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Gynaecology Emergencies in Primary Care
Mr Philip KalooConsultant Gynaecologist and
Laparoscopic Surgeon
Until proven otherwise -
• All vaginal bleeding is due to pregnancy• All pelvic pain is due to ectopic pregnancy• All pelvic pain + pyrexia = PID
Bleeding
28 year old comes into your practice complaining of heavy bleeding
ABCHistory – How much?
Menstrual, LMPMedical hx, Drug hx
Examination – ObservationsAbdominal Vaginal
Investigations – pregnancy test
Scenario
7/40 pregnant, heavy bleeding. Soaked 4 pads at home.
BP 90/40, pulse 50Looks pale, not happy
Diagnosis?What do you do?
Speculum and remove products, refer.
So – if Pregnant + bleeding
Ectopic – unlikelyThreatened miscarriageInevitable miscarriageComplete miscarriage
So – if not pregnant + bleeding
Uterine pathologyFibroids, adenomyosis, endometrial pathology (e.g. polyp)
Anovulatory bleeds PCO, perimenopause, perimenarche
Systemic diseaseThyroid disorders, hepatic diseases, renal diseases, adrenal hyperplasia and Cushing's disease
CoagulopathyVon Willebrands disease, thrombocytopenia
IatrogenicIUCD in situ, Anticoagulants, antipsychotics, corticosteroids, pop, SSRI’s, tamoxifen, thyroxine, herbal and other supplements such as ginseng, ginkgo and soy
Dysfunctional uterine bleedingDiagnosis of exclusion
Pain
33 year old, G3P0, IVF 6 weeks ago, PMH – Endometriosis, CIN 3Sx - pelvic pain, no pv bleeding.Hx and examination
What is your differential?1. Ectopic until proven otherwise2. Ovarian cyst incident / torsion3. OHSS4. ?Endometriosis
Pregnancy test
Ectopic till proven
otherwise
GYNAECOLOGICAL
Symptoms – PainAmenorrhoeaEpisodes of syncopeChange in bowel habit
Ovarian cyst incidentOvarian torsionOHSSPIDTubo-ovarian abscess
And ECTOPIC!
+ve -ve
Refer Refer
Ovarian torsion
Uncommon cause of gynae emergencies <4%. 80% in reproductive ageIncreased with pregnancy (14%), ovarian cysts,
previous abdominal surgery, right sided.
Presentation •Systemically unwell (↑ Temp,↑ Pulse, ↑ Resp rate)•Unilateral lumbar or abdominal pain•Pain duration >8 hours•Nausea / Vomiting
Infectiona) PIDb) Tubo-ovarian abscessc) Bartholins cyst/abscessd) Toxic-shock syndrome
PID Presentation:● bilateral lower abdominal tenderness (sometimes radiating to the legs)● abnormal vaginal or cervical discharge● fever (greater than 38°C)● abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’)● deep dyspareunia● cervical motion tenderness on bimanual vaginal examination● adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).
PID – when to refer in
• Surgical emergency cannot be excluded• Clinically severe disease• Tubo-ovarian abscess• PID in pregnancy• Lack of response to oral therapy• Intolerance to oral therapy.
Toxic Shock SyndromeRare 18 cases per year in UK. ½ related to menstruationAcute, noncontagious, toxin-mediated febrile illness caused by staphylococcal
infection
Presentation•pyrexia (>39°C)•hypotension•diarrhoea and vomiting•headache •muscle cramps and myalgias•rash (diffuse macular erythroderma or 'sunburn')•multi-organ dysfunction•shock, adult respiratory distress syndrome, disseminated intravascular coagulation and renal failure