Pelvic Masses

Pelvic Masses
Preentation by:Anna Mae Smith, MPAS, PA-C
Lock Haven University

Central Pelvic Masses
* Pregnancy
* Leiomyomata - uterine fibroids
* Endometrial malignancy or uterine sarcoma
* Ovarian or other laterally located masses may present centrally
* Bladder

Leiomyomas
* benign smooth muscle tumors of the uterus
* commonly called “fibroids”
* estrogen dependent
* rarely occur before menarche or after menopause
* grow larger during pregnancy
* rarely malignant
* most common indication for pelvic surgery in women

Leiomyomas in Pregnancy
* interfere with fetal growth and nutrition
* increase the risk of
o spontaneous abortion during the first and second trimesters
o preterm labor

Epidemiology of Leiomyomas
* develop from smooth muscle cells by means of metaplasia
* cause for growth is unknown
* occurs in 20% of women of reproductive age
o most often occurs among African American women
o nulliparous women
o women older than 35
o nonsmokers
o oral contraceptive or IUD users


Classification of Leiomyomas
* submucous - protrude into the uterine cavity
* intramural - within the myometrial wall
* subserous - growing toward the serous surface of the uterus
* intraligamentous - located in the cervix or in between the folds of the broad ligament

Leiomyomas: Symptoms
* usually asymptomatic
* symptoms increase as tumors grow
* common symptoms
o pelvic pressure
o bloating
o pelvic congestion
o feeling of “heaviness”
o urinary frequency
o dysmenorrhea
o dyspareunia
o menorrhagia
o pain - less common
* may report infertility
* pregnant women complain more of pain

Leiomyomas: Physical Exam
* absence of ascites
* normal bowel sounds
* enlarged uterus that is firm and irregular but not tender
* may be mistaken for adnexal mass if situated laterally
* if mass moves with the uterus, likely to be a leiomyoma

Leiomyomas: Diagnostic Tests
* CBC to determine if anemic
* UA to r/o urinary tract infection
* Pregnancy test
* Hemoccult
* Ultrasound
* Barium enema
* IVP
* Endometrial biopsy

Leiomyomas: Differential Diagnoses
* ovarian neoplasm
* tubo-ovarian inflammatory mass
* diverticular inflammatory mass
* pregnancy
* ectopic pregnancy
* adenomyosis
* pelvic kidney
* malignancy

Leiomyomas: Treatment
Leiomyomas: Conservative Surgery
* myomectomy
* Leiomyomas: Hysterectomy
* GI Tract

Lateral Pelvic Masses
* Ovary
* Normal premenopausal ovary - 3x2x1.5cms
* Early Menopausal ovary - 2x1.5x0.5cms
* Postmenopausal ovary - 1.5x0.75x0.5cms
* GI causes
* Pelvic kidney
* PID with tubo-ovarian abscess
* Ectopic pregnancy

Ectopic Pregnancy
* Potentially life-threatening condition in which the embryo implants outside the uterine endometrial cavity.
* Leading cause of pregnancy-related death during the first trimester
* Must be considered in all sexually active women of reproductive age who have abdominal pain or abnormal vaginal bleeding

Risk Factors for Ectopic
* current IUD use
* previous tubal surgery
* history of pelvic inflammatory disease
* history of infertility
* In-utero DES exposure
* H/o STD’s
* Smoking
* Progesterone only contraception
* Use of fertility drugs

Classic Triad of Symptoms
* Amenorrhea
* Irregular vaginal bleeding
* Pelvic pain

Physical Findings of Ectopic Pregnancy
* Prior to rupture may feel nothing…usually some form of abnormal bleeding present
* Ruptured:
o Hypovolemic/orthostatic hypotension
o Peritoneal signs
o Positive CMT & adnexal tenderness
o Bulging cul-de-sac of Douglas

Ectopic Testing
Fallopian Tube
Dermoid Cyst/Teratoma
Ovary
Laparoscopy

Pelvic Masses.ppt

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Acute Abdomen in Pregnancy

Acute Abdomen in Pregnancy
Presentation by:Kate Pettit, MS III

DDx of Abdominal Pain in Pregnancy
* Divided into three categories:
1) Conditions incidental to pregnancy
2) Conditions associated with pregnancy
3) Conditions due to pregnancy

