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 Women’s Health Conference Big Island, Hawaii July 2016 Jennifer Kerns, MD, MS, MPH Assistant Professor, UCSF Department of Obstetrics, Gynecology and Reproductive Sciences Gynecologically speaking, what could HAPPY JULY 4 th ! possibly be wrong? G C B A F E D

Gynecologically speaking, what could Case 1: Miranda Amanda possibly be wrong?  It’s 4:00 – you think your last patient is a no ‐ show, and then… G A. Intrauterine pregnancy she shows up. B B. PID C C. Ectopic pregnancy  New patient, scheduled for pap. A D. Tubo ‐ ovarian abscess F  You walk in the room and she’s holding her lower belly. E. Ruptured ovarian cyst E D F. Torsion  She tells you that she’s had this pain for the last few days and it G. Fibroids started right after she had sex.  You ask her more about the pain… Case 1: Miranda Amanda’s pain Case 1: Miranda Amanda’s history  Constant, started more mild, now more painful, across entire  29 yo G0 lower abdomen  3 lifetime partners – currently with partner for 6 months  She was able to go to work yesterday, but was in pain  Has had LNG ‐ IUS for 2 years ‐ amenorrheic  Reports the pain 6/10  Had chlamydia age 15 and was treated  Nothing makes it better or worse  Appendectomy at age 10  Some nausea, no vomiting, no diarrhea, unsure about fever/ chills  No vaginal discharge, no vaginal bleeding

Case 1: Miranda Amanda’s DDx More data on Miranda Amanda  Ectopic pregnancy Check UPT before you go  Temp 38.0, otherwise normal vitals  Ectopic pregnancy any further!  Diffusely tender to palpation across entire lower abdomen  Ectopic pregnancy  On pelvic exam, IUD strings visible, no discharge or bleeding, nl appearing cervix, +cervical motion tenderness, +adnexal  UPT negative! What now for the DDx? tenderness L>R  Pelvic inflammatory disease (PID), +/ ‐ tubo ‐ ovarian abscess (TOA)  Other adnexal mass  What’s 1 st on your differential? What’s after that?  Ruptured ovarian cyst  Fibroids Pelvic inflammatory disease: Diagnosis of PID what where why who when how salpingitis Tubo-ovarian  Wide variation in presentation  imprecise clinical findings abscess (TOA)  Spectrum of inflammatory disorders  Clinical dx PID  65 ‐ 90% PPV for salpingitis (via laparosc) endometritis peritonitis  Endocervical canal = barrier  Even mild cases can lead to infertility cervicitis  Vaginal flora upper tract  infertility=17%, recurrent PID=14%, CPP=37%  Sexually transmitted pathogens can disrupt this barrier  Infertility assoc w/ delay in treatment  chlamydia or gonorrhea infection  15% progress to PID  Low threshold for diagnosis  Favor  sensitivity (and  false pos)  Risk factors: age 16 ‐ 24, hx of STI/PID, multiple partners CDC 2015 Sexually Transmitted Diseases Treatment Guidelines 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!! Further workup  Initiate presumptive treatment  Ultrasound?  Sexually ‐ active young women or women at risk of STIs  Yes: diagnosis of TOA, consideration of other etiologies  Pelvic or lower abdom pain w/ no other known cause  No: if pt is afebrile & access to usg difficult  CMT or uterine tenderness or adnexal tenderness  STI testing: GC, CT, HIV, consider syphilis  Indications for hospitalization:  Additional (optional) criteria  High fever  Temp > 101 (38.4)  Unable to tolerate Pos (n/v)  Mucopurulent discharge, friability  Can’t r/o surgical emergency (e.g. appy, torsion)  ++ WBCs on saline wet mount of vag fluid  TOA  ESR, CRP   Pregnancy  + chlamydia or gonorrhea  Outpatient mgmt failed Treatment of PID: oral regimens Treatment of PID: parenteral regimens ★★ Ceftriaxone 250mg IM OR Cefox 2g IM (+probenicid ★★ Cefotetan 2g IV q12 or 1g PO) Complete 14 days w/ ★★ Cefoxitin 2g IV q6 doxy alone 100mg bid ★★ Doxy 100mg BID x14 days ★★ Doxy 100mg IV or PO BID (Metronidazole) 500mg BID x14 days ฀ Azithro 500mg IV QD x2 days ★★ Clindamycin 900mg IV q8 Complete 14 days w/ ฀ Azithro 250mg PO QD x14 days doxy alone 100mg bid ★★ Gentamicin (daily dosing or q8) or clinda alone 450mg qid (Metronidazole) 500mg PO BID x14 days • For cephalosporin allergy • Only if low risk for GC ฀ Levofloxacin/ ofloxacin/ moxifloxacin • If GC +, treat based on Complete 14 days w/ For TOA……………………………………………… sensitivities or consult ID (Metronidazole) 500mg BID x14 days doxy + clinda doxy + metronidazole

Drainage of TOA Follow ‐ up after PID  Re ‐ examine patient in 48 hours  Early drainage may result in higher efficacy  Transvaginal, transrectal, transgluteal, percutaneous  If no improvement, consider  hospitalization  Consult radiology/ interventional radiology  ultrasound (80% treatment failures bc of undiagnosed TOA)  More successful if  medication change  unilocular,  early in development  >5cm  Test and treat partner(s)! Good news about fireworks! Most likely to be injured by fireworks?

