Acute Pelvic Pain

History requiring ectopic to be considered

- Amenorrhoea - Erratic bleeding - Lower abdominal pain/pelvic pain, dyspareunia - Abnormal bleeding in early pregnancy - Shoulder tip pain - Dizziness or fainting spell - Rebound tenderness Adnexal tenderness or cervical excitation

History in PID

- Lower abdo pain/discofort - Dyspareunia on deep penetration - Abnormal vaginal discharge - Intermenstrual or postcoital bleeding - Systemic symptoms - malaise and fever Dysuria Always consider PID and treat for same in a young sexually active woman (<25) with recent onset bilateral lower abdominal pain associated with local tenderness on bimanual examination in whom pregnancy has been excluded.

Investigations in suspected PID

- NAAT for chlamydia - Endocervical gram stain and culture for N gonorrhoea and possible anaerobes - Gonorrhoea NAAT alternative if culture unavailable - Urinary bHCG - US to exclude tubo-ovarian pathology - Testing for mycoplasma genitalia if available - Consider MSU Remember cervical swabs may not always demonstrate the pathogen as may have ascended further up. Also remember if likely caused by sexual contact must treat all sexual partners of the woman or reinfection risk high.

History in acute pelvic pain

- Nature of the pain: sharp, dull, crampy. Intermittant/constant, duration. Similar in past. Exacerbating/relieving factors - Associated pain: dyspareunia, shoulder tip pain (peritoneal involvement), association with urination/defaecation - Menstrual history: LNP, usual cycle, abnormal/unusual bleeding ('light' period, intermenstrual or postcoital bleeding) - Risk of pregnancy: contraception - method and how reliably, slip ups, pregnancy symptoms - often worth doing urine HCG even if feels pregnancy unlikely - most common cause of cycle disturbance - Sexual history and risk of STIs: remember even those in a monogomous relationship may be at risk second to partners behaviour. - Vaginal discharge: recent change in discharge - colour, consistency, odour or irritation. Brownish discharge = bleeding, ask about it as may not report as such. - Recent genital tract procedures: TOP, IUD insertion, D&C, colposcopy and biopsy, endometrial bopsy, hysteroscopy - Past history of pelvic infection, tubal surgery and previous ectopic pregnancy: all these increase the possibility of a further ectopic pregnancy - Urinary symptoms

Exam findings in PID

- Pelvic exam: cervicitis, mucopurulent discharge from os, pain on rocking of cervix, fundal or adnexal tenderness on bimanual, adnexal masses

Dif Diag of acute pelvic pain

- Pregnancy - ectopic, miscarriage - Pelvic inflammatory disease - Ovarian cyst complications (torsion/rupture/haemorrhage) - Endometriosis - Recent instrumentation/surgery eg. Perforation of uterus - Acute appendicitis - UTI - Acute bowel obstruction - Inflammatory bowel disease - Diverticulitis

Investigations in ectopic pregnancy

- Quantitative bHCG: first do urine bHCG then arrange for serum quantitative bHCG. If diagnosis unclear is helpful to have 2 quntitative bHCGs undertaken 48 hours apart. Greater than 66% rise is suggestive of viable intrauterine pregnancy, although 22% may still turn out to have ectopic. If rising <66% ecotpic more likely (ectopic 65%, failed intruterine pregnancy 30% and intrauterine pregnancy 5%). A fall in bHCG by less than 50% associated with an abnormal pregnancy, whilst a fall of more than 50% highly suggestive of spontaneous miscarriage. - Serum progesterone: less useful in confirming diagnosis of ectopic but useful in determining whether pregnancy viable or not.>60nmol/L indicates normal pregnancy, <20nmol/L mostly indicate spontaneous miscarriage. If level 20-60 then chance of ectopic 33% Pelvic USS: TV scan will reveal lack of intrauterine sac (unless very rare heterotopic prenancy). Fluid in pouch of Douglas often indicates intraperitoneal haemorrhoage. Ovarian or fallopian tube mass may be seen although mass may not be found in 30% of cases

Cause of PID

- Sexually transmitted - Up to 40% no organism isolated - Chlamydia trachomatic most likely organism, Neissaria gonorrhoea should be considered outside of metropolitan areas or if partner has travelled from region with higher background rate Can also result from other insults to the cerival mucus integrit including pregnancy, following delivery, following recent gynaecological instrumentation - TOP, D&C, colposcopy, insertion of IUD

Investigations

- Urinary bHCG - perform on all occasions where there is the slightest possibility of pregnancy. - Serum bHCG - useful in early pregnancy where quantitative estimation is useful such as management of ectopic pregnancy, early suspected miscarriage or follow up of trophoblastic disease - Endocervical swab: for chlamydia nucleic acid amplification test (NAAT eg PCR) and gonorrhoea NAAT or culture. Need to insert cotton tipped swab 0.5-1cm into endocervical canal and rotate swab before withrawing (flocked swabs used at my current practice for PCRs) - High vaginal swab for MCS/wet film - sample any discharge from the posterior fornix with a cotton tipped swab (blue cap) - Vulvovaginal swab for MCS including candida if symptomatic area - sample this area (blue) Note: if patient declines speculum examination a self collected vaginal swab or first pass urine testing (for chlamydia and gonorrhoea NAAT) is acceptable but not preferred. - FBC/ESR: elevated WCC/ESR gives indication of severeity of infective/inflammatory causes for symptoms and baseline to judge improvement. - Pelvic/transvaginal USS: size of uterus, thickness and regularity of endometrium, duration and viability of intrauterine pregnancy, ovarian cysts - simple or complex, endometriotic cysts may give indication of endometriosis, dialted fallopian tubes - ectopic pregnancy or hydrosalpinx, intraperitoneal fluid may be indicative of active inflammatory process or recent bleed or ruptured ovarian cyst, neoplasms - Diagnostic laparoscopy: if diagnosis unclear, also means of treatment for endometriosis, ectopic pregnancy and simple ovarian cysts

