Acute pelvic pain I have no disclosures to report UCSF Obstetrics - - PowerPoint PPT Presentation

10/28/2016 1

• Acute pelvic pain

UCSF Obstetrics and Gynecology Update

October 2016 Jennifer Kerns, MD, MS, MPH Assistant Professor, UCSF Department of Obstetrics, Gynecology and Reproductive Sciences

I have no disclosures to report

For those of you working November 1… Gynecologically speaking, what could possibly be wrong?

A B C D E F G

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Gynecologically speaking, what could possibly be wrong?

A B C D E F G

• A. Intrauterine pregnancy
• B. PID
• C. Ectopic pregnancy
• D. Tubo-ovarian abscess
• E. Ruptured ovarian cyst
• F. Torsion
• G. Fibroids

Case 1: Miranda Amanda

It’s 4:00 – you think your last patient is a no-show, and then…

she shows up.

New patient, scheduled for pap. You walk in the room and she’s holding her lower belly. She tells you that she’s had this pain for the last few days and it

started right after she had sex.

You ask her more about the pain…

Case 1: Miranda Amanda’s pain

Constant, started more mild, now more painful, across entire

lower abdomen

She was able to go to work yesterday, but was in pain Reports the pain 6/10 Nothing makes it better or worse Some nausea, no vomiting, no diarrhea, unsure about fever/

chills

No vaginal discharge, no vaginal bleeding

Case 1: Miranda Amanda’s history

29 yo G0 3 lifetime partners – currently with partner for 6 months Has had LNG-IUS for 2 years - amenorrheic Had chlamydia age 15 and was treated Appendectomy at age 10 What’s on your DDX?

Ectopic pregnancy Ectopic pregnancy Ectopic pregnancy

Pelvic inflammatory disease (PID),

+/- tubo-ovarian abscess (TOA)

Other adnexal mass Ruptured ovarian cyst Fibroids

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More data on Miranda Amanda

Temp 38.0, otherwise normal vitals Diffusely tender to palpation across entire lower abdomen On pelvic exam, IUD strings visible, no discharge or bleeding, nl

appearing cervix, +cervical motion tenderness, +adnexal tenderness L>R

What’s 1st on your differential? What’s after that?

Pelvic inflammatory disease:

what where why who when how

Spectrum of inflammatory disorders Endocervical canal = barrier

• Vaginal flora

upper tract Sexually transmitted pathogens can disrupt this barrier chlamydia or gonorrhea infection 15% progress to PID Risk factors: age 16-24, hx of STI/PID, multiple partners,

partner w/ STI

CDC 2015 Sexually Transmitted Diseases Treatment Guidelines

cervicitis endometritis salpingitis Tubo-ovarian abscess (TOA) peritonitis

Diagnosis of PID

Wide variation in presentation imprecise clinical findings Clinical dx PID 65-90% PPV for salpingitis (via laparosc) Even mild cases can lead to infertility

Infertility=17%, recurrent PID=14%, CPP=37% Infertility assoc w/ delay in treatment

Low threshold for diagnosis

Favor sensitivity (and false pos)

Peipert et al. AJOG 2011 Ness et al. AJOG 2002 Gaitan et al. Infec Dis Obstet Gynecol 2002 Weisenfeld Obstet Gynecol 2012

Criteria for diagnosis of PID – NEW!!

Initiate presumptive treatment

• Sexually-active young women or women at risk of STIs
• Pelvic or lower abdom pain w/ no other known cause
• CMT or uterine tenderness or adnexal tenderness
• Additional (optional) criteria
• Temp > 101 (38.4)
• Mucopurulent discharge, friability
• ++ WBCs on saline wet mount of vag fluid
• ESR, CRP
• + chlamydia or gonorrhea

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Further workup

Ultrasound?

