Pelvic Pain Flashcards
Define ectopic pregnancy
Ectopic pregnancy is the implantation of a pregnancy outside the endometrial cavity.
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In the UK, 11 maternal deaths were attributed to ectopic pregnancy in the last triennial CMACE report.
List types of ectopic pregnancy
Tubal 98% of ectopic.
haematosalpinx, tubal miscarriage, rupture
Pain (prostaglandins and blood in the peritoneal cavity).
fimbrial end (5%), ampullary section (80%), isthmus (12%),
Ovarian ectopic pregnancy
Very rare.
Laparoscopy with ovarian sparing, or medical management are the treatments of choice
Interstitial pregnancy
1–2% of ectopic pregnancies implant in the interstitial part of the tube
Morbidity higher (more vascular, more difficult to treat surgically).
Cornual pregnancy
Implantation in arudimentary horn of a bicornuate uterus.
Scar pregnancy
Abnormally adherent placenta with subsequent heavy bleeding and the high risk of uterine rupture
Abdominal ectopic pregnancy
Implantation on any organ within the peritoneal cavity. Delivery of a live baby by laparotomy have been reported
What is the incidence of ectopic pregnancy
The incidence of ectopic pregnancy in the UK is approximately 1% .
Ectopic pregnancy rates have been strongly linked to trends in pelvic inflammatory disease or, more specifically,
Chlamydia trachomatis infection.
How is ectopic diagnosed?
The assessment and diagnosis of ectopic pregnancy is achieved using some or all of the following:
history and examination findings ultrasound investigations
quantitative serum β-HCG measurements laparoscopy findings
How is an ectopic excluded on USS?
An intrauterine gestation sac is highly specific (99%) for exclusion of an ectopic pregnancy. ( errors psudosac, heterotopic)
Transvaginal scanning can identify most intrauterine pregnancies from when the hCG level reaches 1000 iu/l (the discriminatory level).
Early intrauterine pregnancy I
include an intrauterine sac with an echogenic rim.
A confirmed gestation sac include a yolk sac, fetal pole and fetal heart beat.
How are Serial β HCG used to diagnose ectopic?
In early viable intrauterine pregnancies, the level of serum doubles (rises by 66% or more) approximately every 2 days
In failing intrauterine and continuing ectopic pregnancy, the doubling time for β-hCG is usually longer.
Ectopic pregnancies with a rising β-hCG is at most risk of rupture.
How is Laparoscopy used to diagnose ectopic?
Laparoscopy is the gold-standard diagnostic tool
It involves surgical risk and should be undertaken by properly trained personnel, ideally within normal working hours.
Can miss early (small) ectopic pregnancies
Diagnosis is challenging with pelvic adhesions or hydrosalpinx.
Outline the Haemodynamic assessment for ectopic pregnacy
Haemodynamically unstable
Rapid pulse, low blood pressure and altered conscious Urgent resuscitation
Haemodynamically stable
A careful history is taken to assess risk factors
Examination for abdominal tenderness, rebound, guarding cervical excitation
Look for signs suggestive of miscarriage such as an open cervical os or passage of products of conception.
Clinical diagnosis of ectopic pregnancy prior to tubal rupture is highly unreliable.
Management of ectopic after discharge - information to give.
Inform women who have had an ectopic pregnancy that they can self-refer to an early pregnancy assessment service in future pregnancies if they have any early concerns.
Give all women with an ectopic pregnancy oral and written information about:
How they can contact a healthcare professional for post-operative advice if needed,
who this will be and
where and when to get help in an emergency
Patient selection for Expectant management of ectopic pregnancy.
Clinically stable women
ultrasound diagnosis of ectopic pregnancy decreasing b-hCG level initially less than 1500 iu/l.
Initial serum b-hCG level is a key prognostic indicator
They must be willing and able to attend for follow-up, have minimal pain,.
Success rates range from 57–100% Very dependent on case selection
Patient selection for Medical management of ectopic pregnancy.
Offer systemic methotrexate as a first-line treatment to women who are able to return for follow-up and who have all of the following:
no significant pain
an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat a serum hCG level less than 1500 IU/litre
no intrauterine pregnancy (as confirmed on an ultrasound scan).
Offer surgery where treatment with methotrexate is not acceptable to the woman
Patient selection for surgical management of ectopic pregnancy.
Offer surgery as a first-line treatment to women who are unable to return for follow-up after methotrexate treatment or who have any of the following:
an ectopic pregnancy and significant pain
an ectopic pregnancy with an adnexal mass of 35 mm or larger
an ectopic pregnancy with a fetal heartbeat visible on an ultrasound scan an ectopic pregnancy and a serum hCG level of 5000 IU/litre or more.