Examination in suspected ectopic

- Vitals: BP, HR, temp, RR, general appearance and haemodynamic state - Abdo: this will NOT hasten rupture. Carefully palpate for tenderness, mass or signs of peritonism - Pelvic: speculum for bleeding from os. Gentle pelvic exam for uterine size (?consistent with dates), mass in posterior fornix or either adnexae and localised tenderness

Examination

- Vitals: appearance, hydration, apllor, temp (look for >38), pulse, BP - Abdo exam: ask to localise area of maximum discomfort. Examine with flat hand around abdomen gently then more deeply - note obvious masses or guarding, rigidity or rebound. - If pain of gynae origin suspected speculum should be performed - look for bleeding, products of conception or mucopurulent discharge from os - Gentle bimanual pelvic exam should be performed checking for: uterine size and tenderness, tenderness on cervical rocking (cervical motion tenderness suggests infection), masses, tenderness to the sides of the uterus (diffuse bilateral tenderness tends to suggest infection but tenderness to one side suggests ectopic and ovarian cysts - exclude!)

Risk factors of ectopic pregnancy

- pelvic infection - pelvic inflammatory disease - Infertility - Pelvic surgery (c-section, tubal surgery) Rarely heterotopic pregnancy (concurrent ectopic and intrauterine pregnancy) occurs in between 1 in 100 and 1 in 4000

Management options in ectopic

Medical/surgical/expectorant depending on: - Clinical condition - unstable and imminent rupture is a medical emergency, place 2 large bore (14g) IV lines for fluids and arrange urgent admission - Reproductive history - Desire for future fertility - Risk factors for surgery and medical management - Investigation findings

Subsequent pregnancies following ectopics

Note subsequent pregnancy rate is 85% - 15% of women will be infertile following an ectopic. 20% of those who fall pregnant again will have a recurrent ectopic. Consider performing a routine early pelvic US in women who've had previous ectopic to ensure pregnancy indeed intrauterine.

Ectopic pregnancy

Pregnancy has implanted outside of the uterus. Most commonly in the tube (97%) usually the lateral end (ampulla), but can occur anywhere from ovary to peritoneum Prevalence is 2% of all pregnancies - risk factors are becoming increasingly common so prevalence is rising.

PID

The clinical syndrome associated with ascending infection from the vagina or cervix to involve the endometrium, fallopian tubes and contiguous pelvic structures. Typical presentation with history of pelvic pain and dyspareunia. If left untreated is associated with subfertility.

Surgical management of ectopic

Women who are not haemodynamically stable or cannot be managed medically should be directed to surgical management. Laparascopy or laparotomy. Options include salpingectomy (affected tube excised) and salpingostomy (tube incised and trophoblastic tissue removed with forceps leaving tube to heal). Salpinectomy has lower recurrence rate and post op does not require serial bHCG monitoring, however infertility can result if contralateral tube lost to subsequent ectopic. Salpingotomy has higher future fertility rates (85% vs 80%) but must monitor bHCG until levels return to 0 as risk of retained trophoblastic material, higher rate of recurrent ectopic pregnancy (15% vs 5%).

When can a pregnancy be detected

can detect a normal pregnancy sac within a uterus on pelvic USS by 6 weeks amenorrhoea. Urinary bHCG will detect as early as serum bHCG but when ectopic suspected then serum quantitative is also required. A gestational sac regardless of inra or extrauterine typically visable at bHCG of 1500IU/L on TV scan.

medical management of ectopic

methotrexate. Must meet clinical criteria. Must be clinically stable and willing to attend for serial review and quantitative bHCG testing.Criteria (RWH): - Haemodynamically stable - No pelvic pain/tenderness - bHCG <3500 (though may bleed or rupture even as low as <200) - No foetal heart activity on TV USS, unruptured ectopic mass <3.5cm and no fluid in peritoneal cavity or Pouch of Douglas - Agree to use reliable contraceptive for 3-4 months post treatment (significant risk of neural tube defects whilst on anti-folate methotrexate)High dose (5mg) folate daily required if unintended early pregnancy - Desire future fertility - No pre-existing severe medical condition or disorder - No abnormailty of LFT, EUC or FBC - No known contraindications for methotrexate - Not currently taking NSAIDs, diuretics, penicillin or tetracycline drugs - No co-existing intrauterine pregnancy - Not breastfeeding - Medical management may be indicated after failed surgical treatment eg. Ongoing raised bHCG following salpingotomy - Be compliant with regular follow ups