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GYNECOLOGIC EMERGENCIES

GYNECOLOGIC EMERGENCIES. Ectopic pregnancy. DEFINITION Ectopic pregnancy- implantation outside of the uterine cavity. The most common reason of peritoneal signs in gynecology. Frequency of ectopic pregnancy in Europe 1-2: 100. Types of ectopic pregnancy by location. Ampullary 78%

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GYNECOLOGIC EMERGENCIES

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  1. GYNECOLOGIC EMERGENCIES

  2. Ectopic pregnancy

  3. DEFINITION Ectopic pregnancy- implantation outside of the uterine cavity The most common reason of peritoneal signs in gynecology

  4. Frequency of ectopic pregnancy in Europe 1-2: 100

  5. Types of ectopic pregnancy by location • Ampullary 78% • Isthmic 12% 95% „tubal pregnancy” • Fimbrial 5% • Interstitial 2-3% • Ovarian 1% (3% after ART) • Abdominal 1-2% (high mortality) • Cervical 0,5%

  6. Risk factors for ectopic pregnancy • (30-50%) Salpingitis; PID (Chlamydia trachomatis!!!) damage for such infection may retard the passage of the fertilized ovum through the tube to the endometrial cavity • Operations • surgery of fallopian tubes • plastic reconstruction of fallopian tubes • ART • ovarian stimulation • embryo transfer reflux • Previous ectopic pregnancy • Age 35-45

  7. Risk factors for ectopic pregnancy • Contraception ??? • Endometriosis • Congenital defects of fallopian tubes • Psychical spasm of fallopian tubes • Smoking • Multiparous women • Black and Hispanic women • Idiopatic

  8. Symptoms of unrupted ectopic pregnancy Very different - depends of location and development of ectopic pregnancy • Abdominal/pelvic pain- unilateral or bilateral; intermittent or constant • Amenorrhea • Pregnancy symptoms • Vaginal bleeding • Pregnancy test or  HCG

  9. Gynecological examination • Adnexal tenderness • Cervical motion tenderness • Adnexal mass • Uterus- normal size (70%) or enlarged (30%) • Hemoperitoneum; convexity of cul-de-sac

  10. Ectopic pregnancyDiagnosis • Pregnancy test - detects level of  HCG (Human Chorionic Gonadotropin) a) 5 days after conception – serum assays b) 14 days after conception – urinary tests  HCG < 10 mIU/ml – no pregnancy  HCG > 25 mIU/ml – pregnancy 4-5 Hbd  HCG > 750 mIU/ml (or 1000 mIU/ml) and visible in USG Early pregnancy- up to 6 weeks • Increasing of  HCG > 66% in 48 hours • Increasing of  HCG > 114% in 72 hours • Increasing of  HCG > 175% in 96 hours

  11. Ectopic pregnancyDiagnosis 2.USG: • 4-5 weeks of pregnancy- visible in USG • Enlarged size of fallopian tube • Empty uterine cavity • Large endometrium

  12. Ectopic pregnancyDiagnosis 3. Progesterone (always with HCG and USG) • > 25ng/ml - normal pregnancy • < 5 ng/ml - ectopic pregnancy or obsolete pregnancy 4. high concentration of: Estradiol; Il 6; Il 8; TNFα; creatine kinase

  13. The most common symptom of ruptured ectopic pregnancy Hemoperitoneum

  14. Symptoms of ruptured ectopic pregnancy • Hypovolemic shock- a decrease in blood pressure and an increase in pulse • Syncope • Acute abdominal pain • Temperature > 37º C • Urge to defecate or urinary urge • Vomiting • Peritoneal signs- hemoperitoneum • Irritation of the diaphragm- shoulder pain

  15. Differential Diagnosis of Ectopic Pregnancy • any woman of reproductive age with • acute pelvic or lower abdominal pain • abnormal bleeding • amenorrhea • complications of intrauterine pregnancy (complited or incomplited abortion) • acute or chronic salpingitis