• Yes: diagnosis of TOA, consideration of other etiologies
• No: if pt is afebrile & access to usg difficult

STI testing: GC, CT, HIV, consider syphilis Indications for hospitalization:

• High fever
• Unable to tolerate Pos (n/v)
• Can’t r/o surgical emergency (e.g. appy, torsion)
• TOA
• Pregnancy
• Outpatient mgmt failed

Treatment of PID: oral regimens

★★Ceftriaxone 250mg IM OR Cefox 2g IM (+probenicid 1g PO) ★★Doxy 100mg BID x14 days (Metronidazole) 500mg BID x14 days

Azithro

500mg IV QD x2 days

Azithro

250mg PO QD x14 days (Metronidazole) 500mg PO BID x14 days

Levofloxacin/ ofloxacin/ moxifloxacin

(Metronidazole) 500mg BID x14 days

• For cephalosporin allergy
• Only if low risk for GC
• If GC +, treat based on

sensitivities or consult ID

Treatment of PID: parenteral regimens

★★ Cefotetan 2g IV q12 or ★★ Cefoxitin 2g IV q6 ★★ Doxy 100mg IV or PO BID ★★ Clindamycin 900mg IV q8 ★★ Gentamicin (daily dosing or q8) For TOA……………………………

Complete 14 days w/ doxy alone 100mg bid

• r clinda alone 450mg qid

Complete 14 days w/ doxy alone 100mg bid Complete 14 days w/ doxy + clinda doxy + metronidazole

Follow-up after PID

Re-examine patient in 48 hours If no improvement, consider

hospitalization ultrasound (80% treatment failures bc of undiagnosed TOA) medication change

Test and treat partner(s)!

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Drainage of TOA

Early drainage may result in higher efficacy Transvaginal, transrectal, transgluteal, percutaneous Consult radiology/ interventional radiology More successful if

• Unilocular, early, >5cm?

93% success in largest study

• No assoc w/ size, locularity

Granberg et al. Best Pract Res Clin Obstet Gynaecol 2009 Gjelland et al. AJOG 2005

Which of the following is false:

• A. The fear of halloween is called

samhainophobia.

• B. The largest pumpkin ever grown weighed 836

lbs.

• C. Halloween is thought to have originated in 200

A.D.

• D. Orange is a symbol of strength and endurance;

black is a symbol of death.

T h e f e a r

• f

h a l l

• w

e e n i s c . . . T h e l a r g e s t p u m p k i n e v e . . . H a l l

• w

e e n i s t h

• u

g h t t

• .

. . O r a n g e i s a s y m b

• l
• f

s t r . . .

18% 25% 24% 33%

Case 2: Fernanda Amanda:

Miranda Amanda’s twin sister

• Add-on, same day appt for a patient with pelvic pain
• You know her well because you delivered her first baby 3 months ago

– uncomplicated NSVD

• Other relevant history…
• h/o dermoid cyst, Lapx left salpingo-oophorectomy 3 years ago
• BMI 40
• Exclusively breastfeeding, no menses since delivery
• Her pain
• “excruciating”, constant but w/ episodes of incr intensity
• started right after sex yesterday
• + n/v

Fernanda Amanda’s exam

Difficulty walking into exam room Vitals normal except HR 105 +guarding, +rebound, +peritoneal signs Diffuse tenderness w/ abdom and pelvic exam, R>L

• No masses felt but limited by pt’s BMI of 40

(Most likely) DDX at this point? But first, rule out…?

• 1. Torsion
• 2. Ruptured hemorrhagic cyst
• 3. Fibroids
• 4. PID/ TOA
• 1. Appendicitis
• 2. Ectopic pregnancy

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Fernanda Amanda’s workup

Transvaginal ultrasound obtained Radiologist calls in a panic:

• “There’s no flow to the right ovary!”

Your next step is to…

• Rush her to the OR?
• Ask if they see an adnexal mass

7cm solid and cystic mass on R ovary, no free fluid, L ov WNL

• Consistent with dermoid
• Uterus 11 x 7 x 5 w/ 5cm intramural fibroid at fundus
• 1. Torsion
• 2. Ruptured hemorrhic cyst
• 3. Fibroids
• 4. PID/ TOA

Adnexal (ovarian) torsion

Complete or partial rotation of ovary or tube on its ligaments Often results in impedance of blood flow pain Risk increases w/ size of mass More likely w/ benign masses More common in pregnancy

Varras et al. Clin Exp Obstet Gynecol 2004 Pansky et al. Obstet Gynecol 2007 Houry et al. Ann Emerg Med 2001

Torsion diagnosis

• A. Torsion is a clinical diagnosis
• B. Ultrasound is the best way to diagnose

torsion

• C. CT is the best way to diagnose torsion

Which of the following is true?

