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Emergency lectures - Pelvic pain and pelvic inflammatory disease
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Emergency lectures - Pelvic pain and pelvic inflammatory disease



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  • Round ligament pains – typically dull, pulling sensations in lower quadrants, may radiate to vagina and labia, may be severely painful. Exam will be normal
  • Increase in incidence – More STDs (chlamydia), improved ID, delayed childbearing, increased IUD and tubal sterilization rates (and therefore more failures), also increase in assisted reproduction (IVF, intrauterine insemination)Decrease in mortality – Better diagnostic and treatment protocols. Still leading cause of early pregnancy-related death in US
  • Acute inflammation of tubes causes the damage which predisposes to ectopics
  • Discriminatory Zone is institutionally dependent.Typically 1000 to 1500Important to known your own institution’s DZCaveat: hcg is higher in women with multiple gestations (may be above DZ but no IUP on US)Serial hcgs:Rise <53% over 48hours = abnormal pregnancy (either ectopic or early pregnancy failure)Serum Progesterone- if <5 = abnormal pregnancy- Not clinically useful when high-quality TVUS available, most labs take 48h to process (send-out)
  • Features of Pseudosac:Elliptical (not round) shapeAbsence of decidual reaction (no bright white ring)
  • Extremely rare, but rates increasing with use of IVF.
  • Single, two, and multidose regimens of methotrexate (Ob/Gyn will decide this)Diagnostic lap is still gold standard for diagnosis of ectopic+ pregnancy test, free fluid on FAST  To OR with GynMethotrexateDihydrofolatereductase inhibitor  interrupts purine synthesis thus DNA synthesis and cell replicationSide effects rare at doses used for ectopic pregnancy, but include mouth sores, sensitivity to sun, hair loss, GI upset. No NSAIDs or alcohol while on methotrexate
  • Currentligo:Non-viable pregnancy: closed internal os, no expulsion of products of conception, and one ofthe following ultrasound findings: embryonic pole >5mm without cardiacactivity (fetal/embryonic demise) gestational sac with mean sac diameter>16mm and without embryonic pole (anembryonic gestation)other criteria based on hCG change orserial ultrasound examinations that, based on clinical judgement, ruleout a normal intrauterine gestationIncomplete abortion: expulsion of some products of conception with or without active bleedingfrom the cervical os and the following findings: retained products of conception on ultrasoundexaminationendometrial lining (anterior-posteriordiameter) >15mm internal cervical os open or closedon digital examinationInevitable abortion: an intrauterine gestational sac on ultrasoundexamination and an open cervical os on digital examination with activevaginal bleeding
  • Misoprostol regimens:General info:Cramping within 2-4 hours, most will expel pregnancy within 24 hours, if not may repeat dose. If not expelled after 2 doses Ob/Gyn follow-upComes in 100 and 200mcg tabletsVaginal:800mcg inserted all at once, push up towards cervix. May want to advise pt to lay down for 30 minutes to prevent them from falling out. Oral:Nausea & diarrhea side effectsLess effective than vaginal route400mcg swallowed, best if given with anti-emetic concurrentlyBuccal/Sublingual:Less GI upset, but still more than vaginalEquivalent efficacy to vaginal800mcg allowed to dissolve then swallow (will be a mushy mess)
  • 20-30% perinatal mortality.Also increased risk for long-term neurobehavioral outcomes and SIDSWe don’t’ really talk about grade of abruption
  • Classify by organ? Vagina/vulva, uterus, ovary/adnexa?
  • Neoplastic growth vs disruption of normal ovulation cycle.A lot of times, can’t tell based on imaging or tumor markers  managed as a single entity
  • Cystic and solid components
  • In most cases, intraovarian venous Q is absent. In advance cases, arterial Q may be lacking.Low-Pressure veins compresses easily  continued inflow  congestion and edema (bull’s eye target, whirlpool, or snail shell)  may not infarct
  • Risk of subsequent necrosis (fever, leukocytosis, peritoneal signs)Cystectomy – generally delayed to be sure there is adequate blood flowOophoropexy – minimize risk of repeated torsion
  • Endomyometritis – infection within uterine cavity (endometrium and myometrium). Occurs after instrumentation of uterus (placement of IUD, D&C, endometrial biopsy).
