EARLY PREGNANCY
EMERGENCY PRESENTATIONS
ECTOPIC PREGNANCY Ovarian mass/Torsion Acute PID
• Embryo attaches outside uterus usu. in fallopian tube (cornual region) -also Partial/ complete twisting of ovary Ascending infection of upper female
cervix, ovary or abdomen and fallopian tube around genital tract
Define supporting ligaments Usu. chlamydia trachomatis or Neisseria
• 1-2% of pregnancies (1 in 100)
gonorrhoea
Anatomical • Anatomical = ovarian • Multiple sexual partners
• hx of ectopic, enlargement (cysts/tumours),
• Unprotected sex
long ovarian ligament’s or
• hx of endometriosis, • Hx of STI or adnexitis
laxity of pelvic ligaments
• hx of PID (tubal scarring)
• Non-anatomical = mirena IUD • IUDs (copper, mirena)
RF Non-anatomical
(+++ cysts), adolescents,
• Smoking, obesity, pregnancy and IVF
• Advanced age,
• IUD (coils)
• IVF
• Amenorrhoea 4-6 wks LMP • SUDDEN onset unilateral • Bilateral lower abdo pain (may
abdo-pelvic pain have concurrent appendicitis)
• Recent UPSI
• Crescendo-decrescendo pain • Fever
Non-rupture = • Nausea and vomiting • N/V
• crampy lower abdo or pelvic pain, • Vitals (stress response) = ↑HR, • Dysuria, dyspareunia
• pregnancy signs (nausea, tender breasts) HTN • PV or cervical discharge
• Pain on palpation (abnormal in smell/colour)
Sx • cervical motion tenderness (localised/diffuse – depends Exam:
• vaginal bleeding (Usu. less bleeding than last period (DO NOT DISMISS!!)) on size of cysts) • Vitals (HTN, tachycardia,
Ruptured • ?palpable adnexal mass (i.e. tachypnoea, febrile)
growth around uterus) • Adnexal tenderness on palpation
• severe sudden onset abdo pain,
• NO PAIN = ischeamia of • Vag exam ® cervical discharge
• Dizziness / syncope / hypoTN, tachycardia (hypovol) affected ovary and
• Shoulder tip pain (peritonitis) compromised blood supply
• Pregnancy of unknown location (+B-HCG but no sign of pregnancy on TVUS) • •
• Ovarian torsion
DDx • PID
• Appendicitis/diverticulitis
• Serum B-HCG (> 1000-1500) - pregnancy of unknown location • FBC (++WBC) • FBC (++WBC)
o Serial B-HCG every 48 hrs • ++ CRP • ++ ESR
o Rise > 63% = intra-uterine pregnancy
• Serum B-HCG (exclude • Urine and serum B-HCG
o Rise < 63% or static over 2 days = ectopic or pregnant pregnancy) • TVUS (free fluid, abscess,
o Fall > 50% = miscarriage
pyo/hydrosalpinx)
• FBC (anaemia) + Group + X-match
TVUS + doppler • GU swabs (endocervical, high
• EUC, LFT
Ix • Reduced blood flow vaginal, urethral) è C+G PCR
• COAGs (if suspected coagulopathy)
• ≥ 6cm – highest risk of torsion • Endometrial biopsy è
• TVUS (best)
?endometritis
o free fluid in POD or uterine cavity • Thickened fallopian tube
• Exploratory laparoscopy è
o empty uterus
ambiguous cases
o gestational sac with yolk sac or fetal DDx: appendicitis, ruptured ectopic,
pole in fallopian tube (“blob sign” or renal colic
“bagel sign”)
• Infertility • Compress ovarian vein + • Infertility (tubal scarring and
• Death – hypovol. Shock /sepsis lymphatics ® reduced adhesion) ® O+G referral
Comp. • Cervical shock = HypoTN and bradycardia (due to vagal stimulation)
venous outflow • Ectopic pregnancy
• Oedema ® ischemia ® • Peritonitis, perihepatitis
necrosis • Chronic pelvic pain
Unstable • Emergency exploratory Unstable
1) Help – O+G consult laparoscopy for ALL patients
• DRS ABCD:
