1. Gynae Case Presentation
Nick Harper

2. • Abdominal pain
Ms X, 37
History of Presenting Complaint

3. History of Presenting Complaint
• Abdominal pain
•Right Iliac Fossa
•3/52
•Intermittent, “crampy”
•No radiation
•Paracetamol – didn’t help
•Severity 5/10
•1 episode 10/10 for half an hour

4. • G2 P0
• Miscarriage at 18/40
Obs & Gynae History
• Regular unprotected sex
• LMP 6/52
• +ve pregnancy test 3/52
• Regular cycle 7/21
• Chlamydia when 23
• No smear history

5. Examination
Obs:
• HR 80
• BP 115/80
• RR 14
• Sats 99% on air
Abdo:
•Soft, no guarding
•Tender RIF
•Bowel Sounds
present
•Rovsing’s sign –ve
Speculum:
•Normal vulva & Vagina
•Small cyst @ 2 o’clock
on Cervix
•No evidence of
bleeding
•HVS & NAATs taken
Bimanual:
•No cervical
tenderness
•Right adenexal
tenderness
•No mass palpable

6. Differential Diagnosis
• Ectopic Pregnancy
• Appendicitis
• Renal Colic
• UTI
• Ovarian cyst
• Salpingitis
• IBS

7. • Several small fibroids noted
• Spherical mass in right adnexa
Investigations - TVS
•20x15x20mm
•Yolk sac & 4mm fetal node
•Fetal heart pulsitations seen
•Small amount of free fluid
(βHCG >1500 & no sac seen on TVS)

8. Diagnosis
Ectopic Pregnancy
11:1000 pregnancies
Incidence rising
7% of maternal deaths

9. Diagnosis
Ectopic Pregnancy
PID
Previous ectopic
IUD
Endometriosis
Tubal ligation
smoking

10. • Ruptured ectopic can be fatal
• Anti-D prophylaxis if Rh -ve
Management

11. • Expectant
– 88% resolve if βHCG <1000
– No acute symptoms, blood, fluid in PoD
Management
• Conservative
– Methotrexate
– <3.5cm, min symptoms, no fetal heart, βHCG <3000
• Surgical
– Laparotomy if urgent
– Laparoscopy preferred

12. Management
• Laparoscopic Salpingectomy

13. Ectopic locations

14. Salpingotomy

15. Salpingotomy

16. Salpingotomy

17. Salpingotomy

18. Fitz-Hugh-Curtis Syndrome
• Gonorrhea/Chlamydia
• Acute onset RUQ pain
• Aggravated by breathing
• Referred to right shoulder
• Follows episode of PID
• Inflammation - Glisson’s capsule
• “Violin string” adhesions

19. Outcome
• Histology – confirmed POC
• Chlamydia/Gonorrhea negative
• βHCG 1243 (3 days later)
705 (7 days later)

20. Conclusion
“Always think of an ectopic in a sexually active
woman with abdominal pain, bleeding,
fainting, or diarrhoea and vomiting.”
(OHCS)