Pelvic pain Flashcards
Where is the most common site for an ectopic pregnancy to implant?
Ampulla
What are the risk factors for ectopic pregnancy?
PID Endometriosis Previous ectopic IUD/IUS Tubal surgery Previous pelvic surgery IVF
What is the classical sign of an ectopic pregnancy?
Prune juice discharge
What are typical findings on bimanual in ectopic pregnancy?
CMT
Adnexal tenderness
How is an ectopic pregnancy diagnosed?
- Positive urinary hCG
- Transabdominal and transvaginal USS show no IU pregnancy
- Serum hCG >1500 = ectopic until proven otherwise
How should serum hCG be interpreted in ectopic pregnancy?
1500+ = ectopic until otherwise proven Less than 1500: serial hCGs performed Viable pregancy: hCG doubles every 48hrs Miscarriage: hCG halves every 28hrs Outside of these limits (rise or fall): treat as ectopic
What are the main treatment and conditions for these in ectopic pregnancy?
Expectant: stable patient with low hCG. Serial hCGs to check falling by 50% every 48hrs.
Medical: IM methotrexate. Stable patient with hCG under 1500. Serial hCGs to show decline. Repeat dose if not declining.
Surgical: if 1500+ or unwell
Salpingectomy: preferred
Salpinotomy: if contralateral tube damaged and wish to preseve fertility
Following the management of an ectopic pregnancy, when should a urinary pregnancy test show a negative result?
After 4wks
What is the most common benign ovarian cyst?
Follicular cyst
What type of ovarian cyst occurs most commonly in woman with endometriosis?
Endometrioid cysts (chocolate cysts)
What type of ovarian cyst occurs most frequently in young and pregnancy women?
Dermoid cyst (germ cell tumour, teratoma)
Which blood markers should be measured in women under 40 with a new ovarian cyst and why?
LDH, AFP and hCG: possibility of dermoid cyst (germ cell tumour, teratoma)
What pathology would a whirlpool sign on USS show?
Ovarian torsion
What are the classical symptoms of PID?
Lower abdominal pain
Deep dyspareunia
IMB or PCB
Abnormal discharge
How is PID treated?
Doxycline PO 100mg BD 14/7
Metronidazole PO 400mg BD 14/7
Ceftriaxone IM 1000mg single dose
For what condition is Fitz-Hugh-Curtis (perihepatitis) syndrome a complication of?
PID
What is Mittelschmerz?
Cyclical lower abdominal pain occuring with ovulation
What are the cardinal symptoms of endometriosis?
Painful and heavy periods
Subfertility
Deep dyspareunia
What findings on bimanual would suggest a diagnosis of endometriosis?
Fixed and tender uterus
Retroverted position of uterus
Adnexal tenderness
What findings on bimanual would suggest a diagnosis of PI?
Adnexal tenderness
CMT
Describe the first, second and third and fourth line management for endometriosis
First line: analgesia
Second line: hormonal contraceptives (Mirena, COCP)
Third line: GnRH analogues
Fourth line: surgical interventions
What are the three layers of vaginal support?
Cervix and proximal vagina: cardinal and uterosacral ligament
Mid-vagina: fascia attaches to pelvid side wall
Lower vagina: levator ani and perineal body
What classification system is used to grade the severity of a vaginal prolapse?
Baden-Walker system
Describe the grading of a prolapse
0 = normal anatomy 1 = descent halfway to the hymen 2 = descent to the hymen 3 = descent halfway past the hymen 4 = maximum possible descent
How would a prolapse present?
Visible bulge Dragging sensation in the pelvis Pressure sensation in the vagina Urinary incontinence Sexual discomfort
How is a prolapse managed?
Conservative: if limited impact on life
Medical: pessary
Surgical: hysterectomy, repair, uterosacral ligament suspension
What is cervical stenosis
Pathological narrowing of the uterine cervix - inability to pass 2.5mm dilator through cervical os.
What are the causes of cervical stenosis?
Congenital Menopause Chronic cervicitis Trauma (e.g. due to LLETZ) Polyp Carcinoma
How might cervical stenosis present?
Largely asymptomatic
May present with haematometra, subfertility and endometriosis
How is cervical stenosis managed?
Gradual dilation of the cervix under USS
What is vulvodynia?
Chronic discomfort in the vulva without pathology or neurological disorder.
How is vulvodynia managed?
First line: topical anaesthetics, emollients, CBT.
Second line: tricyclic antidepressants, gabapentin
What is Asherman’s syndrome?
Syndrome caused by adhesions resulting in uterine adhesions and cervical stenosis
How might Asherman’s syndrome present?
Secondary amenorrhoea
Miscarriage
Infertility
Decrease in menstrual bleeding
How is Asherman’s syndrome managed?
Hysteroscopic removal or adhesions
