1 / 71

PELVIC PAIN AND NON-PREGNANT BLEEDING

PELVIC PAIN AND NON-PREGNANT BLEEDING. Alyssa Morris, R2 May 14, 2009. Thanks to Dr Jen Butler. Objectives. Causes of pelvic pain in women Mx of pelvic pain in the ED Causes of non-pregnant bleeding in adolescents Causes of non-pregnancy bleeding in post-menopausal women

eros
Télécharger la présentation

PELVIC PAIN AND NON-PREGNANT BLEEDING

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. PELVIC PAIN AND NON-PREGNANT BLEEDING Alyssa Morris, R2 May 14, 2009 Thanks to Dr Jen Butler

  2. Objectives • Causes of pelvic pain in women • Mx of pelvic pain in the ED • Causes of non-pregnant bleeding in adolescents • Causes of non-pregnancy bleeding in post-menopausal women • Dx and Mx of DUB In the ED

  3. Not Covered • Pelvic anatomy • Menstrual Cycle • Pathophysiology of pelvic pain • Pregnant bleeding • Sexual assault

  4. CASE #1 18F with CC of lower pelvic pain which started yesterday and has gradually gotten worse • What else do you want to know? (ie. nb features on Hx)

  5. History • PQRST • Factors that exacerbate/alleviate • Vaginal D/C • Associated Sx • GU Sxs

  6. Hx • Gynecologic • LMP • Obstetrical • Gravida, Para, Complications • Sexual • #partners, current partner, previous STIs, contraception

  7. Case #1 Cont… • States she has had 1 day of sharp, crampy RLQ pain, not radiating that is 5/10 • Nothing alleviates nor exacerbates, not positional • No associated urinary/GI sxs • No vaginal D/C • Otherwise healthy • No STDs, one partner, last sexual intercourse 3m ago, always used condoms • LMP 2 weeks so says no chance she is pregnant…

  8. Annal Emerg Med 1989;18:48-50 • 7% of pts who stated their LMP was N and denied any chance of being pregnant had a positive serum beta

  9. Case #1 Cont… • What is your DDX of acute pelvic pain?

  10. DDX Pelvic Contents • Vagina • Uterus • Fallopian tubes • Ovaries • Ureter • Bladder • Sigmoid colon • Rectum

  11. DDX Think in terms of systems! • Reproductive tract • Nonpregnant • Pregnant • Intestinal tract • Urinary tract

  12. DDX- Reproductive NON-PREGNANT PREGNANT 1st Trimester Ectopic Threatened abortion Endometritis Corpus Luteal Cyst Ovarian hyperstimulation Ovarian Torsion 2nd/3rd Trimester Placenta Previa Placental abruption • Salpingitis/tubo-ovarian abscess • Ovarian Cyst • Ovarian Torsion • Endometriosis • Fibroids • Uterine Perforation • Round Ligament Pain

  13. DDX- Intestinal Tract • Appendicitis • Diverticulitis • IBD • Gastroenteritis • Ischemic bowel dz • Bowel obstruction • Incarcerated hernia • Perforated Viscus

  14. DDx- Urinary Tract • Pyelonephritis • Cystitis • Ureteral stone

  15. Case #1 Cont… What would you like to do on physical exam?

  16. Exam • Vitals • Abdo exam • Speculum exam • Bimanual exam • How good is the bimanual?

  17. CJEM 2003;5(2) • Findings on pelvic exam are subjective • Not reliably reproducible b/t observers • Literature suggests unwise to base decisions on a clinical exam of the female pelvis

  18. Obstet Gynecol 2000;96:593 • Compared ability of med students, obs residents, obs staff to accurately detect adnexal mass • Sens of bimanual for adnexal mass: 15-36% • Spec 79-92% • PPV 26-69% • Up to 2/3 of surgically identified masses were missed on exam • ¾ of pts thought to have mass o/e did not

  19. Case #1 • Temp 37.3, HR 75, RR 16, BP 120/80, O2 99% • CVS, Resp exam N • Abdo- mild tenderness to RLQ, no rebound/peritoneal signs • Speculum exam N • Bimanual- tender to right adnexa, No CMT • Labs are N and Urine Preg Negative

  20. Case #1 Cont… • Let’s assume it is Sunday night at 8pm • How are you going to manage this patient?

  21. Case #1 Cont… • You ask the patient to come back in the morning for an U/S • U/S shows a 3cm, uniloculated, R sided ovarian cyst • What are the complications of ovarian cysts?

  22. Ovarian Cysts • Rupture • Hemorrhage • Torsion • Infection • Resolution What kind of cysts are worrisome?

  23. Ovarian Cysts • BENIGN FEATURES • <8cm • Uniloculated • Unilateral • Thin walls • WORRISOME FEATURES • >8cm • Loculated • Solid • Calcification • Thick walls and septations Ovarian endometriomas, dermoid cysts are CA until proven otherwise

  24. Ovarian Cysts- Mx • <6cm • Usually observed • Most spontaneously resolve in 1-2m • +/- OCP • >6cm, growing or worrisome features • Gyne o/p f/u

  25. Case #1 Cont… • Your patient is back... She was playing soccer, got kicked in the abdomen. 10 mins later had sudden severe right sided lower pelvic pain, 10/10 • What would you be concerned about?