Torsion is a clinical diagn... Ultrasound is the best wa... CT is the best way to dia...

34% 10% 56%

Ultrasound to diagnose torsion

Prospective study of 199 women with acute pelvic pain: Skill & experience required (sensitivity and specificity in practice

are lower than in research studies)

Other studies: sensitivity 43%, specificity 92% for absent venous

flow

Finding Sensitivity Specificity PPV NPV Tissue edema 21% 100% 100% 88% Absent intra-ovarian vascularity 52% 91% 50% 91% Absent arterial flow 76% 99% 92% 96% Absent venous flow 100% 97% 85% 100%

Nizar et al. J Clin Ultrasound 2009

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Fernanda Amanda’s treatment

Prompt surgical evaluation/ treatment Untwist ovary + remove cyst… no salpingo-oophorectomy! Exceptions?

• Post menopausal women
• Concern for malignancy
• Technically difficult (pregnancy…)

Prevention for the future?

• Ovarian suppression

Harkins et al. J Minim Invasive Gynecol 2007 Bider et al. Surg Gynecol Obstet 1991 Mashiach et al. Fertil Steril 1990 Oelsner et al. Fertil Steril 1993

• OCPs
• Depo
• Nexplanon

How long before the ovary dies?

Depends on degree of ischemia One study in children… median

time from onset of pain:

Viable ovary = 14 hrs Non-viable ovary = 27 hrs

Early diagnosis is critical to save ovarian function Gyn consult (even before ultrasound) if high suspicion

Fernanda Amanda’s fibroid

Fibroids rarely cause acute or severe pain Acute pain

Degenerating Torsion (twisting on a pedicle)

usg shows solid mass

Prolapsing through the cervix

crampy abd pain + bleeding

Degenerating fibroid

Risk factors

very large fibroids (>10cm) pregnancy

Onset gradual, not acute Exam

localized tenderness over the fibroid no peritoneal signs can have low grade fever, incr WBC Usg shows fibroid; cystic changes can suggest degeneration

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Case 3: Leandra Amanda

the younger sister

24yo G0, sudden onset pain after sex, brought in by friend Pt is doubled over, crying Pain started on left, now all over lower abdomen Worse w/ movement and lying flat No relevant PMH What’s on the differential?

Rule out an ectopic!

More data for Leandra Amanda

UPT negative Normal vitals TTP across lower abdomen, +guarding Normal labs (hct = 35, repeat = 34) Usg: ++ free fluid in pelvis, collapsed cyst

Usg can be normal (no collapsed cyst seen and/or minimal

free fluid)

Ruptured hemorrhagic cyst

Common! Most likely cyst: Corpus luteum cyst, follicular cyst Less likely cyst: dermoid, endometrioma, TOA Usually occurs in luteal phase Pain is from blood

• accumulating within ovary stretching capsule
• causing peritoneal irritation

Anti-coagulated / bleeding disorder (VWD) = risk OCP use (or other methods of ovarian suppression) = risk

Management of Adnexal Masses

Benign vs malignant

> 10cm, papillary or solid, irreg, high color Doppler

Simple cysts are almost always benign

> 2,700 PM women, simple cysts <10cm Mean f/u 6.3 yrs No cases of cancer, 2/3 resolved spontaneously Observation recommended, even in PM women

1 yr if no solid components, 2 yrs if solid

Modesitt et al. Obstet Gynecol 2003 ACOG Practice Bulletin #174 2016

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Take-aways

Have a low threshold to treat PID Leave an IUD in place, and only remove if

no improvement with PID treatment

Clinical diagnosis crucial – usg supportive Prompt evaluation and treatment for

torsion

Common, supportive tx, prevention Consider observation if appears benign

Always order a pregnancy test