Vaginas are SCARY …

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

2. Gynaecology in the ED • https://youtu.be/3HwJ_0BSN8k

3. 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

4. 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 bHCG is NEGATIVE, it is NOT an ectopic pregnancy

5. 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

6. What is PID? • Inflammation of female pelvic structures • Ascending spread of infection from the 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

7. 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)

8. 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

9. PID Risk Factors • Age of 1st 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)

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Endometriosis Investigations • Physical examination • There may be tender nodules in the uterosacral ligaments • Ultrasound • Of little value unless there are endometriomas • Menstrual phase Ca125 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

17. 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 3m continuously • But the Mirena IUS and sometimes Depot Provera has a role

18. 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

19. 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 cervixetc • With removal of stimulus rapid recovery usually follows

20. 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

21. bHCG • Threshold βHCG – level at which intrauterine gestational sac can be seen with TVUS • 1000-2000IU/L (6500IU/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

23. Assessment of Early Pregnancy • Quantative pregnancy test (useful if uterine pregnancy prev. confirmed on USS but suspected fetaldemise 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

24. Cervical shock • Call for help & move to resus/monitored bay. • IV access and bloods if not already taken. • 500mL – 1L 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, consideAtropine 600mcg (rpt to 3mg) if persistantly bradycardic and hypotensive

25. ? 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

27. 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)

28. Treatment of Ectopic • Surgery • Unstable • fluid resucitation, Large lines bilaterally, Massive transfusion protocol as req. • Urgent Gynaecology review, anaethetics, theatres • Large >3.5cm • peritonitis • Medical (Methotrexate) or conservative • no peritonitis • < 3.5cm • no free fluid on USS • ability to closely monitor as an outpatient

29. DUB • Norethisterone (Primolut) 5mg tablets • Weaning schedule • 10mg QID => 10mg TDS => 10mg BD => 5mg BD • TXA 1g QID for 4-5 days • NSAIDs esp if pain => reduction in blood loss by 30-40% • Consider COCP • Treat anaemia (? PRBC vs iron infusion vs oral Fe)