Case 2: Fernanda Amanda: Fernanda Amanda’s exam Miranda Amanda’s twin sister  Difficulty walking into exam room  Add ‐ on, same day appt for a patient with pelvic pain  You know her well because you delivered her first baby 3 months ago  Vitals normal except HR 105 – uncomplicated NSVD  +guarding, +rebound, +peritoneal signs  Other relevant history…  h/o dermoid cyst, Lapx left salpingo ‐ oophorectomy 3 years ago  Diffuse tenderness w/ abdom and pelvic exam, R>L  BMI 40  No masses felt but limited by pt’s BMI of 40  Exclusively breastfeeding, no menses since delivery 1. Torsion  (Most likely) DDX at this point?  Her pain 2. Ruptured hemorrhagic cyst 3. Fibroids  “excruciating”, constant but w/ episodes of incr intensity  But first, rule out…? 4. PID/ TOA  started right after sex yesterday 1. Appendicitis  + n/v 2. Ectopic pregnancy Fernanda Amanda’s workup Adnexal (ovarian) torsion  Transvaginal ultrasound obtained 1. Torsion  Complete or partial rotation of ovary or tube on its ligaments 2. Ruptured hemorrhic cyst 3. Fibroids  Radiologist calls in a panic:  Often results in impedance of blood flow  pain 4. PID/ TOA  “There’s no flow to the right ovary!”  Risk increases w/ size of mass  Your next step is to…  More likely w/ benign masses  Rush her to the OR?  Ask if they see an adnexal mass  More common in pregnancy  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 Varras et al. Clin Exp Obstet Gynecol 2004 Pansky et al. Obstet Gynecol 2007 Houry et al. Ann Emerg Med 2001

Ultrasound to diagnose torsion Torsion diagnosis  Studies small, most retrospective  How is the diagnosis of ovarian torsion made?  Study of 199 women with acute pelvic pain: Finding Sensitivity Specificity Torsion is a clinical diagnosis Tissue edema 21% 100% 1. Absent intra ‐ ovarian vascularity 52% 91% Absent arterial flow 76% 99% Ultrasound is the best way to diagnose torsion 1. Absent venous flow 100% 97% 1. CT is the best way to diagnose torsion  Skill & experience required (sensitivity and specificity in practice are lower than in research studies)  Other studies: sensitivity 43%, specificity 92% for absent venous flow Nizar, J Clin US 2009 How long before the ovary dies? Fernanda Amanda’s treatment  Prompt surgical evaluation/ treatment  Depends on degree of ischemia  Untwist ovary + remove cyst… no salpingo ‐ oophorectomy!  One study in children… median  Exceptions? time from onset of pain:  Post menopausal women  Viable ovary = 14 hrs  Concern for malignancy  Non ‐ viable ovary = 27 hrs  Technically difficult (pregnancy…) • OCPs  Prevention for the future? • Depo  Early diagnosis is critical to save ovarian function.  Ovarian suppression • Nexplanon  Call gyn early (even before ultrasound if high suspicion). 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

Degenerating fibroid Fernanda Amanda’s fibroid  Fibroids rarely cause acute or severe pain  Risk factors  very large fibroids (>10cm)  Acute pain  pregnancy  degenerating  twisting on a pedicle  Onset gradual, not acute  prolapsing through the cervix  Exam  Torsion of fibroid  presentation=adnexal torsion but u/s shows solid mass  localized tenderness over the fibroid  no peritoneal signs  Prolapsing fibroid  can have low grade fever, incr WBC  Waves of crampy abdominal pain + bleeding  Easily diagnosed on speculum exam  Usg shows fibroid; cystic changes can suggest degeneration Case 3: Leandra Amanda More data for Leandra Amanda the younger sister  24yo G0, sudden onset pain after sex, brought in by friend  UPT negative  Pt is doubled over, crying  Normal vitals  Pain started on left, now all over lower abdomen  TTP across lower abdomen, +guarding  Worse w/ movement and lying flat  Normal labs (hct = 35, repeat = 34)  No relevant PMH  Usg: ++ free fluid in pelvis, collapsed cyst  What’s on the differential?  Usg can be normal (no collapsed cyst seen and/or minimal  Rule out an ectopic! free fluid)