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Gynaecological emergency
 

Gynaecological emergency

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    Gynaecological emergency Gynaecological emergency Presentation Transcript

    • DR KARIMAH BT MOHD O&G DEPARTMENT HSNZ ,TRG Seminar Gynaecology (2013)
    • 31 G3P2 at 12 week s +1 days POA Sod ,LMP-25.6.2013 ,not on contraception Referred from district hospital ? Molar Pt went for RME at KK and was asymptomatic Routine scan was done –findings multiple cyst within uterine cavity ,no iugs seen ,no fetal echo noted ,no free fluid No hx passing out vesicles/pv bleed /abd pain Clinically pt stable ,pink ,comfortable p/a soft non tender ,no palpable mass Ve/speculum done –documented normal Cervical excitation was + Case was seen by mo –and scan comfirm by specialist Findings –TAS –no iugs ,ET-6.6 mm,uterus anteverted TVS-regular GS with fetal echo at rt adnexa ,25 mm=6 weeks 2/7 min fluid at POD Bhcg –sent results 7513 iu/ml (retrospective review) IMP-…………………………
    • Diagnosis was ….Leaking Ectopic pregancy Proceed for laparoscopic left salphingectomy 18.9.2013 Findings intraop: Hemoperitoneum 700 cc .left tubal ectopic pregnancy Uterus normal ,both ovaries normal Rt fallopian tube normal and intraop uneventful Pt was dc well with advice on 20.9.2013 with tca gynae 3/12
    • •MISCARRIAGE •HYPEREMESIS GRAVIDARUM •CERVICAL INCOMPETENCE ECTOPIC PREGNANCY •MASSIVE MENSTRUAL BLOOD LOSS •EMERGENCY CONTRACEPTION SEVERE ACUTE PELVIC PAIN
    • DEFINITION :  Ectopic – from Greek word ‗ektopos‘ meaning out of place  Any implantation outside uterine cavity
    •  Rising incidence -1% of all pregnancy  95% located in f.tube  Always exclude ectopic pregnancy  Delay ----------------catastrophic  Counselling on future pregnancy : recurrence rate 12-20% .  Early comformation on future pregnancy  Early usg –to confirm site of pregnancy
    • Site of ectopic pregnancy : 1. Tube ( > 95 % ) : ampulla : 80% isthmus : 12 % fimbria : 5 % cornual : 2 % 2. Uterus : intramural , angular, cervical(0.2%), rudimentary horn 3. Ovary : < 0.2 % 4. abdominal : 1.4 %
    • CLINICAL PRESENTATION Can present in many ways Most common presenting complaint : 1. Lower abdominal pain : 9 % no pain 2. Delayed or irregular menses followed by vaginal bleeding, brownish discharge or syncopal attack. ‘if a patient who is a few weeks pregnant complains of little pain and heavy vaginal bleeding, the pregnancy is probably intrauterine, whereas if she has much pain and little bleeding, she is more likely to have an ectopic’- Stabile(1996) Presentation : Acute or Subacute
    • Acute Presentation : Following tubal rupture an intraperitoneal haemorrhage.  Acute abdominal pain - typically referred to shoulder tip or interscapular area - may be provoked by lying down / inspiration  Cardiovascular collapse : hypotensive & tachycardia  Peritoneal irritation  Cervical excitation pain  May be moderate leucocytosis  Cullen‘s sign – bluish umbilicus; unusual sign
    • Subacute Presentation : Frequently give rise to diagnostic confusion Abdominal pain : Localized to one illiac fossa Delayed menstruation Vaginal bleeding May be referred pain to shoulder tip Peritoneal irritation : less marked Bimanual Examination : . Localized tenderness : one of the fornices . Cervical excitation pain . Posterior fornix tenderness : presence of affected tube in POD * Have to be very gentle to prevent rupturing unruptured tube
    •  Isthmic implantation  Narrow segment ; less distensible  Often occurs at 6-8 weeks  Ampullary implantation  Usually occur at 8-12 weeks  Wider segment  80% of ectopic  Interstitial implantation (cornual ectopic)  Surrounded by myometrium; can accommodate enlarging conceptus.  Later stage of rupture : 12-14 weeks  Results in damage of highly vascularized cornual end of uterus  Severe intraabdominal hemorrhage
    • DIAGNOSIS Early diagnosis is critically important in terms of outcome When detected early, major morbidity is reduced and treatment options are enhanced In recent years, in spite of increase in the incidence of ectopic, the case fatality rate is reducing. Due to :- widespread introduction of diagnostic tests - awareness of the seriousness of ectopic leading to early diagnosis and effective treatment
    • Diagnosis : cont 1. High index of suspicion : Any women in her reproductive age group, sexually active with PV bleeding after a period of delayed menses is a case of ectopic until proven otherwise 2. Combination of TVS and serial hCG : still remain the cornerstone for diagnosis 3. Laparoscopy : gold standard in very early stages , ectopic is not visualised ; 3- 4% is missed.