  16. Differential Diagnosis of EctopicPregnancy • Follicular or corpus luteum cyst rupture • Endometriosis • Adnexal torsion • Gastroenteritis • Appendecitis

  17. Combined pregnancy (heterotopic pregnancy) • intrauterine and extrauterine gestations 1: 30 000 • after ART 1: 100 approximately 1 in 3 of the intrauterine pregnancies are reproted as surviving

  18. Managment of Ectopic Pregnancy • expectant treatment • pharmacotheraphy (Methotrexate) • surgery

  19. Managment of Ectopic Pregnancy „ expectant treatment” Indications • low  HCG level • ectopic gestation < 4 cm in diameter • ampullary localization • no bleeding • no symptoms of rupture

  20. Managment of Ectopic Pregnancy Pharmacotheraphy Methotrexate (folinic acid antagonist) Indications •  HCG level < 10 000 mIU/ml • ectopic gestation < 4cm in diameter • cervix, ovarium, intramural localization for 20% of women 1 dose is enough

  21. Managment of Ectopic Pregnancy„surgery” • Unruptured • Laparoscopy • salpingtomy • salpingectomy • Laparotomy- surgical techniques • Ruptured • - Laparoscopy • - Laparotomy- surgical techniques • - salpingectomy

  22. Ectopic Pregnancy • Rh- negative mothers with ectopic pregnancy should recieve Rh immune globulin to prevent Rh sensitisation • risk of Rh sensitisation < 1%

  23. Pelvic Inflammatory Disease PID is a polymicrobal infection involving endogenous aerobes and anaerobes as well as sexually transmitted pathogens.

  24. PID Variables that increase the incidence of PID: • teenage years • multiple sexual partners • previous PID • intrauterine device (two months after insertion only) • uterine instrumentation

  25. PID- etiology • Chlamydia trachomatis • Neisseria gonorrhoeae • Escherichia colli, Proteus, Klebsiella, Streptococcus- endogenous aerobes • Bacteroides, Peptostreptococcus, Peptococcus- endogenne anaerobes • Actinomyces israeli- IUCD

  26. Chlamydia trachomatis(intracellular parasite) Infection rates • 20-40% of sexually active women have antibodies to Chlamydia • five times higher in women with three or more partners • four times higher in women using no contraception or nonbarrier methods • up to 20% has asymptomatic cervical infection

  27. Chlamydia trachomatis(intracellular parasite) Symptoms • subtle and nonspecific physical findings • mucopurulent cervicitis • acute urethritis • salpingitis • PID • Fitz-Hugh-Curtis syndrome (perihepatitis) • localized fibrosis with scarring of the liver and adjacent peritoneum

  28. Chlamydia trachomatis(intracellular parasite) Infertility and ectopic pregnancy • mild form of salpingitis with insidious symptoms • established infection remain active for many months • increasing tubal damage

  29. Chlamydia trachomatis(intracellular parasite) • infection is suspected on clinical grounds • culture results (obtained after 48-72 h) confirms the diagnosis • ELISA performed on cervical secretions 95% specificity • monoclonal fluorescent antibody test carried out on dried specimens 90% sensitivity; 95% specificity;

  30. Neisseria gonorrhoeae(Gram-negative intracellular diploccocus) • Easy acquired – single encounter with infected partner leads to infection 80-90% of the time • First signs or symptoms of infection: • 3-5 days after exposure, often mild • malodorous purulent discharge from the urethra, Skene`s duct, cervix, vagina or anus • „mucopus” – greenish or yellow discharge from the cervix • infection of the Bartholin`s gland • Fitz-Hugh-Curtis syndrome • 15% of women with N. gonorrhoeae develop acute pelvic infection (PID)

  31. Neisseria gonorrhoeae(Gram-negative intracellular diploccocus) Laboratory diagnosis: • cultures obtained from the cervix, uretra, anus, pharynx • Thayer-Martin agar plates kept in CO2-rich environment – 80-90% sensitivity

  32. PID Hager’s criteria for diagnosing acute PID: • history of lower abdominal pain or tenderness • cervical motion tenderness and adnexal tenderness (all necessary for diagnosis !)

