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OBGYN: Pelvic Pain
OBGYN: Pelvic Pain
35
Accounting
Graduate
08/14/2012

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Cards

Term
Pelvic pain starting at END of period:
Definition
PID
Term
Pelvic pain starting with period:
Definition
Endometriosis
Term
Pelvic pain midcycle:
Definition
follicular cyst rupture
Term
sudden onset of pain during coitus/exercise:
Definition
ruptured ovarian cyst
Term
Unilateral pelvic pain ddx:
Definition
- Ectopic Pregnancy
- Appendicitis
- Tubo-ovarian abscess
- Ovarian torsion
- Ovarian cyst rupture
- Ureteral colic
Term
Bilateral pelvic pain ddx:
Definition
- Endometrisosis (chocolate cysts)
- PID (tubo-ovarian abscess)
Term
Central pelvic pain:
Definition
cystitis
Term
An in pulse of 20-30 beats per minute or a decrease in systolic pressure of 20-30 mm/Hg with position change is suggestive of a 30% or more loss of intravascular volume.
Definition
Term
Beta hcg should increase by __/week.
Definition
1000
Term
Treatment options for ectopic pregnancy:
Definition
- beta hcg <15,000, no heart rate, mass less than 3.5 cm> Methotrexate, beta hcg should drop 15% with each dose
- if methotrexate does not work> laparoscopic removal of fallopian tube
Term
Before treating an ectopic pregnancy with methotrexate, what should be done?
Definition
- Renal function studies, BUN & Cr
- Liver function studies
- CBC and WBC
Term
Describe methotrexate treatment for ectopic pregnancy:
Definition
- Day 1: 50mg/m2 Methotrexate IM
- Day 4: Measure b-hcg
- Day 7: Measure b-hcg

If hcg fails to fall by more than 15%, second dose of methotrexate given and follow up restarted

- Once, beta-hcg begins to fall, weekly testing should be done until it is less than 5

(mean time to resolution- 35 days)
Term
How do you treat at ruptured ectopic pregnancy?
Definition
- Laparoscopic surgery immediately
Term
CDC says IF THERE IS__ __ __, OR __ __ __ OR __ __, TREAT WITH ANTIBIOTICS FOR PID. GONHORRHEA AND CHLAMYDIA ARE MAIN CAUSES OF PID. SO IF DON’T TREAT THIS> INCREASED RISK OF ___ BY 15-20%, AND INCREASES RISK OF __ __ 15-25% AND INCREASES RISK OF ___ __ __ 15-25%.
Definition
- bilateral abdominal pain
- cervical motion tenderness
- adnexal tenderness
- infertility
- ectopic pregnancy
- chronic pelvic pain
Term
Who should be screened for gonorrhea and chlamydia?
Definition
All sexually active women under the age of 25 y/o and all women over 25 with multiple sex partners
Term
Pt may have PID but negative cervical culture for G &C. This is bc can have infected tubes but not on cervix.
Definition
Term
When are PID symptoms most likely to occur:
Definition
- end of menses and first 10 days after cycle
Term
PID is a clinical dx. So treat if lower abdominal tenderness, adexal tenderness, or CMT and no other explainable reason. But here are some tests to aid in dx:

Pregnancy test
Differential diagnosis of ectopic pregnancy
Urinalysis
Exclude cystitis or pyelonephritis
WBC count
Fewer than 50% of women with PID have an WBC >10,000
An elevated WBC is NOT a CDC criteria for diagnosing PID
Erythrocyte sedimentation rate (ESR)
Other diagnoses may elevate ESR
C-Reactive protein
Gonorrhea and chlamydia cultures
Definition
Term
Transvaginal u/s findings in acute PID (not routinely done, but helpful to differentiate b/w tubo-ovarian abscess):
Definition
- tubal wall thickening
- incomplete septa in tube
- fluid in cul de sac
Term
Oral tmt for mild-moderate PID:
Definition
- Ofloxacin 400 mg po bid x 14 days, with or without Metrondizazole (Flagyl) 500 mg po bid x 14 days