2) ABCD – vasopressors / inotropes with suspected torsion
3) IVF o Broad spectrum IV abx
(even if imaging is inconclusive) (cephalosporin + adjuncts)
4) TVUS = identify location of free fluid
• Pre-menopausal è adnexal o Analgesia
5) Surgery – laparotomy/laparoscopy/ salpingectomy
detorsion and preservation of
Stable ovaries
Expectant Medical Surgery
• Post-menopausal è salpingo- Stable = Mild-mod
Unruptured ectopic Unruptured ectopic Haem unstable
oopherectomy o outpt monitoring
• if HCG < 1500 1. if HCG < 5000 • if HCG > 5000
Ind
• mass < 3.5cm 2. mass < 3.5cm • mass > 3.5cm
• no FHB or pain 3. no FHB or pain • Visible HB or pain Additional: Stable = Severe
Mx Natural termination IM MTX 50mg/kg – NBM + IVF maintenance Ø Ovarian cystectomy and • surgery (NBM, anaesthetics, bowel
dissolve POC +/- Vasopressor drainage (if indicated) prep)
1. CI: allergy,
How? interstitial ectopic, Ø Oophoropexy ® fix ovary to • Previous meds (e.g. anti-coags,
Laparoscopic abdominal wall to reduce
HIV/BBV anti-DM, thyroid meds, COCP, anti-
1. salpingectomy motion OR shorten utero- HTN)
2. A/E N/V, PV
2. Salpingotomy ovarian ligaments
bleed, conjunctivitis
Follow up in EPAS Follow up in EPAS Follow up in EPAS FOLLOW-UP
• Analgesia 1. Repeat HCG on Ø Anti-D in Rh -ve Long-term
Day 4, 7 post dose women • Contact tracing of sexual partners
Post- • Bereavement/ Ø COCP (prevent cyst formation) (once swab results return)
Counselling (↓15% expected) Ø salpingostomy – risk of
Mx Ø CA-125 and cancer work up
2. Contraception for persistent o 2/12 if gonorrhoea
• Plans for
3/12 post MTX – trophoblastic disease
future o 6/12 if chlamydia
prevent teratogen Ø counsel pain + grief
EMERGENCY PRESENTATIONS
ECTOPIC PREGNANCY Ovarian mass/Torsion Acute PID
• Embryo attaches outside uterus usu. in fallopian tube (cornual region) -also Partial/ complete twisting of ovary Ascending infection of upper female
cervix, ovary or abdomen and fallopian tube around genital tract
Define supporting ligaments Usu. chlamydia trachomatis or Neisseria
• 1-2% of pregnancies (1 in 100)
gonorrhoea
Anatomical • Anatomical = ovarian • Multiple sexual partners
• hx of ectopic, enlargement (cysts/tumours),
• Unprotected sex
long ovarian ligament’s or
• hx of endometriosis, • Hx of STI or adnexitis
laxity of pelvic ligaments
• hx of PID (tubal scarring)
• Non-anatomical = mirena IUD • IUDs (copper, mirena)
RF Non-anatomical
(+++ cysts), adolescents,
• Smoking, obesity, pregnancy and IVF
• Advanced age,
• IUD (coils)
• IVF
• Amenorrhoea 4-6 wks LMP • SUDDEN onset unilateral • Bilateral lower abdo pain (may
abdo-pelvic pain have concurrent appendicitis)
• Recent UPSI
• Crescendo-decrescendo pain • Fever
Non-rupture = • Nausea and vomiting • N/V
• crampy lower abdo or pelvic pain, • Vitals (stress response) = ↑HR, • Dysuria, dyspareunia
• pregnancy signs (nausea, tender breasts) HTN • PV or cervical discharge
• Pain on palpation (abnormal in smell/colour)
Sx • cervical motion tenderness (localised/diffuse – depends Exam:
• vaginal bleeding (Usu. less bleeding than last period (DO NOT DISMISS!!)) on size of cysts) • Vitals (HTN, tachycardia,
Ruptured • ?palpable adnexal mass (i.e. tachypnoea, febrile)
growth around uterus) • Adnexal tenderness on palpation
• severe sudden onset abdo pain,
• NO PAIN = ischeamia of • Vag exam ® cervical discharge
