Vaginas are SCARY Gynaecology HMO Teaching April 2018

Vaginas are SCARY … Gynaecology HMO Teaching April 2018 Dr Sarah Cox Senior O&G Registrar

Gynaecology in the ED • https: //youtu. be/3 Hw. J_0 BSN 8 k

Acute pelvic pain • In the emergency assessment of women of reproductive age it is important to exclude: – Ectopic pregnancy – Acute PID – Ovarian cyst – Endometriosis • And you may be left with a diagnosis of Primary Dysmenorrhoea

Investigation with USS • Unless you are suspecting appendicitis, intermittent ovarian torsion or a tubo-ovarian abcess, there is VERY LITTLE role for URGENT ED investigation for pelvic pain in non-pregnant, fertile females • If the b. HCG is NEGATIVE, it is NOT an ectopic pregnancy

PID • Diagnosis requires a patient at risk • Usually younger patient (15 – 25 years) • New partner or multiple partners • Or a partner at risk e. g. one that travels • • It is a bilateral disease Pelvic peritoneal tenderness is a subtle sign WCC & ESR or C-reactive protein can be useful Requires careful microbiology • Test for all STD’s simultaneously • A role for laparoscopy in diagnosis

What is PID? • Inflammation of female pelvic structures • Ascending spread of infection from the cervix through the uterus, to fallopian tubes, ovaries and adjacent peritoneum • Upper genital tract infection • It is not infection in the vagina or vulva

Two types of PID • Acute • • Patient has generalised symptoms Lasts a few days May recur in episodes Very infectious in this stage • Chronic • • Patient may have no symptoms Occurs over months and years Progressive organ damage & change May burn out (arrest)

Causes of PID • 85 – 95% is due to specific sexually transmitted organisms • Neisseria gonorrhoea • Chlamydia trachomatis • Others e. g. Mycoplasma species • 5 – 15% begins after reproductive tract damage • From pregnancy • From surgical procedures e. g. D&C • Includes insertion of IUCD

PID Risk Factors • • Age of 1 st intercourse Number of sexual partners Number of sexual contacts by the sexual partner Cultural practices • Polygamy, • Sex workers • Attitudes to menstruation and pregnancy • • Frequency of intercourse (Age) IUCD design Poor health resources Antibiotic exposure (resistance)

PID • Requires a high index of suspicion in a patient “at risk” when there is: • • Lower abdominal pain (90%) Fever (sometimes with malaise, vomiting) Mucopurulent discharge from cervix Pelvic tenderness • Tests • • Raised WCC Endocervical swab for organisms or PCR Ultrasound evidence of pelvic fluid collections Laparoscopy

Fitz-Hugh-Curtis Syndome • • Perihepatic inflammation & adhesions Occurs with 1 – 10% acute PID Causes RUQ and pleuritic pain May be confused with cholecystitis or pneumonia

Ovarian cysts • Very common • But not always the source of pain • Pain can be due to: • • Rapid enlargement Rupture Haemorrhage - typical of the corpus luteum Torsion (rare) • Ultrasound is both a boon and a bane because • • Paraovarian cysts • Mesenetric cysts & Adhesive collections • Hydrosalpinx, Bladder or even Ureter May be imaged but do not cause acute pain

Functional Ovarian cysts • Not uncommon with Mirena • Ignore alarming reports from the radiologist • If the patient is <50 then it is usually benign • Analgesia, observation and reassurance is best • Repeat scan in 3 – 4 months • Can use COC to suppress the ovaries and prevent confounding “cysts” appearing • Laparoscopy, drainage and biopsy rarely required

Ovarian Torsion • Almost always associated with ovarian pathology • Presents as “reverse renal colic” (groin to loin) • May present with acute abdomen • Pulls cervix to the side of the torsion • Usually requires ovarian cystectomy or unilateral salpingo-oophorectomy

Endometriosis • Common • As many as 1: 4 women if your diagnostic criteria are liberal • The “At Risk” Individual • Has delayed pregnancies • Family history common • Cardinal symptoms are: • • • Dysmenorrhoea Dyspareunia Infertility Premenstrual staining Pain with defaecation during menstruation