    • Quantitative hCG Ectopic pregnancy produces lower concentration of hCG than normal pregnancy, but the change in concentration provides more information. In normal pregnancy : Doubling time : 2 – 3.5 days during 4 – 8 weeks , At 6 weeks : BhCG - > 6000 – 10000 iu/L reaching a peak around 8 – 12 weeks 2 days sampling interval is recommended Failure of increase of at least 66 % is suggestive of ectopic .(85%confident limit) 15% ectopic BhCG > 66% within 48H
    • Cacciatore et all 94 : In women at high risk, absence of IUGS ( TVS ) + serum hCG > 1000iu / L Indicates ectopic in > 80 % of women
    • Ultrasonography 1. TAS : detect IUGS – hCG > 6500 iu/L * Absence of an IUGS on TAS in conjunction with hCG level greater than 6500 iu/L is suggestive of ectopic 2. TVS : * Detect IUGS – hCG > 1000 –1500 iu/L * Corespond to 1 week after missed period when IUGS measurement is 2 – 4mm. * Ectopic is suspected if TVS doesn‘t detect IUGS when hCG level is > 1500iu / L
    • Ultrasonography : cont… Literature provide a wide range of sensitivity & specificity for TVS in detecting ectopic pregnancy :  Sensitivity ranging 69 – 99 %  Specificity ranging 84 – 99.6 %
    • Other Diagnostic Modalities : 1. Culdocentesis : * Rarely performed today as USG can reveal presence of fluid in POD * Used primarily when USG is not readily available. Non clotting blood on culdocentesis – strongly suggest bleeding ectopic Yellow or straw colour fluid – rupture ovarian cyst Negative test – does not exclude ectopic
    • 2. Serum progesterone: Some clinicians continue to find it useful. Rational is that viable intrauterine pregnancies were associated with serum progesterone level of : 1. 11 ng/mL , in one study : sensitivity 91 % 2. 25 ng/mL , in another study : sensitivity 97.5% Although level less than 11 ng/mL is indicative of an abnormal pregnancy, it doesn’t distinguish between an ectopic and failing intrauterine pregnancy. In addition, ectopic pregnancy are known to occur when serum progesterone level is > 25 ng/mL & there are reports of several woman with documented very low serum progesterone ( < 5 ng/mL ) who delivered normal baby at term
    • 3. Other Markers of ectopic :  Cervical fetal fibronectin  Serum creatine kinase  Vascular cell adhesion molecule – 1  Vascular Endothelial Growth Factors • All are found to be not useful except Vascular Endothelial Growth Factors, which showed encouraging result, however the sample size of the study was small which limits the ability to generalize. • There is active research going on to find ―ectopic pregnancy hormone.” If found, it will revolutionize the diagnosis and management of this problem.
    •  Ruptured corpus luteum cyst  Threatened / incomplete miscarriage  Pelvic Inflammatory Disease  Degeneration of fibroid
    • MANAGEMENT 1. Once diagnosed, should be admitted and evaluated. 2. Options : a. Controlled expectant Mx b. Medical c. Surgery : commonest d. Combination. Surgery remains the mainstay of treatment. Expectant and medical management are possible and should be considered in selected cases.