• Dizziness / syncope / hypoTN, tachycardia (hypovol) affected ovary and
• Shoulder tip pain (peritonitis) compromised blood supply
• Pregnancy of unknown location (+B-HCG but no sign of pregnancy on TVUS) • •
• Ovarian torsion
DDx • PID
• Appendicitis/diverticulitis
• Serum B-HCG (> 1000-1500) - pregnancy of unknown location • FBC (++WBC) • FBC (++WBC)
o Serial B-HCG every 48 hrs • ++ CRP • ++ ESR
o Rise > 63% = intra-uterine pregnancy
• Serum B-HCG (exclude • Urine and serum B-HCG
o Rise < 63% or static over 2 days = ectopic or pregnant pregnancy) • TVUS (free fluid, abscess,
o Fall > 50% = miscarriage
pyo/hydrosalpinx)
• FBC (anaemia) + Group + X-match
TVUS + doppler • GU swabs (endocervical, high
• EUC, LFT
Ix • Reduced blood flow vaginal, urethral) è C+G PCR
• COAGs (if suspected coagulopathy)
• ≥ 6cm – highest risk of torsion • Endometrial biopsy è
• TVUS (best)
?endometritis
o free fluid in POD or uterine cavity • Thickened fallopian tube
• Exploratory laparoscopy è
o empty uterus
ambiguous cases
o gestational sac with yolk sac or fetal DDx: appendicitis, ruptured ectopic,
pole in fallopian tube (“blob sign” or renal colic
“bagel sign”)
• Infertility • Compress ovarian vein + • Infertility (tubal scarring and
• Death – hypovol. Shock /sepsis lymphatics ® reduced adhesion) ® O+G referral
Comp. • Cervical shock = HypoTN and bradycardia (due to vagal stimulation)
venous outflow • Ectopic pregnancy
• Oedema ® ischemia ® • Peritonitis, perihepatitis
necrosis • Chronic pelvic pain
Unstable • Emergency exploratory Unstable
1) Help – O+G consult laparoscopy for ALL patients
• DRS ABCD:
2) ABCD – vasopressors / inotropes with suspected torsion
3) IVF o Broad spectrum IV abx
(even if imaging is inconclusive) (cephalosporin + adjuncts)
4) TVUS = identify location of free fluid
• Pre-menopausal è adnexal o Analgesia
5) Surgery – laparotomy/laparoscopy/ salpingectomy
detorsion and preservation of
Stable ovaries
Expectant Medical Surgery
• Post-menopausal è salpingo- Stable = Mild-mod
Unruptured ectopic Unruptured ectopic Haem unstable
oopherectomy o outpt monitoring
• if HCG < 1500 1. if HCG < 5000 • if HCG > 5000
Ind
• mass < 3.5cm 2. mass < 3.5cm • mass > 3.5cm
• no FHB or pain 3. no FHB or pain • Visible HB or pain Additional: Stable = Severe
Mx Natural termination IM MTX 50mg/kg – NBM + IVF maintenance Ø Ovarian cystectomy and • surgery (NBM, anaesthetics, bowel
dissolve POC +/- Vasopressor drainage (if indicated) prep)
1. CI: allergy,
How? interstitial ectopic, Ø Oophoropexy ® fix ovary to • Previous meds (e.g. anti-coags,
Laparoscopic abdominal wall to reduce
HIV/BBV anti-DM, thyroid meds, COCP, anti-
1. salpingectomy motion OR shorten utero- HTN)
2. A/E N/V, PV
2. Salpingotomy ovarian ligaments
bleed, conjunctivitis
Follow up in EPAS Follow up in EPAS Follow up in EPAS FOLLOW-UP
• Analgesia 1. Repeat HCG on Ø Anti-D in Rh -ve Long-term
Day 4, 7 post dose women • Contact tracing of sexual partners
Post- • Bereavement/ Ø COCP (prevent cyst formation) (once swab results return)
Counselling (↓15% expected) Ø salpingostomy – risk of
Mx Ø CA-125 and cancer work up
2. Contraception for persistent o 2/12 if gonorrhoea
• Plans for
3/12 post MTX – trophoblastic disease
future o 6/12 if chlamydia
prevent teratogen Ø counsel pain + grief
