Flashcards in CSS.12.Gyn.AbdPain Deck (46):
What are the five leading diagnoses for acute pelvic pain in females?
ectopic pregnancy, hemorrhagic ovarian cyst, PID, appendicitis, adnexal torsion
what lab test should all women of reproductive age with pelvic pain get?
what is the best initial modality for imaging pelvic pathology and why?
ultrasound, identifies ovarian pathology, notes malignancy, notes any early pregnancy complications
Name 14 common gynecologic causes of acute pelvic pain
spontaneous abortion; ectopic pregnancy; PID; endometritis; salpingitis; tubo-ovarian abscess; degenerating leiomyomas; endometriosis; dysmenorrhea; mittelschmerz; ruptured ovarian cysts; ovarian torsion; pelvic adhesive disease
Name 8 GI/GU causes of acute pelvic pain
UTI, nephroureterolithiasis; interstitial cystitis; gastroenteritis; appendicitis; diverticulitis; IBD, IBS
what are some important history questions to ask a reproductive aged female with acute pelvic pain
age of menarche, LMP start date, duration of flow, quantification of flow, time interval between menses, intermenstrual bleeding, sexual history, contraceptive techniques, h/o pregnancy, h/o STIs, h/o abnormal paps/other gyn procedures
what physical exam should you include when evaluating a reproductive aged female with pelvic pain?
abdominal exam to evaluate for surgical abdomen, pelvic exam to include direct visualization of cervix, cervical motion tenderness, bimanual of uterine size, pelvic masses, possible rectovaginal exam to look for masses
what labs should you obtain when evaluating a reproductive aged female with pelvic pain?
beta-hcg, CBC, BMP, LFTs, UA
what is the most common age group affected by ovarian torsion?
what associated diagnosis is usually found with ovarian torsion?
usually associated with ovarian or tubal tumor, with risk of torsion increasing linearly with tumor size. MCC = dermoid tumors
what patient population is more likely to present with ovarian torsion associated with normal sized ovaries rather than tumors?
children and early adolescents
what is the risk of associated malignant tumor with ovarian torsion?
why is ovarian torsion pain sometimes colicky (comes and goes in waves)?
some ovarian torsions are intermittent, with pain coming in waves, especially associated with activity
what is the underlying pathophysiology of ovarian torsion?
torsion of the ovary's vascular pedicle, initially venous flow is more affected than arterial flow, causing ovarian engorgement --> arterial flow compromised --> ischemia, necrosis, peritonitis
what is the limitation of doppler-ultrasound when evaluating for ovarian torsion?
there can be diminished or absent blood flow in normal adnexa too
what lab and ultrasound findings should you make you suspect ectopic pregnancy?
hCG > 1500-2000 with empty uterus (no intrauterine gestational sac)
what should you do if a patient has an hCG < 1500 but you are suspecting ectopic pregnancy?
get serial hCGs over 48 hours, they will rise in ectopic pregnancy but not with normal pregnancy
what two cervical findings on physical exam are a/w PID?
cervical motion tenderness and mucopurulent cervical discharge
what are the 2 MCC of PID and how is it treated?
gonorrhea and chlamydia, qqf polymicrobial. Tx = abx, qqf surgery to drain tuboovarian abscesses
how do hemorrhagic and ruptured ovarian cysts present?
similarly to ovarian torsion, acute onset pain, adnexal mass on ultrasound, usu a/w more pelvic fluid, no fever, no leukocytosis
how do you treat hemorrhagic and ruptured ovarian cysts?
conservative, U/S abnormalities usu resolve within 6 weeks, any hemodynamic instability requires surgical intervention
what type of ovarian masses can be removed endoscopically and why?
cystic masses can be removed endoscopically b/c they can be decompressed in the endobag
why should you take care not to rupture an endocatch bag when removing a malignant ovarian tumor?
b/c this upstages the malignancy and increases the risk of requiring postop chemo
what type of incision is usually adequate for most benign pelvic pathology? How can it be extended prn?
