Gynaecology Triage

Emma Egan, FY2

Objectives

• Gynae history and examination

• Common gynaecological presentations

• Differentials of pelvic pain

• Management of common gynaecological

conditions

Patient 1

“Could you please assess Miss A, a 19 year old

female who has been referred from GP with

pelvic pain”

History

• PC

• HPC

• Menstrual history

• Gynaecological history

• Obstetric history

• Past medical history

• Drug history

• Family history

• Social history

• Review of symptoms

Examination

• Observations

• Abdominal examination

• Bimanual

• Speculum

Investigations

• Swabs – pending

• Urine – NAD, HCG negative

• Bloods – WCC 14, neutrophils 10, CRP 48

Pelvic Inflammatory disease

• General term for infection in the upper genital tract (uterus, fallopian tubes and ovaries)

• Affects 1-3% of sexually active women

• Can be caused by genital mycoplasmas, endogenous vaginal flora, aerobic streptococci, mycobaterium tuberculosis and STIs (Chlamydia and Gonorrhoea most commonly)

• Risk factors:– Sexually transmitted infection

– Insertion of new IUD

– Termination of Pregnancy

– Post partum endometritis

Pelvic Inflammatory disease

• Management:

– Analgesia

– Antibiotics; Metronidazole 400mg BD +

Ofloxacin 400mg BD for 14 days. Add in Once

off IM ceftriaxone 500mg if high risk of

gonorrhoea infection

– Refer to GUM clinic, contact tracing if high risk

– Review

– Admit if systemically unwell

Pelvic Inflammatory disease

• Complications

– Subfertility

– Ectopic pregnancy

– Chronic pelvic pain

– Fitz-Hugh-Curtis syndrome

– Repeated infections

– Complications in pregnancy

– Neonatal complications

Patient 2

“Could you please assess Mrs B, a 32 year old

female who has been referred from A&E with

pelvic pain”

History

• PC

• HPC

• Menstrual history

• Gynaecological history

• Obstetric history

• Past medical history

• Drug history

• Family history

• Social history

• Review of symptoms

Examination

• Observations

• Abdominal examination

• Bimanual

• Speculum

Investigations

• Swabs – pending

• Urine – NAD, HCG negative

• Bloods – Hb 98, WCC 8, CRP 10

• US pelvis - enlarged left ovary, 5x6x5cm,

no free fluid

Ovarian Cyst Accidents

• Cyst Rupture

• Haemorrhage

• Torsion

– Rare, ~4 in 10,000

– Ovary rotates around its supporting ligaments

– US initially, but if high suspicion will need

diagnostic Lap +/- oophrectomy

– Salvage rates = oophrectomy rates

Patient 3

“Could you please assess Miss C, a 26 year old

female who has been referred from A&E with

pelvic pain”

History

• PC

• HPC

• Menstrual history

• Gynaecological history

• Obstetric history

• Past medical history

• Drug history

• Family history

• Social history

• Review of symptoms

Examination

• Observations

• Abdominal examination

• Bimanual

• Speculum

Investigations

• Swabs – pending

• Urine – NAD, HCG positive

• Bloods – Hb 89, HCG 1500, G&S

• TV US – No intrauterine pregnancy, right

adnexal mass, free fluid in pelvis

• Laparoscopy

Ectopic Pregnancy

• Pregnancy outside uterine cavity

• 2% of all pregnancies

• 95% tubal

– 55% ampullary

– 25% isthmic

– 17% fimbrial

– 2% interstitial

– 5% other, cervical, ovarian, scar

Ectopic Pregnancy

• Risk factors:

– Infertility

– Assisted conception

– History of PID

– Endometriosis

– Previous pelvic/tubal surgery

– Previous ectopic (recurrence rate 10-20%)

– IUCD in situ

– Smoking

– Prior induced abortion

Ectopic Pregnancy

• Management

– Expectant

– Medical

• Methotrexate

– Surgical

– Anti D if required

– 70% of women will have IUP

– Recurrence risk 10-20%

Patient 4

“Could you please assess Mrs D, a 32 year old

female who has been referred from A&E with

pelvic pain”

History

• PC

• HPC

• Menstrual history

• Gynaecological history

• Obstetric history

• Past medical history

• Drug history

• Family history

• Social history

• Review of symptoms

Examination

• Observations

• Abdominal examination

• Bimanual

• Speculum

Investigations

• Swabs – pending

• Urine – NAD, HCG positive

• Bloods – HCG 8000

• TVUS – Gestation sac, no cardiac activity

Miscarriage

• Spontaneous loss of IUP before 20 weeks

gestation

• 10-20% of pregnancies

• Risk increases with maternal age

• 80% diagnosed between 8-12 weeks

Miscarriage

• Threatened miscarriage

• Inevitable miscarriage

• Incomplete miscarriage

• Complete miscarriage

• Missed miscarriage

Miscarriage

• Expectant management

• Medical management

– Misoprostol

• Surgical Management (Dilation and Curettage)