Acute pelvic pain I have no disclosures to report UCSF Obstetrics - PowerPoint PPT Presentation

10/28/2016 � Acute pelvic pain I have no disclosures to report UCSF Obstetrics and Gynecology Update October 2016 Jennifer Kerns, MD, MS, MPH Assistant Professor, UCSF Department of Obstetrics, Gynecology and Reproductive Sciences Gynecologically speaking, what could For those of you working November 1… possibly be wrong? G C B A F E D 1

10/28/2016 Gynecologically speaking, what could Case 1: Miranda Amanda possibly be wrong? G � It’s 4:00 – you think your last patient is a no-show, and then… A. Intrauterine pregnancy B she shows up. B. PID C A C. Ectopic pregnancy � New patient, scheduled for pap. F D. Tubo-ovarian abscess � You walk in the room and she’s holding her lower belly. E. Ruptured ovarian cyst E D F. Torsion � She tells you that she’s had this pain for the last few days and it G. Fibroids started right after she had sex. � You ask her more about the pain… Case 1: Miranda Amanda’s pain Case 1: Miranda Amanda’s history � Constant, started more mild, now more painful, across entire � 29 yo G0 lower abdomen � 3 lifetime partners – currently with partner for 6 months � She was able to go to work yesterday, but was in pain � Has had LNG-IUS for 2 years - amenorrheic � Reports the pain 6/10 � Had chlamydia age 15 and was treated � Nothing makes it better or worse � Appendectomy at age 10 � Some nausea, no vomiting, no diarrhea, unsure about fever/ � Ectopic pregnancy � Pelvic inflammatory disease (PID), chills +/- tubo-ovarian abscess (TOA) � What’s on your DDX? � Ectopic pregnancy � Other adnexal mass � No vaginal discharge, no vaginal bleeding � Ectopic pregnancy � Ruptured ovarian cyst � Fibroids 2

10/28/2016 Pelvic inflammatory disease: More data on Miranda Amanda what where why who when how salpingitis Tubo-ovarian abscess (TOA) � Temp 38.0, otherwise normal vitals � Spectrum of inflammatory disorders endometritis peritonitis � Diffusely tender to palpation across entire lower abdomen � Endocervical canal = barrier cervicitis � On pelvic exam, IUD strings visible, no discharge or bleeding, nl � Vaginal flora upper tract appearing cervix, +cervical motion tenderness, +adnexal � Sexually transmitted pathogens can disrupt this barrier tenderness L>R � chlamydia or gonorrhea infection � 15% progress to PID � What’s 1 st on your differential? What’s after that? � Risk factors: age 16-24, hx of STI/PID, multiple partners, partner w/ STI CDC 2015 Sexually Transmitted Diseases Treatment Guidelines Diagnosis of PID Criteria for diagnosis of PID – NEW!! � Initiate presumptive treatment � Wide variation in presentation � imprecise clinical findings Sexually-active young women or women at risk of STIs � � Clinical dx PID � 65-90% PPV for salpingitis (via laparosc) � Pelvic or lower abdom pain w/ no other known cause � Even mild cases can lead to infertility � CMT or uterine tenderness or adnexal tenderness � Infertility=17%, recurrent PID=14%, CPP=37% Additional (optional) criteria � � Infertility assoc w/ delay in treatment Temp > 101 (38.4) � � Low threshold for diagnosis � Mucopurulent discharge, friability � ++ WBCs on saline wet mount of vag fluid � Favor � sensitivity (and � false pos) � � ESR, CRP � + chlamydia or gonorrhea Peipert et al. AJOG 2011 Ness et al. AJOG 2002 Gaitan et al. Infec Dis Obstet Gynecol 2002 Weisenfeld Obstet Gynecol 2012 3

