TOA/PID/Ectopic

Question 1

A 25 year old woman presents to the ED with worsening L sided pelvic pain, a L iliac fossa mass and vaginal discharge. How would you assess and manage her?

Answer 1

Impression
In this setting I would first want to rule out Red Flag presentations such as ectopic pregnancy +/- rupture. However, would also provisionally concerned about PID and/or a TOA.

Other DDx to consider;

• gynae: ovarian torsion, ruptured ovarian cyst
• GIT: diverticulitis +/- abscess, neoplasia (unlikely)
• Renal

Goals

• targeted Hx/Ex/Ix, rule out red flag differentials, looking for shock secondary to abscess or rupture ectopic
• appropriate dispositioning and empirical treatment, referral to O&G

Question 2

TOA/PID/Ectopic - Assessment

Answer 2

Assessment

- initially call for senior help and take A to E approach to ensure HD stable before proceeding

Question 3

TOA - History

Answer 3

History

• sx: pain (SOCRATES), acute vs gradual onset. nature of vaginal discharge - blood/purulent, odour? volume?
• assoc: bowel/urinary habit changes, PR bleeding
• sexual history, menstrual history, contraceptive method
• CST/STI screening
• PMHx, past O&G hx

Question 4

TOA - Examination

Answer 4

Examination

• General appearance + vitals
• abdominal exam: tenderness, free abdo fluid, peritonitis, mass
• Speculum examination for origin of discharge + other diagnostic features, then endocervical swab for STI and opportunistic CST if not already done
• Bimanual palpation: cervical motion tenderness, adnexal mass

Question 5

TOA - Investigations

Answer 5

Investigations

• Bedside: UA, urine ß-HCG
• Bloods serum ß-HCG, FBC, UEC, CRP/ESR, cultures for ? sepsis. endocervical swab for PCR, ?rest of septic screen
• Imaging: TV IS for ectopic/free fluid/abscess, consider pelvic CT (if not pregnant and diagnostic uncertainty)

Question 6

TOA - Management

Answer 6

Management
- O&G referral, usually in-patient management

Supportive

• analgesia
• fluids (resus if shocker initially)
• NBM for ?surgical treatment

Definitive

• ABX coverage for PID (metro + doxycycline + ceftriaxone)
• Ectopic: depends if stable vs unstable (surgery +/- methotrexate)
• TOAPID: abscess drainage, ABx, PHU notification, contact tracing, treatment of sexual partners