    • Controlled Expectant Management Not all ectopic pregnancies progress & pose a risk to the mother. 7 observational studies ( 478 pt ), managed expectantly showed 67 % resolved spontaneously. Spontaneous resolution more likely if : 1. Initial hCG is low ( < 1000-2000 iu/L ) and level progressively declining (15% fall in initial BhCG). 2. Hemoperitoneum < 50 ml 3. Tubal mass < 2 cm 4. Absence of recognizable fetal parts on U/S 5. Absence of clinical symptoms.
    • Surgical Treatment 1. Laparotomy vs Laparoscopy Laparoscopy is inappropriate if patient is in shock In 3 RCT : Laparoscopic approach is associated with : 1. Significantly less blood loss 2. Lower analgesic requirement 3. Shorter hospital stay 4. Quicker post operative recovery time 5. Subsequent IUP of 70 % (55 % in laparotomy) 6. Recurrent ectopic of 5 % (16.6% - laparotomy) 7. Less adhesion ( p < 0.001 )
    • b) Salpingectomy vs Salpingotomy In meta-analysis of 40 studies, salpingectomy is associated with : 1. IUP rate of 44 % ( 46 % salpingotomy ) 2. Repeat ectopic of 10 % (15 % in salpingotomy) 3. Almost no cases of persistant trophoblastic tissue ( 4.4 – 11 % in salpingotomy ) Suturing of salpingotomy incision : No benefit ( Grade A )
    • RCOG : 1. Salpingectomy is to be preferred to salpingotomy when the contralateral tube is healthy as it is associated with lower rate of persistant trophoblastic tissue and subsequent repeat ectopic while having a similar IUP rate (Grade B) 2. Salpingotomy is reasonable when there is only one tube but it is associated with 20 % rate of further ectopic. Whenever possible patient should be councelled about it.
    • Management In Cases Of Haemodynamic Shock  In UK between 94 – 96, there were 12 deaths due to ruptured ectopic, of which 2 were associated with laparoscopic treatment.  It is important to remember that when a patient is in shock, she must be operated upon as rapidly as possible, and by the fastest method – open laparotomy is usually the preferred method
    • MEDICAL MANAGEMENT Use of Methotrexate :50mg/m2 check BhCG on Day 4 and 7 expected 15% reduction of BhCG 14% need second dose of MTX <10% need surgical intervention Route : - Systemic ( IV, IM, oral ) - Local injection ( U/S / laparoscopic guidance or hysteroscopically inserted intra-tubal catheter ) Methods of Administration : 1. IM : 3 trials ( 172 pts ) : single dose of 50 mg/m2 - resorption rate : 92 % - subsequent IUP : 58 % - recurrent ectopic : 9 %
    •  Haemodynamically stable , no active bleeding , no haemoperitoneum , minimal or no pain  No contraindications to MTX  Non laparoscopic diagnosis of ectopic  Initial pretreatment BhCG level < 10,000 IU/L  Tubal diameter < 2cm  Absence of fetal heartbeat  Able to return for follow up care for several weeks  General anaestheisa poses a significant risk
    •  Symptomatic patients  Haemodynamically unstable patients  Presence of haemoperitoneum  Initial BhCG > 10,000 IU/L  Tubal diameter > 2 cm  FH+  Evidence of liver disease, renal insufficiency or myelosuppresion  Patient poor compliance
    • SUMMARY : 1.Incidence of ectopic is raising, while case fatality is reducing. 2. Early diagnosis is the key to less invasive treatment. 3.The trend is towards conservative treatment. 4. Unruptured ectopic – laparoscopic approach may be the choice of management 5.Ruptured ectopic should be operated immediately, and open laparotomy usually preferred.
