Pelvic Pain and Ectopic Pregnancy

How are women who are in shock on admission managed? 3

1. Immediate pregnancy test 2. Urgent laparatomy 3. Resus and blood transfusion occasionally

What are some clinical signs of ectopic pregnancy? 1/3

1. Pelvic tenderness and/or cervical excitation 2. Shoulder tip pain due to diaphragmatic irritation 3. Haemoperitoneum

What are predisposing factors to CPP? 3

1. Physical/sexual abuse 2. Endometriosis 3. Adhesions/pelvic varices

What are the management options for women with chronic pelvic pain syndrome? 6

1. Psychosocial therapy 2. Analgesia with gabapentin 3. Hormonal treatments 4. Antidepressants e.g. amitriptyline 5. Complementary treatments e.g. acupuncture, reflexology, homeopathy 6. Surgery e.g. uterine nerve albation

What two further investigations are sometimes done in acute pelvic pain? 1/2

1. USS for ovarian cysts 2. Laparoscopy

What can be tried if investigations are negative? If this is successful what is a possible cause of the CPP?

3 mo trial of GnRH analogue Adenomyosis

Who is expectant management suitable for?

Clinically stable asymptomatic women with an USS diagnosis of EP and a decreasing serum hCG initially less than 1000 IU/L

What are the most common causes of acute pelvic pain? 3/4

Ectopic pregnancy Miscarriage PID Torsion of a ruptured ovarian cyst

What investigations should be performed if a pregnancy test is negative? 3

High vaginal swab Endocervical Swab FBC Assess for infection

What does a USS in a stable woman with suspected ectopic pregnancy help distinguish?

If the woman is stable Ectopic pregnancy from miscarriage and from continuing intrauterine pregnancy

What is the definition of chronic pelvic pain?

Intermittent or constant lower abdo/pelvis pain of at least 6 mo duration not occurring exclusively with menstruation or intercourse and not associated with pregnancy

How is a woman with a positive pregnancy test, clinical signs of EP and an empty uterus on US managed?

Laparoscopy and subsequent salpingectomy or salpingotomy

What is the management of a positive pregnancy test, no clinical signs and an empty uterus on USS?

Serum hCG if it is over 1500 IU/L a laparoscopy should be performed Recheck in 48 hours and if they are not doubled/steady or slightly reduced consider laparoscopy

What are the conditions for medical management with methotrexate? 2

Woman is well with minimal symptoms Clinically stable bhCG less than 3000 IU/L

What is necessary post salpingotomy?

beta hCG tracking to identify the small number of cases complicated by persistent trophoblast

What is a pregnancy of unknown location defined by? How should these women be managed?

hCG levels below 1000 IU/L and there is no pregnancy visible on transvaginal USS Expectant management with 48 hour follow up and serial serum hCG measurements until they are less than 15