Patient selection for Surgery /Methotrexate management of ectopic pregnancy.
Offer the choice of either methotrexate or surgical management to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/litre and less than 5000 IU/litre, who are able to return for follow-up and who meet all of the following criteria:
no significant pain
an unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat no intrauterine pregnancy (as confirmed on an ultrasound scan).
Advise women who choose methotrexate that their chance of needing further intervention is increased and they may need to be urgently admitted if their condition deteriorates.
How is ectopics managed surgically?
When surgical treatment is indicated for women with an ectopic pregnancy, it should be performed laparoscopically whenever possible, taking into account the condition of the woman and the complexity of the surgical procedure.
Surgeons providing care to women with ectopic pregnancy should be competent to perform laparoscopic surgery.
When is laparotomy indicated over a laparoscopic approach in surgical management of ectopic?
Laparoscopic approach should be used if the patient is stable and providing suitably trained medical personnel are available.
Laparotomy is recommended in collapsed cases of ruptured ectopic pregnancy unless a very experienced laparoscopic surgeon is performing the surgery.
When should salpingectomy be offered to women with an ectopic pregnancy?
Offer a salpingectomy to women undergoing surgery for an ectopic pregnancy unless they have other risk factors for infertility.
Consider salpingotomy as an alternative to salpingectomy for women with risk factors for infertility such as contralateral tube damage.
Inform women having a salpingotomy that up to 1 in 5 women may need further treatment. This treatment may include methotrexate and/or a salpingectomy.
For women who have had a salpingotomy, take 1 serum hCG measurement at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained.
Advise women who have had a salpingectomy that they should take a urine pregnancy test after 3 weeks. Advise women to return for further assessment if the test is positive.
How does methotrexate work in the management of ectopic pregnancy? what are the advantages of methotrexate?
Methotrexate is the most widely reported medical therapy for ectopic pregnancy.
It acts as a folic acid antagonist interfering with DNA synthesis. It can be administered systemically (intravenous, intramuscular and oral) or locally (ultrasound, laparoscopic or hysteroscopic guided).
Approximately 80–92% of appropriately selected unruptured non-live ectopic pregnancies will respond to methotrexate therapy and resolve without the need for an operation.
Methotrexate vs Surgery
avoidance of the need for admission and an operation,
and the preservation of the uterine tube,
no difference has been reported in future pregnancy rates.
Indicators that patient is Suitable for Medical management of ectopic?
Clinically stable with no evidence of intraperitoneal bleeding Ectopic sac <3.5 cm
No fetal heart seen on scan
β-hCG <5000
Empty uterus
No medical contraindications Will accept blood products Compliant with follow-up plan Wants conservative management
How do we know if management of ectopic is failing?
How do we know if treatment is failing
Significant increase in abdominal pain suggesting rupture Signs of a haemoperitoneum
Increase in β-hCG at day 7
β-hCG decline on day 7 that is not >15%
β-hCG levels rise or fail to fall further after the first 7 days of treatment.
Define Chronic pelvic pain
Intermittent or constant pain in the lower abdomen or pelvis of at least 6months in duration
not exclusively with menstruation or intercourse
and not associated with pregnancy
‘It is a symptom not a diagnosis’
List zCauses of chronic pelvic pain
Enometriosis Uterine fibroids Pelvic inflammatory disease Adhesions ovarian cysts
Gastrointestinal causes of chronic pelvic pain
Irritable bowel syndrome
Diverticulitis
Appendicitis
Urological causes of chronic pelvic pain
Interstitial cystitis
Urinary tract tinfection
Kidney stones
Adenomyosis-symptoms
Pelvic pain
Dyspareunia
Dysmenorrhea
Menorrhagia
Adenomyosis-Treatment
- Same as endometriosis
- Pseudo-pregnancy state
- Pseudo-menopause state
- Mirena intra-uterine system
- Hysterectomy
Define Pelvic Inflammatory Disease
Acute and subclinical infection of the upper genital tract in women, involving any or all of the: Uterus Fallopian tubes Ovaries Neighbouring pelvic organs
What are the complications of PID
Endometritis Salpingitis Tubo-ovarian abscess Perihepatitis Oophoritis Peritonitis
Investigations for chronic pelvic pain
1. High vaginal swab Bacterial vaginosis Trichomonas vaginalis Candida 2.Endocervical swab Gonorrhoea Chlamydia 3. Chlamydia
Positive swabs support the diagnosis Negative swabs do not exclude it!
