1. Gynaecology Emergencies in Primary Care Mr Philip Kaloo Consultant Gynaecologist and Laparoscopic Surgeon

2. Symptoms Bleeding InfectionPain

3. Until proven otherwise - All vaginal bleeding is due to pregnancy All pelvic pain is due to ectopic pregnancy All pelvic pain + pyrexia = PID

4. Bleeding 28 year old comes into your practice complaining of heavy bleeding ABC History – How much? Menstrual, LMP Medical hx, Drug hx Examination – Observations Abdominal Vaginal Investigations – pregnancy test

5. Scenario 7/40 pregnant, heavy bleeding. Soaked 4 pads at home. BP 90/40, pulse 50 Looks pale, not happy Diagnosis? What do you do? Speculum and remove products, refer.

6. So – if Pregnant + bleeding Ectopic – unlikely Threatened miscarriage Inevitable miscarriage Complete miscarriage

7. So – if not pregnant + bleeding Uterine pathology Fibroids, adenomyosis, endometrial pathology (e.g. polyp) Anovulatory bleeds PCO, perimenopause, perimenarche Systemic disease Thyroid disorders, hepatic diseases, renal diseases, adrenal hyperplasia and Cushing's disease Coagulopathy Von Willebrands disease, thrombocytopenia Iatrogenic IUCD in situ, Anticoagulants, antipsychotics, corticosteroids, pop, SSRI’s, tamoxifen, thyroxine, herbal and other supplements such as ginseng, ginkgo and soy Dysfunctional uterine bleeding Diagnosis of exclusion

8. Pain 33 year old, G3P0, IVF 6 weeks ago, PMH – Endometriosis, CIN 3 Sx - pelvic pain, no pv bleeding. Hx and examination What is your differential? 1.Ectopic until proven otherwise 2.Ovarian cyst incident / torsion 3.OHSS 4.?Endometriosis

9. Pregnancy test Ectopic till proven otherwise GYNAECOLOGICAL Symptoms – Pain Amenorrhoea Episodes of syncope Change in bowel habit Ovarian cyst incident Ovarian torsion OHSS PID Tubo-ovarian abscess And ECTOPIC! +ve-ve Refer

10. Ovarian torsion Uncommon cause of gynae emergencies <4%. 80% in reproductive age Increased with pregnancy (14%), ovarian cysts, previous abdominal surgery, right sided. Presentation Systemically unwell (↑ Temp,↑ Pulse, ↑ Resp rate) Unilateral lumbar or abdominal pain Pain duration >8 hours Nausea / Vomiting

11. Infection a)PID b)Tubo-ovarian abscess c)Bartholins cyst/abscess d)Toxic-shock syndrome PID Presentation: ● bilateral lower abdominal tenderness (sometimes radiating to the legs) ● abnormal vaginal or cervical discharge ● fever (greater than 38°C) ● abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’) ● deep dyspareunia ● cervical motion tenderness on bimanual vaginal examination ● adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).

12. PID – when to refer in Surgical emergency cannot be excluded Clinically severe disease Tubo-ovarian abscess PID in pregnancy Lack of response to oral therapy Intolerance to oral therapy.

13. Toxic Shock Syndrome Rare 18 cases per year in UK. ½ related to menstruation Acute, noncontagious, toxin-mediated febrile illness caused by staphylococcal infection Presentation pyrexia (>39°C) hypotension diarrhoea and vomiting headache muscle cramps and myalgias rash (diffuse macular erythroderma or 'sunburn') multi-organ dysfunction shock, adult respiratory distress syndrome, disseminated intravascular coagulation and renal failure

14. Gynae scanning

15. Take home messages Bleeding – Assume pregnant Don’t underestimate Pain – Ectopic till proven otherwise A negative pregnancy test does not exclude an ectopic Ovarian torsion if treated <48 hours = viable ovary Infection – Treat early, refer early