OR

Levofloxacin (Levaquin) 500 mg po qd x 14 days
Term
IM and oral dosing for PID:
Definition
- Ceftriaxone 250 mg IM single dose + Doxycycline 100 mg bid x 14 days, with or without Metronidazole 500 mg bid x 14 days

OR

Cefoxitin 2 gm IM single dose+ Probonecid 1 gm po single dose + Doxycycline 100 mg po bid x 14 days, with or without Metronidazole 500 mg bid x 14 days

if not better in 72 hrs> admit to hospital

all women with PID should be offered HIV testing
Term
Criteria for hospital admission with PID:
Definition
- pregnancy
- surgical emergencies (appendicitis) cannot be excluded
- no response to oral abx
- cannot follow outpt directions
- severe illness
- tubo-ovarian abscess present
Term
Parenteral abx for tmt of PID:
Definition
- Cefoxitin or Cefotetan 2 gm IV q6hr + Doxycycline 100 mg po/IV q12hrs

OR

- Clindamycin 900 mg IV q8hr + Gentamycin

OR

- Ampicillin and sulbactam (Unasyn) 3 gm IV q6hr + Doxycyclin 100 mg po/IV q12h
Term
Parenteral therapy for PID can be d/c 24hrs after clinical improvement, then continue the following meds:
Definition
- Doxycycline 100 mg bid x 14 days
- Clindamycin 450 mg 4 times a day x 14 days
Term
You have a pt with PID. What should you do about her sexual contacts?
Definition
Document and make an attempt to contact her sexual partners from the past 60 days, if do not attempt or document this> lawsuite materal
Term
Barrier contraceptives (e.g. diaphragms with spermicidal agents) and oral contraceptives are thought to reduce the risk of developing PID.

Intrauterine devices predispose patients to PID
Definition
Term
Before you dx PID make sure you have ruled out everything else (i.e. pregnancy). Also make sure you test for syphilis and offer HIV testing.
Definition
Term
Indurated nodules in the cul de sac on the uterosacral ligament:
Definition
Classic sign of Endometriosis
Term
Endometriosis:
Definition
Limited to reproductive years
More frequent in white population
More frequent in nulliparous patients
Pain more prominent during menses
All sites of endometriosis symptomatic during menses
Term
With endometriosis there is NO relationship b/w severity of symptoms and severity of disease.
Definition
Term
Endometriosis medical treatment:
Definition
GnRh – agonist
Temporary medical castration producing a marked but temporary regression of endometriosis
Danazol
Androgenic derivative used as a “pseudomenopause” regimen to suppress pain
40% recurrence rate
Oral contraceptives
Oral progesterone
Levonorgestrol –releasing IUD reduces dysmenorrhea

Get rid of endometriosis the same way you get rid of fibroids: get rid of estrogen make them menopausal, create an anti-estrogenic atmosphere by giving GnRH agonist: stop bleeding and pain but increase risk of osteoporosis. For every injection you give, reduce bone density by 1%, so no more than 3-6 months. So jusst use this for severe symptoms for short period of time> then birth control pills or progesterone
Term
Surgical tmt endometriosis:
Definition
Desire for future fertility
Laparoscopic or open surgery designed to destroy endometriotic implants and remove all adhesive disease

Most comprehensive surgery includes abdominal hysterectomy, bilateral salpingo-oophorectomy with destruction of peritoneal implants and dissection of all adhesions.

Large endometriomas (>3cm) are amenable only to surgical resection
Term
Sudden acute pain in RLQ: probably not rupture b/c rupture pain would be in all 4 quadrants.

Acute sudden pain: cut off blood supply to any organ

Pelvic mass and intermittent pain> think torsion
Definition
Term
Ureteral calculus lab data:
Definition
Urinalysis
RBC’s
Occasion WBC
Albumin
Crystals
Abdominal Plain Films
Radio opaque stones seen often (80%)
CT Scan
Shows filling defect (80%)
IVP
Shows filling defect (80%)
Term
criteria for dx appendicitis:
Definition
- dull periumbilical pain> RLQ
- N/V
- WBC 12-15,000
- Temp 99-100F
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