  • Unknown cause for alteration  risk factors include oral sex, douching, black race, cigarettes, sex during menses, IUD, early age of sexual intercourse, new or multiple sexual partners, sexual activity with other womenNot considered a STD as women can have without any sexual encounters
  • Can often base on historyUsually non-irritating. Normal exam without erythema or cervical abnormalities.Whiff test – add 10% KOH to secretions. Often don’t need KOH
  • Blurred edges as coated with bacteria
  • Cottage cheese dischargeOften can diagnose based on history
  • Easiest and quickest  PO fluconazole
  • Micro – only 60-70% sensitive
  • Risk factors - <25 yo, other STDs, new or multiple sexual partners, lack of barrier protection, drug use, commercial sex workersIn US  reportable disease to CDC
  • Intracellular  glandular infection leads to significant dischargeEnzyme Linked Immunosorbent Assay
  • All organs can be involved, but tubes are most important (TOA, future effects on fertility)Many have been treated for PID when they don’t have and vice-versa
  • Chlamydia doesn’t cause acute inflammation, but damage to tract thought to be 2/2 delayed hypersensitivity reaction
  • These features enhance diagnostic specificity
  • May mimiccholecystitis.May or may not be associated with PID symptoms.Dx: PID symptoms/dx with negative RUQ U/S, LFTs, CXR, UA
  • For mild/moderate disease can treat as outpatient
  • Recommended hospitalization characteristics – Adolescents, drug addicts, severe, dz, suspected abscess, uncertain diagnosis, generalized peritonitis, temp > 38.3, failed outpatient therapy, recent uterine instrumentation, WBC >15,000, vomiting precluding PO therapy
  • Current antibiotic regimens obviate need for surgery.Abscess drainage usually with perc drainage with CT guidance per radiology


  • 1. Pelvic Pain andPelvic Inflammatory Disease Joshua Radke, MD Emergency Medicine UC Davis Medical Center
  • 2. Disclosures• None
  • 3. Outline• Pregnant – Ectopic – Early pregnancy failure – Placental abruption – Uterine failure• Not Pregnant – Ovarian cyst – Ovarian torsion• Infectious Disease – Vaginitis – Cervicitis – PID • TOA • Fitz-Hugh-Curtis Syndrome
  • 4. Pregnancy
  • 5. Pregnant Classify by Trimester• First trimester – Ectopic Pregnancy – Early pregnancy failure• Second trimester – Round ligament pain – Ovarian torsion• Third trimester – Placenta abruption – Uterine rupture• Don’t forget non-gynecologic causes!
  • 6. Ectopic Pregnancy• Implantation of blastocyst anywhere other than endometrial lining of uterus• Majority are tubal – Tubal – 95% – Ovarian – 3.2% – Abdominal – 1.3%
  • 7. Ectopic Pregnancy Epidemiology• 2% of pregnancies• Incidence increasing in US – 4.5 per 1000 in 1970 – 19.7 per 1000 in 1992• Mortality decreasing
  • 8. Ectopic Pregnancy Risk FactorsFactor Odds RatioPrior ectopic 12.5Prior tubal surgery 4.0Smoking (>20 cigs/day) 3.5Prior PID 3.4≥ 3 prior SAB 3.0Age ≥ 40 2.9Prior medical or surgical abortion 2.8Infertility >1 year 2.6Lifelong sexual partners >5 1.6Previous IUD use 1.3
  • 9. Ectopic Pregnancy Symptoms• Amenorrhea• Abdominal pain• Vaginal bleeding• 18% of women presenting to ER with 1st trimester bleeding and abdominal pain• Symptoms of normal pregnancy – Nausea – Urinary frequency – Breast tenderness• More serious symptoms – Shoulder pain (phrenic nerve irritation) – Syncope/orthostatic/vertigo
  • 10. Ectopic Pregnancy Signs• Vital Signs – Normal – Hypotensive and tachycardic• Physical exam – Minimal prior to rupture – Marked tenderness on abdominal and pelvic examination – Pelvic mass palpated in only ~20%
  • 11. Ectopic Pregnancy Diagnosis• β-hcg – Discriminatory zone – Abnormal rise• TVUS – Absence of intrauterine pregnancy – Adnexal mass – “Pseudosac” in uterus – Free fluid in pelvis (rupture)