Management of PID
- Antibiotics (oral/intravenous)
* Laparoscopy(no response to therapy/severe disease
What are the complications of Ovarian cysts
Torsion
Rupture
Pressure symptoms
Investigations of ovarian cysts
History and examination
Ultrasound imaging
MRI if nature of the cyst is uncertain
List types of ovarian cysts
Dermoid cysts Haemorrhagic cyst Mucinous cyst Endometriotoc cyst simple cysts
Management of ovarian cysts
Laparoscopic ovarian cystectomy
Conservative follow up depending on symptoms
What are the causes of adhesions?
Previous pelvic/abdominal surgery Pelvic inflammatory disease
Management-adhesions
Laparoscopic adhesiolysis
Conservative- with involvement of the pain team
Define Pelvic venous congestion
Retrograde flow through incompetent valves- ovarian varicosities Pelvic ache and heaviness- worse pre-menstrually, with prolonged
standing or sitting
Diagnosis- pelvic venography, CT scan, MRI, ultrasound, laparoscopy
Treatment- Progestogens, GnRH analogues, ovarian vein embolization/ligation, hysterectomy with bilateral salpingo- oophorectomy
Management of Pelvic floor pain syndrome
Spasm and strain of pelvic floor muscles
Treatment- Biofeedback, pelvic floor physical therapy, TENS (Transcutaneous electrical nerve stimulation) units, anxiolytic medications
Botulinum toxin (botox) injections
How is Irritable bowel syndrome treated
Treatment
Anti-diarrhoeals and antispasmodics Antidepressants
Serotonin receptor antagonists
Dietary changes
Cognitive psychotherapy/decrease stress
Define Interstitial cystitis
Chronic inflammation of the bladder
Increased bladder permeability due to loss of mucosal surface
protection of the bladder
Present in 38-85% women presenting with chronic pelvic pain Symptoms- urinary frequency
Interstitial cystitis
Diagnosis-
Diagnosis- Double fill cystoscopy
Presence of glomerulations- (Hunners ulcers) Intra-vesicular potassium sensitivity test
interstitial cystitis- treatment
Antibiotics and Analgesics
Anti-depressants
Antihistamines
Elmiron (pentosane polysulphate sodium)- FDA approved
Nerve stimulation- TENS
Bladder filling- with DMSO (dimethyl sulfoxide) with local anesthetic, weekly for 6-8 weeks then maintenance every two week for upto a year.
Surgical- fulguration, resection, bladder augmentation
Management of Psychosocial causes of chronic pelvic pain
40-50% of women with chronic pelvic pain have a history of abuse (physical, verbal, sexual)
Psychosomatic factors
Treatment
Psychotropic medication, therapy MULTIDISCIPLINARY PAIN CLINIC
Define endometriosis
‘Functioning endometrial glands and stroma outside the uterus’
Adenomyosis (within muscle)
Endometriosis
(outside cavity and muscle)
Prevalence of endometriosis
5% women in the reproductive age range
25-50% infertile women
50% women with chronic pelvic pain
Investigation of endometriosis
Diagnostic imaging for endometriosis Ultrasonography Mostly to see endometriomas Can assess (lack of) organ movement
MRI 90% sensitivity and 91% specificity Best non-invasive test Can be used for follow up Best for pigmented lesions that contain blood Adhesions not directly seen, only distortions identified
Laparoscopy (gold standard Ix) - views
Stages of endometriosis
stage 1 minimal
2 mild
3 modertate
4 severe
Medical treatment of endometriosis
Pregnancy like state with Progestogens
Menopause like state with GnRH analogues
Surgical management of endometriosis
Ablation is like burning or destroying the tops of weeds
Roots remain….and weeds come back
Excision is like trowelling out the whole plant
Acute presentations of ovarian Cysts
- Rupture
- Hemorrhage
- Torsion
Assessment of query ovarian cyst
- Examination: Abdominal, vaginal
- FBC, CRP,
- USS
- Tumour markers
Common ovarian masses: Premenopausal
- Follicular/lutein cysts
- Dermoid
- Endometrioma
- Benign epithelial tumour (serous, mucinous)
Common ovarian masses: Postmenopausal
- Benign Epithelial tumour ( serous, mucinous)
* Malignancy
What blood tests should be ordered in a women under 40 years old with a complex ovarian mass?
Lactate dehydrogenase (LDH), α-FP and hCG should be measured in all women under age 40 with a complex ovarian mass because of the possibility of germ cell tumours
Best modality for evaluating ovarian mass
A pelvic ultrasound is the single most effective way of evaluating an ovarian mass
Management of premenopausal ovarian cysts
Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.
Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.
Ovarian cysts that persist or increase in size are unlikely to be functional and may warrant surgical management.