  33. PID Hager’s criteria for diagnosing acute PID: • fever > 38°C • leukocytosis > 10 000 WBC/mm3 • culdocentesis fluid containing WBCs or bacteria • inflammatory mass on pelvic examination or USG • evidence of gonococcus or Chlamydia on cervical Gram’s stain (one or more of the objective findings necessary for diagnosis !)

  34. PID Clinical diagnosis of PID is often imprecise • white cell count above 10 000 > 50% of patients • positive chlamydia cultures ~ 30% of patients • positive gonorrhea cultures ~ 25% of patients

  35. PID Correct diagnosis in cases of misdiagnosis of PID • acute appendicitis 28% of cases • endometriosis 17% of cases • corpus luteum bleeding 12% of cases • ectopic pregnancy 11% of cases • adhesions 7% of cases • „other” 28% of cases

  36. PID Indications for hospitalization • presence of tuboovarian complex or abscess (TOA) • uncertain diagnosis • significant gastrointestinal symptoms • nulliparity • pregnancy

  37. PID Recommendations for hospitalized patients (no pelvic mass, IUD, recent history of pelvic instrumentation) • cefoxitin 2g IV q6h • cefotetan 2g IV q12h + doxycycline 100 mg q12h regimen continued for at least 48 hours after the patient clinically improves

  38. PID Recommendations for hospitalized patients (pelvic mass, IUD, recent history of pelvic instrumentation) • clindamycin 900 mg IV q8h + gentamycin 2 mg/kg IV, followed by gentamycin 1,5 mg/kg IV q8h regimen continued for at least 48 hours after the patient clinically improves

  39. PID Tests that should be also obtain: • Trichomonas vaginalis screening (wet preparat) • serology syphilis screening • HIV screening

  40. PID If outpatient treatment is used, the patient must be reexamined after 48 to 72 hours. If the response for the treatment is suboptimal, the patient need to be hospitalized and intravenous antibiotics initiated.

  41. PID Recomendation for outpatient therapy • cefoxitin 2g IM + probenecid 1g PO • ceftriaxon 250 mg IM + doxycycline 100 mg PO q12h for 10 - 14 days • tetracycline 500 mg PO q6h for 10 - 14 days • erythromycin 500 mg PO q6h for 10 - 14 days

  42. PID Laparoscopy - diagnosis of PID is in doubt - the patient does not respond to medical therapy

  43. PID Laparoscopic criteria for acute PID minimum criteria • erythema of fallopian tubes • edema and swelling of fallopian tube • exudate from fimbria or on serosa of fallopian tube

  44. PID Scoring • mild: minimum criteria, tubes freely movable and patent • moderate: more marked , tubes not freely movable, patency uncertain • severe: inflammatory mass

  45. PID Complications of PID • formation of tuboovarian abscess (TOA) • ectopic pregnancy(rate seven to ten times normal) • infertility(rate increase proportional to the number of episodes of acute PID) • chronic pelvic pain(approximately 20%) • recurrent PID(approximately 25%)

  46. PID Surgical treatment of PID (extirpation) • Ruptured TOAs, • TOAs that do not respond to medical therapy within 4 to 5 days • TOAs that results in chronic pain

  47. teenanger multiple sexual partners previous PID IUD uterin instrumentation pain pelvic tenderness fever mass vaginal discharge Ectopic pregnancy Infertility Chronic pain RecurentPID Discharge on antibiotic Response Outpatient treatment Complications PID Antibiotic Hospitalization No response Tuboovarian abscess WBC Chlamydial culture or antigen detection test Gonorrhea culture Syphilis wet prep., serology HIV USG Laparoscopy Operative drainage

  48. PID Therapy of the symptomatic as well as asymptomatic male partners is an integral part of treatment PID.

  49. PID Variables that decreases the incidence of PID • use of mechanical contraceptives • use of oral contraceptives

  50. Other causes of bleeding into the abdominal cavity • Rupture of follicular cyst • Corpus hemorrhagicum • Rupture of ovarian tumor • Postoperation bleeding

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