    •  24 GIP0 at 10 weeks POA  Dx as pregnanc y with ovarian cyst –under Sg.Buloh f/up  Admitted 15.9.2013  Sudden onset LIF pain in morning ,pricking nature,  Pain score 10/10  Vomittingx5  No uti sx /urti sx/fever /pv loss  At ED given iv nubain 10 mg stat ,iv morphine 2 mg stat..pain not resolve ..  o/e vital sign stable  Mile pale ,lethargic  p/a soft not distended  Mass felt at left side tender ,no guarding  Ps/ve –  Tas –intrauterine pregnancy with fetal heart seen  Left adnexa –multiloculated cyst 9.8x 5 cm
    •  What is the differential diagnosis ?  How do you manage this case ?  What is the definitive treatment ?  -Conservative /surgery  What is the effect of surgery towards pregnancy ?  How do you counselled this patient ?  In pregnancy with ovarian cyst when is the best time for surgery if indicated
    •  Dx was twisted ovarian cyst  Risk of intra and post op explain to pt and relatives Pt underwent laparotomy salphingoophorectomy Intraop findings : Uterus 10 week ,min ascites fluid (peritoneal reaction – inflammatory) Left ovarian cyst twisted x 3 ,gangrenous and blackish ,tissue was not viable. left tube also oedematous and gangrenous -sent for HPE  Patient was dc well 17.9.2013  Usg done before dc  Pt was given tca 2/12 –f/up and review HPE
    •  Definition - ―the acute clinical syndrome associated with ascending spread of microorganism (unrelated to pregnancy and surgery) from the vagina or cervix to the endometrium, fallopian tubes and/or contiguous structure‖ Weström & W lner-Hanssen 1993  Includes endometritis,salppigitis,tuboovarian abscess and pelvic peritonitis
    •  Mild disease  Fallopian tubes (FT) appears reddened (hyperemic) and are edematous.  FT freely mobile with  Patent lumen
    •  Moderately severe disease  more pronounced edema and inflammation of FT  Limited tubal motility.  Patchy fibrin deposits are seen on the serosal surface and  loose adhesions between the pelvic and abdominal viscera.  The distal end of the fallopian tubes are often phimotic and may not be patent.
    •  Severe disease –  occlusion of the tubal ostia  formation of a pyosalphinx.  distorted anatomy.  congested pelvic peritoneum and the  pelvic organs become adherent causing formation of a complex inflammatory mass.  If the infection has not been sealed off in the fallopian tubes, then a tubo-ovarian abscess developed
    •  Most women recover completely after an episode of PID.  The likelihood of developing tubal factor infertility following PID is determined by the severity and number of episodes of the disease.  Follow-up of the Lund cohort indicates tubal factor infertility occur in woman with PID:  8% after one episode  19.5% after two episode  40% after three or more
    •  In this same series the ectopic pregnancy rate was 9.1% compared to a rate of 1.4% in the control group (Weström et al 1992).  chronic abdominal pain which occur frequently and contributes to the high rate of hospitalization and a 10- fold increase in hysterectomy rate seen in women following PID (Buchan et al 1993).
    •  PID has a wide clinical spectrum, which extends from a woman with little evidence of systemic upset to a seriously ill woman with life-threatening pelvic sepsis.
    •  Subacute dull lower abdominal pain and usually bilateral  fever  purulent vaginal discharge  Deep dyspareunia  Abn vaginal bleeding ,including post coital ,IMB and menorrhagia  bilateral adnexal tenderness  cervical excitation on bimanual examination  Fever (>38 C)  elevated ESR but could be non specific .
    •  It is now evident that historical, clinical and laboratory findings are not consistently useful in the diagnosis of PID, either individually or in combination (Kahn et al 1991).  It has therefore been proposed that the criteria should be all that required to trigger early antibiotic treatment for probable PID in women with milder presentations (Rolfs 1991).  Although in this approach, some unnecessary antibiotics will be administered, this would set against the potential benefits of earlier intervention in a larger number of cases of PID.
    •  PID may be symptomatic /asx .clinical sn & sx lack of sensitivity and specificity (PPV of clinical dx 65-90% compared to laparoscopic dx  Testing for gonorrhea and chlamyidia in lower genital tract is recommended since positive report support the diagnosis. However the absence of infection does not exclude PID .  Elevated ESR/CRP –support dx but non specific  The absence of endocervical or vaginal pus cells a good negative predictive value (95%) for dx PID but their presence is non specific.
    •  In women with a more severe presentation, hospitalization is required for further investigations.  Important competing diagnoses such as ectopic pregnancy and appendicitis should be ruled out and treated accordingly.