  • 12. β-hcgFinding on TVUS Weeks from LMP β-hcgGestational sac 5 1000“Discriminatory Zone” 5-6 1500-2000Yolk sac 6 2500Fetal pole 7 5000Fetal heart motion 8 17,000
  • 13. Ectopic Adjacent to Ovary
  • 14. Tubal Ectopic
  • 15. Pseudosac
  • 16. Heterotopic Pregnancy
  • 17. Ectopic Pregnancy Management• Stabilize – ABC’s• Medical Management – Methotrexate – Absolute contraindications: hepatic, renal, or hematologic disorders, PUD, breastfeeding – Relative contraindications: GS > 3.5cm, fetal cardiac activity – Reliable patient• Surgical Management – Salpingectomy – Salpingostomy (tubal preservation)
  • 18. Ectopic Pregnancy Laparoscopy
  • 19. Early Pregnancy Failure Epidemiology• 1 in 4 women will experience a miscarriage in her lifetime• 31 % of pregnancies will fail after implantation – 2/3 of these are silent• 80% of spontaneous abortions are in the first 12 weeks – At least 50% are from chromosomal abnormalities
  • 20. Early Pregnancy Failure Risk Factors• Age – 12% risk < 20 yo – 26% risk > 40 yo• Infection• Endocrine Abnormalities – Hypothyroidism – Diabetes mellitus• Drug Use• Inherited Thrombophilias• Trauma• Uterine abnormalities
  • 21. Early Pregnancy Failure Classification• Threatened• Inevitable• Incomplete• Missed
  • 22. Early Pregnancy Failure Sonographic Features• No gestational sac at β-hcg of 3000• No yolk sac with gestational sac of 13 mm• 5 mm crown-rump length with no fetal heart tones• No fetus with gestational sac of 25 mm mean diameter• No fetal heart tones after 10-12 weeks gestational age
  • 23. Early Pregnancy Failure Management• Expectant – 81% will resolve spontaneously• Prostaglandin E1 (Misoprostol) – Off-label use – Orally or vaginally – 85% completed abortion in 7 days• Manual Vacuum Aspiration – Performed at bedside with sedation and/or local anesthesia – Patient must be stable – 3% failure rate (?)• Dilation & Curettage – Performed in OR under sedation or general anesthesia – Almost 100% success rate – Increased risk of intrauterine scarring with sharp curettage
  • 24. Placental Abruption• Separation of the placenta from the uterine wall• Accounts for ~30% of episodes of bleeding in 2nd half of pregnancy• 1 in 75 to 1 in 226 deliveries
  • 25. Placental Abruption Risk Factors• Increasing parity and/or maternal age• Cigarette smoking• Cocaine abuse• Trauma• Maternal hypertension• PPROM• Multiple gestation• Polyhydramnios• Thrombophilia• Uterine malformations• Placental anomalies• Previous abruption
  • 26. Placental Abruption Clinical Manifestations - Grading• Grade 1 (40%) – Slight vaginal bleeding, minimal uterine irritability – Normal maternal and fetal VS• Grade 2 (45%) – Moderate bleeding with significant uterine irritability or contractions – Maternal HR often elevated – FHR often shows signs of compromise• Grade 3 (15%) – Severe bleeding, painful contractions – Maternal hypotension – Significant risk of fetal death
  • 27. Placental Abruption Diagnosis• Clinical – Severe abdominal pain – Titanic uterine contractions – Abnormal fetal heart rate (bradycardia, decelerations) – Bleeding silent in 10-20%• Sonography – Low sensitivity• Laboratory Findings – Anemia – Consumptive coagulopathy
  • 28. Placental Abruption Management• Expectant – 82% have term delivery if abruption occurs < 20 weeks GA – Only 27% have term delivery if abruption occurs > 20 weeks GA• Delivery – Non-reassuring fetal status – Women presenting at or near term• Supportive Care – Blood products
  • 29. Uterine Rupture Risk Factors• Prior uterine surgery – Cesarean section – Myomectomy• Enlarged uterus – Multiple gestation – Polyhydramnios – Fetal macrosomia
  • 30. Uterine Rupture Presentation• Abdominal pain• Vaginal bleeding• Non-reassuring fetal heart rate
  • 31. Uterine Rupture
  • 32. Uterine Rupture Management• Stabilize the patient (ABC’s)• Emergency cesarean delivery
  • 33. Fetal parts in abdomen
