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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
I have no disclosures to report A systematic approach to acute pelvic - - PDF document
I have no disclosures to report A systematic approach to acute pelvic - - PDF document
My stomach hurts! I have no disclosures to report A systematic approach to acute pelvic pain Essentials of Womens Health Conference Big Island, Hawaii July 2016 Jennifer Kerns, MD, MS, MPH Assistant Professor, UCSF Department of Obstetrics,
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Case 1: Miranda Amanda’s DDx
Ectopic pregnancy Ectopic pregnancy Ectopic pregnancy
Check UPT before you go any further!
UPT negative! What now for the DDx?
Pelvic inflammatory disease (PID), +/‐ tubo‐ovarian abscess (TOA)
Other adnexal mass
Ruptured ovarian cyst
Fibroids
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
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
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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
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
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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)!
Drainage of TOA
Early drainage may result in higher efficacy Transvaginal, transrectal, transgluteal, percutaneous Consult radiology/ interventional radiology More successful if
unilocular,
early in development
>5cm
Most likely to be injured by fireworks? Good news about fireworks!
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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
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
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Torsion diagnosis
How is the diagnosis of ovarian torsion made?
1.
Torsion is a clinical diagnosis
1.
Ultrasound is the best way to diagnose torsion
1.
CT is the best way to diagnose torsion
Ultrasound to diagnose torsion
Studies small, most retrospective 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 Tissue edema 21% 100% Absent intra‐ovarian vascularity 52% 91% Absent arterial flow 76% 99% Absent venous flow 100% 97% Nizar, J Clin US 2009
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. Call gyn early (even before ultrasound if high suspicion).
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Fernanda Amanda’s fibroid
Fibroids rarely cause acute or severe pain Acute pain
degenerating twisting on a pedicle prolapsing through the cervix
Torsion of fibroid
presentation=adnexal torsion but u/s shows solid mass
Prolapsing fibroid
Waves of crampy abdominal pain + bleeding Easily diagnosed on speculum exam
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
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)
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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
Leandra Amanda’s diagnosis and treatment
Ruptured hemorrhagic cyst is often diagnosis of exclusion Outpatient treatment if stable hct and pain controlled w/
- ral meds
Inpatient treatment if unstable or unable to control pain
Transfusion if hct drops and pt unstable Diagnostic laparoscopy if no improvement in 24‐48 hours
to r/o torsion or other pathology
Prevention for Leandra Amanda
Ovulation suppression! OCPs
High dose (50mcg) most effective, but risks > benefits Modern, lower dose pills: evidence is mixed and benefit is
modest (25% decrease) at best Implant—some ovulation suppression Depo‐provera – reliable ovulation suppression
Take‐aways
Always order a pregnancy test
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 Supportive treatment for hemorrhagic cyst Remember prevention (and contraception)
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