Pfannensteil, can be extended to Cherny incision by detaching rectus muscles from their tendinous insertions
What type of incision should you perform for suspected malignant GYN pathology?
After how many hours of ovarian torsion does the risk of ovarian necrosis increase?
after 24 hours
Which patients should you strongly consider ovarian conservation over salpingoophorectomy when treating ovarian torsion?
children, adolescents, and women early in their reproductive years
Name two ways to assess ovarian perfusion intraoperatively
IV fluoroscein injection and ovarian bivalving
what are the benefits of ovarian bivalving after detorsion?
After the untwisting of ischemic adnexa, ovarian bivalving is an effective technique to decrease ovarian intracapsular pressure, increase arterial perfusion, and facilitate adnexal reperfusion and recovery.
what is the biggest postop risk associated with ovarian conservation in the case of ovarian torsion?
risk of ovarian necrosis --> peritonitis & systemic infection, therefore closely follow postop
what are the indications for ovarian cystectomy
allows for ovarian conservation, indicated for benign pathology or if diagnosis is uncertain
what are the basic steps of ovarian cystectomy?
1) expose & stabilize ovarian mass; 2) linear or elliptical incision of the serosa over the top of the antimestenteric portion of the mass (bovie or scalpel); 3) blunt/sharp dissection to identify underlying tumor (avoid tumor rupture); 4) control bleeding; 5) can either leave serosa open or reapproximate
what should you do if you have a rupture of an ovarian tumor during removal?
if tumor rupture occurs, ensure all portions of the cyst wall are removed
where does the most significant bleeding occur with removal of the ovarian mass?
at the base of the tumor where ovarian vessels enter the ovarian hilum
what should you do if you cannot control bleeding after removal of ovarian mass / ovarian cystectomy?
can perform oophorectomy if unable to control bleeding
name four indications for salpingoophorectomy
malignant pathology; nonviable ovarian tissue following torsion; definitive management of recurrent benign pathology; and in postmenopausal patients
name the 7 key steps to salpingoophorectomy
1) expose pelvic sidewall, identify infundibulopelvic & round ligaments; 2) incise peritoneum 1cm lateral to infundibulopelvic ligament and develop pararectal space; 3) ID important structures in the RP: ureter, external iliac artery, internal iliac artery, external iliac vein; 4) create window thru peritoneum to isolate ovarian veins from ureter; 5) ligate and divide ovarian vessels; 6) ovary and fallopian tube in anterior traction while transecting inferior peritoneal attachments towards uteroovarian ligament; 7) ligate fallopian tube and uteroovarian ligaments close to uterina cornua
name a potential pitfall during salpingoophorectomy that can lead to ureteral injury
failure to properly develop pararectal space and identify ureter
what maneuver can be performed if tumor size or adhesions prohibit adequate visualization during salpingoophorectomy?
controlled tumor decompression or partial debulking to improve visualization
what are the four risks of leaving an incidentally found adnexal mass while performing an ovarian cystectomy / salpingoophorectomy?
future tumor rupture, hemorrhage, torsion, risk of malignant degeneration
what is the management of an incidentally-found ovarian cyst < or = 5cm in a reproductive-aged female?
usually functional and will self-resolve without nintervention
what are three characteristics of incidentally-found adnexal masses that increase risk of malignant potential?
solid tumors; masses greater than or equal to 10cm in size; associated with excrescences (lumps, swelling, nodules)
what is the relationship between the uterine artery and the ureter?
water under the bridge: uterine artery crosses over the ureter
what is the tunnel of Wertheim?
the ureter enters the tunnel of Wertheim when passing under the uterine artery and heads towards the cervical os (basically where the ureter enters paracervical tissue)
how long postop after salpingoophorectomy or ovarian cystectomy should a patient be under "pelvic rest"
4-6 weeks of pelvic rest postop