  • 34. Non-PregnantGynecologic Sourcesof Acute Pelvic Pain
  • 35. Gynecologic• Adnexal mass• Ovarian torsion
  • 36. Ovarian Mass• Most benign and malignant ovarian masses are cystic• Incidence 5-15%• Divided into 2 groups – Cystic neoplasms – Functional ovarian cysts
  • 37. Ovarian Mass Symptoms• Asymptomatic • Increased abdominal girth – Ascites – Concerning for malignancy• Cyclic pain – May indicate endometriosis • Hormonal disruption – Abnormal menses• Intermittent, severe pain – Virilization (increased – Torsion androgens)
  • 38. Ovarian Mass Diagnosis• Ultrasound • CT scan – TVUS or TAS – If concern for – Simple or complex malignancy – Fluid or solid – Ascites – Color flow doppler to – Omental masses / caking evaluate for torsion – Liver nodules
  • 39. Simple Ovarian Cyst
  • 40. Polycystic Ovary “string of pearls”
  • 41. Endometrioma “ground glass”
  • 42. Complex Mass
  • 43. Ovarian Mass Management• Pain control• Observation vs Surgical excision• Risk of torsion if >5cm
  • 44. Ovarian Torsion• Twisting of adnexal components – Ovary and fallopian tube rotate around the broad ligament• Mass is identified in 50-80% of unilateral torsion• 70% in women 20-39 yo – 20-25% during pregnancy
  • 45. Ovarian Torsion Presentation• Sharp lower abdominal pain• Usually localized to involved side• Sudden in onset, worsening over several hours• Nausea and vomiting• Low grade fever suggests adnexal necrosis
  • 46. Ovarian Torsion Diagnosis• Sonography (color doppler) – Disruption of normal adnexal blood flow – Blood congestion and edema – Can also characterize any pelvic masses – Presence of flow does NOT rule-out torsion
  • 47. Ovarian Torsion Management• Adnexal detorsion – 95% success rate• Excision of associated ovarian lesions• Removal of ovary and tube often unnecessary
  • 48. Infectious Diseases• Vaginitis• Cervicitis• PID • TOA • Fitz-Hugh-Curtis Syndrome
  • 49. Vaginitis• Bacterial Vaginosis• Candida vaginitis
  • 50. Bacterial Vaginosis• Caused by alteration in normal vaginal flora• Reduction in Lactobacillus species – Hydrogen peroxide producers• Increase in Gardnerella vaginalis, Ureaplasma urealyticum, Mobiluncus species, Mycoplasma hominis, and Proteus species – Anaerobic
  • 51. Bacterial Vaginosis Diagnosis• Malodorous vaginal discharge• 3 Criteria for diagnosis – Wet Prep • Clue cells – pH > 4.5 – “Whiff test” • Release of volatile amines by anaerobic metabolism
  • 52. Bacterial VaginosisWet Prep - Clue Cells
  • 53. Bacterial Vaginosis Treatment• Metronidazole PO – 500 mg BID x7 days• Metronidazole gel 0.75% – 1 applicator intravaginally qday x5 days• Clindamycin cream 2% – 1 applicator intravaginally qhs x5 days
  • 54. Candida Vaginitis• Related to immunosuppresion, diabetes, pregnancy, antibiotic use• Can be sexually transmitted
  • 55. Candida Vaginitis Diagnosis• Pruritis, pain, swelling• Thick white discharge• KOH Prep – Yeast buds and hyphae
  • 56. CandidaKOH Prep – Hyphae & Spores
  • 57. Candida Vaginitis Treatment• Oral – Fluconazole 150 mg x1 – Repeat in 48 hours if symptomatic• Intravaginal – Butoconazole – Clotrimazole – Miconazole – Nystatin – Tioconazole – Terconazole
  • 58. Cervicitis• Trichomonas• Neisseria gonorrhea• Chlamydia trachomatis
  • 59. Trichomoniasis• Most prevalent non-viral STI in US• Most men are asymptomatic
  • 60. Trichomoniasis Diagnosis• ½ women are asymptomatic• Foul, thin, yellow/green discharge• Dysuria, dyspareunia, pruritis, pain• Microscopic identification
  • 61. Trichomonas“Strawberry Cervix”
  • 62. Trichomonas Wet Prep
  • 63. Trichomoniasis Treatment• Primary Therapy – Metronidazole • 1g PO x1 – Tinidazole • 2g PO x1• Alternative Regimen – Metronidazole • 500 mg PO BID x7 days
  • 64. Neisseria gonorrhea• Often asymptomatic – Regular screening for those at risk• Vaginitis or cervicitis – Non-irritating white-yellow discharge• Diagnosis – Endocervical culture +/- empiric antibiotic coverage