  26. Ovarian/Adnexal Torsion • Ischemia resulting from twisting of the ovary on it’s vascular pedicle • Onset may occur after trauma, intercourse, increased intraabdo pressure or exercise • R>L • Can occur at any age

  27. Torsion- Clinical Presentation • Ann Emerg Med 2001;38(2):156-9 • The most common presentations in adolescents and adults: • N/V 70% • Stabbing pain 70% • Sudden and sharp pain in lower abdo 59% • Pain radiating to back, flank, groin 51% • Peritoneal signs 3%

  28. Ovarian Torsion • U/S with doppler flow evaluation is used for diagnosis • Decreased flow suggestive but not definitive • Surgical evaluation is gold standard • Nb to consider it • Early gyne consultation!!! • Surgical intervention required for adnexal salvage

  29. CASE#2 • 30F comes in with fever, malaise, n/v. Chief complaint is lower abdo pain. • Hx: Multiple sexual partners, previously treated for Chlamydia • O/E: T-38.6, thick d/c from cervix, +CMT • What is at the top of your DDx?

  30. DDx • PID • Cervicitis • Ectopic pregnancy • Endometriosis • Ovarian cyst • Ovarian torsion • Septic abortion • Appendicitis • Diverticulitis • Pyelonephritis • Renal colic • cholecystitis

  31. What do you need to rule out before diagnosing PID?

  32. Ectopic pregnancy Appendicitis

  33. Pelvic Inflammatory Disease • A spectrum of infections of the female upper reproductive tract • Initiated by ascending infection from the cervix and vagina • Includes: • Salpingitis • Endometritis • TOA • Pelvic peritonitis • Perihepatitis

  34. What organisms are mostly responsible?

  35. PID-MOs MO • Gonorrhea and Chlamydia • Polymicrobial- anaerobic and aerobic vaginal flora • GAS, GBS, E. coli, Klebsiella, Proteus, Gardnerella vaginalis, H. influenzae, Streptococcus pyogenes, mycoplasma, Peptococcus • Can also be from TB in endemic areas

  36. What are RFs for PID?

  37. PID- RFs • New or multiple sexual partners • Hx of other STDs • IUD up to 1 month after insertion • Hx of sexual abuse • Younger age of sexual activity • Larger zone of cervical ectopy • Increased cervical mucosal permeability • Risk taking

  38. What are some complications of PID?

  39. PID- Complications • TOA • Reported in 33% • Ectopic pregnancy • Accounts for 50% of ectopic pregnancies • Tubal factor infertility • Increased by 15-50% • Chronic pelvic pain/dyspareunia

  40. PID- Clinical Findings • Lower abdo pain MC presenting complaint • AbN vaginal discharge, vaginal bleeding, poistcoital bleeding, dyspareunia, irritative voiding sxs, fever, malaise, n/v • No single Hx, PE, lab finding is both sensitive and specific for dx of acute PID

  41. What if your pt complained of RUQ pain?

  42. FitzHugh-Curtis Syndrome • Infection may extend by direct or lymphatic spread beyond the pelvis to involve the hepatic capsule or diaphragm • Associated w gonococcal and chlamydial salpingitis • In up to 10% pts w PID

  43. PID-Dx Testing • Pregnancy test always • U/A • CBC • <50% pts with PID have elevated WBC! • ?ESR/CRP • Gram stain and C+S

  44. PID-Swabs • Gen Probe Kit • Large cotton swab is to clean external cervix and the endo cervix, discard it • Insert thin swab into cervix 1-2cm and leave there for 15-30 secs and sent as cervical swab for GC/Chlamydia • Black Top Swab • Use for rectal and oral swabs when you suspect Gonorrhea • Red Top Swab • Used for regular C+S, BV, trichomonas, yeast, GBS

  45. PID-Imaging • Improves accuracy of PID Dx • Transvaginal pelvic u/s • Thickened, fluid filled fallopian tubes, free pelvic fluid • 85% sens, 100% spec • Laparoscopy is gold standard • Hyperemia of the tubal surface, wall edema, exudates

  46. PID- CDC Recommendations Empiric tx of PID should be initiated in sexually active young women and other women at risk for STDs if: • Uterine/adnexal tenderness* • CMT* • Other factors • T>38.3 • AbN cervical/mucopurulent d/c • Presence of WBCs on saline microscopy of vaginal secretions • Elevated ESR, CRP

  47. PID-Tx • Many options • All should cover N. gonorrhea and C. trachomatis, and anaerobic bugs • Quick antibiotics linked to prevention of long term sequelae

  48. PID-Tx 2007 CDC Guidelines (Parenteral) • Cefoxitin 2g IV Q6h or Cefotetan 2g IV Q12h + Doxycycline 100mg PO/IV Q12h • Clindamycin 900mg IV Q8h + Gentamicin 2mg/kg loading then 1.5mg/kg Q8h • Ampicillin-sulbactam 3g IV Q6h + Doxycycline 100mg Po?IV Q12h

More Related