantation bleed: 7 - 14 days post-conception
- Cervical: trauma, polyp, ectropion, cervicitis
Miscarriage: classification
a) Threatened
b) Inevitable
c) Incomplete
d) Complete
e) Missed
f) Recurrent
a) Mild symptoms of bleeding. Usually little or no pain. The cervical os is closed
- 50% progress to complete miscarriage
b) Heavy bleeding with clots and pain; cervical os open; will progress to complete/incomplete
c) Products of conception are partially expelled
d) Hx of confirmed pregnancy; passage of blood; TVUS shows empty uterus
e) Dead but retained foetus; history of threatened miscarriage, dark-brown discharge, uterus small for dates
f) 3 or more consecutive miscarriages
Miscarriage: management
a) Initial management
b) Expectant
c) Medical
d) Surgical
e) Why should POC undergo histology?
a) - Urgent referral to EPAU
- A-E assessment
- Beta-hCG* (> 50% decrease over 48h = lost pregnancy, > 63% increase over 48h = continuing pregnancy)
- Progesterone (single low progesterone indicates lost pregnancy)
- Other bloods: FBC, clotting, group/save, X-match and rhesus antibodies
- Imaging: TVUS
- GTD or germ cell tumours may cause elevated hCG
b) - Indications: 1st trimester, low risk of complications
- Contraindications: coagulopathy, previous adverse event in pregnancy (miscarriage, stillbirth, ectopic, APH)
- Urine pregnancy test at 7 - 14 days
- Counsel what to expect: tissue resorption +/- PV bleed, tissue passage and pain
c) - Oral/vaginal misoprostol
- Analgesia + antiemetics PRN
- Urine pregnancy test at 3 weeks
- Risk of needing emergency surgical intervention
d) - Indications: persistent excessive bleeding, haemodynamic instability, infected RPOC, suspected GTD
- Types: vacuum evacuation or surgical removal
e) To exclude GTD
Gestational trophoblastic disease (GTD).
a) Types of pre-malignant GTD
b) Types of malignant GTD
c) Presentation
d) Investigations
e) Management
f) Counselling for future pregnancies
a) Molar pregnancy:
- Complete - sperm fertilises empty egg - only paternal genetic material present; no foetal tissue
- Partial - 2x sperm fertilise egg at same time - 2x paternal and 1x maternal present; some foetal tissue present
b) - Invasive mole: complete mole invades myometrium
- Choriocarcinoma: follows molar pregnancy or rarely a normal pregnancy, ectopic or TOP; can metastasise
c) - PV bleed, usually 1st trimester
- Hyperemesis, abnormal uterine enlargement
- Rarely, metastatic disease - respiratory/neurology Sx
d) - Bedside: pregnancy test
- Bloods: serum b-hCG
- Imaging: TVUS (snow-storm appearance), CT and MRI staging if metastatic disease suspected
- Special test: biopsy and histology to confirm diagnosis
e) - Register with specialist centre (eg. Weston Park)
- Suction curretage
- 2-weekly urine/serum beta-hCG (weekly if choriocarcinoma)
- Chemotherapy (methotrexate) if evidence of choriocarcinoma (rising hCG after evacuation, metastatic disease, histology)
f) - Not to conceive until their hCG levels have been normal for six months in molar pregnancy (or 1 year if choriocarcinoma) - use contraception
- Risk of further molar pregnancy low (< 2%)
Chronic pelvic pain.
a) Define
b) Aetiology
c) Investigations
d) Management
a) Pelvic/lower abdo pain; lasting > 6 months; not occurring exclusively with menstruation or intercourse; and not associated with pregnancy
b) - Gynae: endometriosis, adhesions, fibroids, prolapse
- Non-gynae: IBS, interstitial cystitis, MSK, functional, depression/psych
c) - Bedside: swabs (chlam/gono), pregnancy test, urine dip + MSU
- Bloods: FBC, CRP/ESR, CA-125, ?coeliac serology
- Imaging: TVUS
- Special tests: diagnostic laparoscopy, cystoscopy, bowel studies, etc.
d) MDT input
- Analgesia, CBT, physio, etc.
- Cyclical pain: trial COCP/ IUS/ GnRH agonist
A 28 year old woman is referred to the gynaecological out-patient department by her GP complaining of severe pelvic pain associated with dysmenorrhoea and dyspareunia. The pain starts three days before her period and ends one day after her period has finished. She had been taking the COCP since 16 and stopped 3 years ago. She has not conceived during this time.
a) What signs would you look for on examination?
b) What is the differential diagnosis?
c) What investigations would you undertake, and how would you manage the patient?
a) Posterior fornix/ adnexal tenderness, posterior adnexal mass, bluish haemorrhagic nodules
b) Endometriosis, mittelschmerz, PID, interstitial cystitis, fibroids (big, bulky uterus), IBS
c) - Bedside: swabs (chlam/gono), pregnancy test, urine dip + MSU
- Bloods: FBC, CRP/ESR, CA-125, ?coeliac serology
- Imaging: TVUS
- Special tests: diagnostic laparoscopy, cystoscopy, bowel studies, etc.
Endometriosis.
a) What is it?
b) Risk factors
c) Presentation - classic 4 symptoms (also timing of symptoms)
d) Signs o/e
e) Investigations
f) Management options
g) Complications
h) Compare with adenomyosis
a) Endometrial tissue outside the uterine cavity; most commonly in the tubes, ovaries and pouch of Douglas
b) Reproductive age (30s most commonly); early menarche, late menopause, delayed childbearing
(multiparity and COCP are protective)
c) Pelvic pain (cyclical or chronic), dysmenorrhoea, dyspareunia, infertility
- worsening of symptoms at the time of menstruation, or just prior to it
d) - May be normal
- Posterior fornix / adnexal tenderness.
- Posterior fornix / adnexal masses (eg ‘chocolate cysts’).
- Bluish haemorrhagic nodules
e) - Acute (exclude differentials): pregnancy test, FBC, CRP, urine dip + MSU
- TVUS - may diagnose ovarian endometrioma
- Diagnostic laparoscopy gold standard
f) - Analgesia: NSAIDs
- Fertility: support, IVF, minimally-invasive surgery
- Suppression of ovarian function for 3 months: create pseudo-menopause (COCP, IUS or GnRH agonist)
- Uterine artery embolisation
- Surgery: ovarian cystectomy, endometrium resection or ablation, oopherectomy, hysterectomy
g) Infertility, chronic pelvic pain
h) Endometriosis - younger (20-30), nulliparous women
Adenomyosis - older (40-50), multiparous women