  • 65. Neisseria gonorrhea Treatment• Ceftriaxone – 250 mg IM x1• Cefixime – 400 mg PO x1• Treat for Chlamydia• Treat sexual partners Center for Disease Control and Prevention, 2010
  • 66. Chlamydia trachomatis• 2nd most prevalent STD in US• Many are asymptomatic• Mucopurulent discharge• Diagnosis – ELISA
  • 67. Chlamydia trachomatis mucopurulent discharge
  • 68. Chlamydia trachomatis Treatment• Azithromycin – 1 g PO x1• Doxycycline – 100 mg PO BID x7 days• Treat for Neisseria• Treat sexual partners Center for Disease Control and Prevention, 2010
  • 69. Pelvic Inflammatory Disease (PID)• Infection of upper reproductive tract organs• AKA acute salpingitis• Incidence unknown
  • 70. PID Microbiology• ALWAYS polymicrobial• Cultures from different sites in same women differ• N. gonorrhea, T. vaginalis, and C. trachomatis commonly recovered• Other organisms such as E. coli, Enterococcus, and Bacteroides have been implicated
  • 71. PID Diagnosis• Clinical• Sexually active female at risk with “pelvic pain and other etiologies not feasible” – Uterine tenderness – Adnexal tenderness – Cervical motion tenderness – Mucopurulent cervical discharge – Red, inflamed cervix
  • 72. PID - Diagnosis• Oral temp > 38.3 C• Mucopurulent discharge• Abundant numbers of WBC on saline microscopy• Elevated ESR/CRP• Laboratory documentation of infection with N. gonorrhea or C. trachomatis
  • 73. Fitz-Hugh-Curtis Syndrome• Ascending pelvic infection – AKA perihepatitis• RUQ pain, R shoulder pain (referred)• RUQ U/S, LFTs are normal• Treatment is same as PID
  • 74. Fitz-Hugh-Curtis Syndrome Laparoscopy
  • 75. PID Outpatient Treatment Regimens Ceftriaxone 250 mg IM x 1 WITH or OR WITHOUT Cefixime Metronidazole 400 mg PO x 1 500mg PO BID x 14 days ANDAzithromycin 1 g PO x 1 OR Doxycycline100 mg PO BID x 7 days
  • 76. PID Inpatient Treatment Regimens Parenteral Regimen A Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours AND Doxycycline 100 mg orally or IV every 12 hours Parenteral Regimen B Clindamycin 900 mg IV every 8 hours ANDGentamicin loading dose IV or IM (2 mg/kg), followed by maintenance (1.5mg/kg) every 8 hours OR single-daily dosing (5mg/kg) every 24 hours
  • 77. Tubo-Ovarian Abscess (TOA)• Eval PID patient’s for TOA with ultrasound• Patient’s receive IV antibiotics until they are afebrile at least 24 hours• Surgery is rarely required – Consider for abscesses >8 cm – Failure of antibiotic therapy
  • 78. PIDTuboovarian Abscess
  • 79. References• Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 28 Jan. 2011. Web. 18 Apr. 2012. http://www.cdc.gov/std/treatment/2010/toc.htm.• Gabbe, Steven G., Jennifer R. Niebyl, and Joe Leigh Simpson. "Chapter 18: Antepartum and Postpartum Hemorrhage." Obstetrics: Normal and Problem Pregnancies. New York: Churchill Livingstone, 2002• Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K. Aaron. "Chapter 98: Selected Gynecologic Disorders.” Rosens Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.• Rosen, Peter, John A. Marx, Robert S. Hockberger, Ron M. Walls, James G. Adams, and Cynthia K. Aaron. "Chapter 176: Acute Complications of Pregnancy." Rosens Emergency Medicine: Concepts and Clinical Practice. Philadelphia: Mosby Elsevier, 2010.• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 6: First-Trimester Abortion." Williams Gynecology. Nueva York: McGraw-Hill, 2008.• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 7: Ectopic Pregnancy." Williams Gynecology. Nueva York: McGraw-Hill, 2008.• Williams, John Whitridge., John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson, Barbara L. Hoffman, Karen D. Bradshaw, and F. Gary. Cunningham. "Chapter 9: Pelvic Mass.” Williams Gynecology. Nueva York: McGraw-Hill, 2008.
  • 80. Questions??