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)