10/28/2016 Further workup Treatment of PID: oral regimens ★★ Ceftriaxone ★★ Doxy 250mg IM OR Cefox 2g IM (+probenicid 1g PO) � Ultrasound? 100mg BID x14 days � Yes: diagnosis of TOA, consideration of other etiologies (Metronidazole) 500mg BID x14 days � No: if pt is afebrile & access to usg difficult � STI testing: GC, CT, HIV, consider syphilis � Azithro 500mg IV QD x2 days � Azithro 250mg PO QD x14 days � Indications for hospitalization: High fever � (Metronidazole) 500mg PO BID x14 days � Unable to tolerate Pos (n/v) • For cephalosporin allergy Can’t r/o surgical emergency (e.g. appy, torsion) � � Levofloxacin/ ofloxacin/ moxifloxacin • Only if low risk for GC � TOA • If GC +, treat based on (Metronidazole) 500mg BID x14 days � Pregnancy sensitivities or consult ID Outpatient mgmt failed � Treatment of PID: parenteral regimens Follow-up after PID ★★ ★★ Cefotetan 2g IV q12 or ★★ � Re-examine patient in 48 hours Complete 14 days w/ Cefoxitin 2g IV q6 doxy alone 100mg bid Doxy 100mg IV or PO BID � If no improvement, consider ★★ � hospitalization ★★ � ultrasound (80% treatment failures bc of undiagnosed TOA) Clindamycin 900mg IV q8 Complete 14 days w/ � medication change doxy alone 100mg bid Gentamicin (daily dosing or q8) or clinda alone 450mg qid � Test and treat partner(s)! Complete 14 days w/ For TOA…………………………… doxy + clinda doxy + metronidazole 4

10/28/2016 Drainage of TOA Which of the following is false: A. The fear of halloween is called � Early drainage may result in higher efficacy samhainophobia. 33% B. The largest pumpkin ever grown weighed 836 � Transvaginal, transrectal, transgluteal, percutaneous lbs. 25% 24% � Consult radiology/ interventional radiology C. Halloween is thought to have originated in 200 18% A.D. � More successful if D. Orange is a symbol of strength and endurance; � Unilocular, early, >5cm? black is a symbol of death. � 93% success in largest study . . . . . . c e . . . . . . s v r i e o t n t s n e t f No assoc w/ size, locularity e i h o � k g w p l u o o m o b l l u h m a p t y h s s t i f s a o e n e s r g a r e i a w e e l g f o e e n h l a h l T a r T H O Granberg et al. Best Pract Res Clin Obstet Gynaecol 2009 Gjelland et al. AJOG 2005 Case 2: Fernanda Amanda: Fernanda Amanda’s exam Miranda Amanda’s twin sister � Difficulty walking into exam room Add-on, same day appt for a patient with pelvic pain � You know her well because you delivered her first baby 3 months ago � � Vitals normal except HR 105 – uncomplicated NSVD � +guarding, +rebound, +peritoneal signs Other relevant history… � � h/o dermoid cyst, Lapx left salpingo-oophorectomy 3 years ago � Diffuse tenderness w/ abdom and pelvic exam, R>L BMI 40 � � No masses felt but limited by pt’s BMI of 40 � Exclusively breastfeeding, no menses since delivery 1. Torsion � (Most likely) DDX at this point? 2. Ruptured hemorrhagic cyst Her pain � 3. Fibroids “excruciating”, constant but w/ episodes of incr intensity � � But first, rule out…? 4. PID/ TOA � started right after sex yesterday 1. Appendicitis + n/v � 2. Ectopic pregnancy 5

10/28/2016 Fernanda Amanda’s workup Adnexal (ovarian) torsion 1. Torsion � Transvaginal ultrasound obtained � Complete or partial rotation of ovary or tube on its ligaments 2. Ruptured hemorrhic cyst 3. Fibroids � Radiologist calls in a panic: � Often results in impedance of blood flow � pain 4. PID/ TOA “There’s no flow to the right ovary!” � � Risk increases w/ size of mass � Your next step is to… � More likely w/ benign masses � Rush her to the OR? � Ask if they see an adnexal mass � More common in pregnancy � 7cm solid and cystic mass on R ovary, no free fluid, L ov WNL � Consistent with dermoid Varras et al. Clin Exp Obstet Gynecol 2004 Uterus 11 x 7 x 5 w/ 5cm intramural fibroid at fundus � Pansky et al. Obstet Gynecol 2007 Houry et al. Ann Emerg Med 2001 Torsion diagnosis Ultrasound to diagnose torsion � Prospective study of 199 women with acute pelvic pain: Which of the following is true? Finding Sensitivity Specificity PPV NPV 56% Tissue edema 21% 100% 100% 88% A. Torsion is a clinical diagnosis Absent intra-ovarian vascularity 52% 91% 50% 91% B. Ultrasound is the best way to diagnose 34% Absent arterial flow 76% 99% 92% 96% torsion Absent venous flow 100% 97% 85% 100% C. CT is the best way to diagnose torsion 10% � Skill & experience required (sensitivity and specificity in practice are lower than in research studies) Torsion is a clinical diagn... Ultrasound is the best wa... CT is the best way to dia... � Other studies: sensitivity 43%, specificity 92% for absent venous flow Nizar et al. J Clin Ultrasound 2009 6