Endometriosis Investigations • Physical examination • There may be tender nodules in the uterosacral ligaments • Ultrasound • Of little value unless there are endometriomas • Menstrual phase Ca 125 may be used • But has poor sensitivity • Laparoscopy required for diagnosis • There is a poor correlation between findings and symptoms • Debate as to the role of biopsy in diagnosis • Treatment • Medical for pain but surgery for infertility

Primary dysmenorrhoea • Is not associated with any pelvic pathology • Also called “spasmodic dysmenorrhoea” • • • Typically a teenager but can occur in the 40's too Worse before and on the day of first flow Accompanied by pallor, prostration & diarrhoea Relieved by NSAIDs in effective doses Best managed with combined OC • Which can be given for up to 3 m continuously • But the Mirena IUS and sometimes Depot Provera has a role

Bleeding in Early Pregnancy • Early pregnancy; is defined as a pregnancy of less than 20 weeks gestation. • It is sometimes referred to as 'nonviable', however this term is not acceptable to patients as their baby is alive. • Speculum examination in early pregnancy is ED investigation and management for bleeding

Cervical shock • Patient has PV bleeding and is hypotensive suspect cervical shock • Vasovagal syncope produced by acute stimulation of the cervical canal during dilatation • POC, instrumentation of cervix etc • With removal of stimulus rapid recovery usually follows

Miscarriage • 25% pregnancies <24/40 • Threatened – Closed os – Viable pregnancy on USS • Inevitable – Bleeding and open os • Incomplete – POC seen in uterus on USS – Early foetal or embryonic demise • Complete – POC, witnessed and not seen in uterus on USS – Bleeding and pain have ceased or are setting

b. HCG • Threshold βHCG – level at which intrauterine gestational sac can be seen with TVUS • 1000 -2000 IU/L (6500 IU/L for TAUS) • β-HCG – First 60 days (weeks 4 -8) doubles every 1. 4 to 2. 1 days • Taking two β-HCG 48 hours apart can be helpful • <20% increase or a reduction it is 100% sensitive for foetal demise or ectopic • If β-HCG >50, 000 ectopic pregnancy very unlikely

Assessment of Early Pregnancy • Quantative pregnancy test (useful if uterine pregnancy prev. confirmed on USS but suspected fetal demise or heterotopic HOWEVER USS is preferred in this instance) • LMP and menstrual history • Bleeding - amount, compared to usual period, any clots/tissue • Previous ectopic, PID, operation on fallopian tube, pregnancy whilst using IUD • Pain - severity and site • Establish physiological status, examine abdomen • Keep fasting • Analgesia • Group and hold esp Rh status for ? Anti-D

Cervical shock Call for help & move to resus/monitored bay. IV access and bloods if not already taken. 500 m. L – 1 L saline stat. Speculum examination ASAP - if products in cervical os remove • If tissue small sweep os with gauze in sponge holding forceps. If large: insert forceps closed, open, grasp tissues, rotate and remove. • If unable to remove, conside Atropine 600 mcg (rpt to 3 mg) if persistantly bradycardic and hypotensive • •

? To exam PV or not • PV exam is controversial • Used to determine if cervical os open v closed, pain in adnexae, palpable masses • Largely replaced with BHCG and ultrasound in cases of spotting / very light bleeding • If any concerns regarding products within cervix then a speculum exam must be performed

Ectopic pregnancy • PV bleeding esp. 6 -8 weeks LMP • abdominal/pelvic pain, shoulder tip pain (large amount of bleeding) • Lightheaded or postural symptoms • Examination – unilateral pelvic tenderness (+/- PV state of cervix, adnexal tenderness +/- masses)

Treatment of Ectopic • Surgery – Unstable – fluid resucitation, Large lines bilaterally, Massive transfusion protocol as req. – Urgent Gynaecology review, anaethetics, theatres – Large >3. 5 cm – peritonitis • Medical (Methotrexate) or conservative – – no peritonitis < 3. 5 cm no free fluid on USS ability to closely monitor as an outpatient

DUB • Norethisterone (Primolut) 5 mg tablets – Weaning schedule – 10 mg QID => 10 mg TDS => 10 mg BD => 5 mg BD • TXA 1 g QID for 4 -5 days • NSAIDs esp if pain => reduction in blood loss by 3040% • Consider COCP • Treat anaemia (? PRBC vs iron infusion vs oral Fe)