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