    •  Ectopic pregnancy  Acute appendicitis  Endometriosis  Complication of ovarian cyst –torsion,ruptured –often sudden onset  UTI –sx of uti  Function pain –may be associatedflong standing symptoms
    • RCOG Guidelines no 23 May 2003 & latest 2009 (www.rcog.org.uk) Uk National Guidelines For Management of PID (Updated June 2011) Nice guidelines (last revised march 2013)
    • Admission should be considered in the following situation: 1. Surgical emergency cannot be excluded 2. Lack of esponse to oral rx 3. Clinically severe disease 4. Presence of tuboovarian abcess 5. Intolerance to oral rx 6. Pregnancy
    •  Out patient regimens  I.M ceftriaxone 500 mg single dose followed by oral doxycycline bd +Metronidazole 400 mg bd x 14 days -Grade A (1b) )  Oral Ofloxacin 400mg OD + oral Metronidazole 400 mg BD x 14 days - Grade A (1b) • Levofloxacin is the L isomer of Ofloxacin and has advantange of once daily dosing (500 mg Odx 14 days) Alternatives regimens ( i.e allergy,intolerance ) -I.M Ceftrixone 500 mg stat ,followed by Azithromycin 1 g/week x 2 weeks Grade A (1b) -Oral moxifloxacin 400 mg OD x 14 days
    •  I.v Ceftrixone 2g od + I.v doxycycline 100 mg bd (oral Doxycycline may be used if tolerated) followed by oral Doxycycline 100 mg bd + Oral Metronidazole 400 mg bd x 14 days  I.v Clindamycin 900mg tds + I.v Gentamycin (2mg / kg loading dose ) followed by 1.5 mg /kg tds followed by oral Clindamycin 450 mg qid /oral Doxycycline 100 mg bd + oral Metronidazole 400 mg bd x 14 days . *Genta levels need to be monitored
    •  I.v Ofloxacin 400 mg bd + I.v metronidazole 500 mg tds x 14 days.  I.v Ciprofloxacin 200 mg bd +I.v (or oral) Doxycycline 100 mg bd + I.v Metronidazole 500 mg tds x 14 days.
    • Treatment in pregnancy  In an intrauterine pregnancy, PID is extremely rare, except in the case of septic abortion.  Treatment regimens will be dependent upon the organisms isolated. Drugs known to be toxic in pregnancy should be avoided e.g. tetracyclines.  Erythromycin and amoxycillin are not known to be harmful in pregnancy.
    •  An intrauterine contraceptive device (IUCD) may be left in situ in women with clinically mild PID  but should be removed in cases of severe disease.
    •  surgical management  is rarely necessary in the management of acute PID, however  laparoscopic surgical techniques can be utilized to drain purulent fluid, lyse bowel adhesion and excise acute and necrotic tubo-ovarian adhesions. There is some evidence that early laparoscopic treatment of tubo-ovarian abscess leads to more rapid short-term recovery and preservation of normal anatomy  USG guided aspiration of pelvic fluid collection s is less invasive and may be equally effective .  Non Steroidal Anti Inflammatory Drugs  as an adjunct to the antibacterial and surgical management of acute PID to prevent long-term sequelae has been considered but is still not clear.
    •  Review after 72 hs is recommended (moderate to severe clinical presentation ),and should show a substantial improvement in clinical symptoms and signs .Failure to to so need further investigation,parenteral therapy and/or surgical intervention.  Further review after 2/52 after therapy may be useful to ensure. -adequate clinical response -compliance to antibiotics
    •  -screening of significance of PID and its sequelae  Repeat pregnancy test ,if clinically indicated Repeat testing for gonorrhea or chlamydia after 2-4 weeks is appropriate in those persisting sx ,antibiotic resistance pattern ,compliance with antibiotis and/tracing of sexual contact indicate the possibility of persistent /recurrence infection.
    •  Quiz 1—what is level of bhcg when iugs should be seen by TVS ?  Quiz 2-what are the differential diagnosis for ectopic pregnancy  Quiz 3 –what are the differential diagnosis of PID
    • Liver
    •  The causal organism is Chlamydia trachomatis, a Gram-negative bacteria that behaves like a virus that it replicates intracellularly.  In UK it affects 3-5% of sexually active woman  It is responsible for at least half of all cases of non-specific genital infection, which includes non-specific urethritis in the male and related conditions in the female.