Conditions Incidental to Pregnancy

* Acute appendicitis
* Acute pancreatitis
* Peptic ulcer
* Gastroenteritis
* Hepatitis
* Bowel obstruction
* Bowel Perforation
* Herniation
* Meckel’s Diverticulitis
* Toxic megacolon
* Pancreatic pseudocyst
* Ovarian cyst rupture
* Adnexal torsion
* Ureteral calculus
* Rupture of renal pelvis
* Ureteral obstruction
* SMA syndrome
* Thrombosis/infarction
* Ruptured visceral artery aneurysm
* Pneumonia
* Pulmonary embolus
* Intraperitoneal hemorrhage
* Splenic rupture
* Abdominal trauma
* Acute intermittent porphyria
* Diabetic ketoacidosis
* Sickle Cell Disease

Conditions Associated with Pregnancy
* Acute pyelonephritis
* Acute cystitis
* Acute cholecystitis
* Acute fatty liver of pregnancy
* Rupture of rectus abdominus muscle
* Torsion of pregnant uterus

Conditions Due to Pregnancy
* Ectopic pregnancy
* Septic abortion with peritonitis
* Acute urinary retention due to retroverted uterus
* Round ligament pain
* Torsion of pedunculated myoma
* Placental abruption
* Placenta percreta
* HELLP Syndrome
* Acute Fatty Liver of Pregnancy
* Uterine rupture
* Chorioamionitis

Ectopic Pregnancy
* Classic Symptoms
o Abdominal pain
o Amennorrhea
o Vaginal Bleeding
* Diagnosis
o Transvaginal U/S (TVS)
o Serum quantitative HCG
* Management
o Option of medical vs surgical management if pt is hemodynamically stable and no rupture has occurred.
o Emergent surgical management if rupture has occurred and/or patient is hemodynamically unstable
* Prognosis
o Ruptured ectopic pregnancies account for 4- 10 percent of all pregnancy related deaths.

HELLP Syndrome
Hemolysis – Elevated Liver Enzymes – Low Platelets
Acute Fatty Liver of Pregnancy
Definition of Acute Abdomen
* Stedman's Medical Dictionary, 27th Edition defines acute abdomen as "any serious acute intra-abdominal condition attended by pain, tenderness, and muscular rigidity, and for which emergency surgery must be considered.”
Epidemiology
# 1 Acute Appendicitis
# 2 Acute Cholecystitis

Challenges of Diagnosis
* Symptoms
* Physical Exam
* Labs

Which conditions require urgent surgical management in pregnancy?
* Trauma
* Acute appendicitis
* Intestinal obstruction
* Perforated duodenal ulcer
* Spontaneous visceral rupture
* Ectopic pregnancy
* Ovarian or uterine torsion

Timing of Surgery
* 1st trimester (wks 1-12)
o 12% SAb rate
* 2nd trimester (wks 13-26)
o 0 - 5.6% SAb rate
o 5% rate of preterm labor
* 3rd trimester (wks 27-40)
o 30-40% rate of preterm labor

Imaging Options

* U/S: No known adverse effects.
* X-ray: Presence of adverse effects depends on total radiation dose.
* CT: Presence of adverse effects depends on total radiation dose.
* MRI: No known adverse effects.
* ERCP: Only recommended for therapeutic use, not for routine imaging.

Radiation during pregnancy
Use of ERCP in Pregnancy
American Society for Gastrointestinal Endoscopy Guidelines

* ERCP should only be used when therapeutic intervention is intended (usually for biliary pancreatitis, choledocholithiasis, or cholangitis).
* Several studies have confirmed the safety of ERCP in pregnancy.
* With precautions, fetal exposure is well below the 5- to 10-rad level.
o Kahaleh et al. reported an estimated fetal radiation exposure of 40 mrads (range 1-180 mrad).
* Precautions for reducing radiation exposure:
o Lead shields placed under the pelvis an

Reducing Radiation in Pregnancy
* X-ray: PA exposures lowers the radiation dose by 2 to 4 mrad compared with the traditional AP exposures because the uterus is located in an anterior pelvic position.
* CT: Narrow collimation and wide pitch (the patient moves through the scanner at a faster rate) results in a slightly reduced image quality, but provides a large reduction in radiation exposure.

Sequelae of Radiation in Pregnancy
* May cause failure of implantation, malformation, growth retardation, CNS abnormalities, or fetal loss.
* Exposure <10 rads (100 mGy) does not  the risk of fetal death, malformation, or developmental delay.*
* Highest risk of radiation damage during embryonic period of organogenesis (weeks 3-9).

*International Commission on Radiological Protection.
Childhood Leukemia and Radiation
Use of contrast in pregnancy
MRI as an imaging modality
American College of Radiology Paper on MRI Safety
MRI should only be used in pregnancy when:
o The information requested from the study cannot be obtained from nonionizing means.
o The information is needed to care for the pt and fetus during pregnancy.
o The ordering MD does not feel it is prudent to delay diagnosis until after pregnancy.

MRI in Pregnancy
* No studies have shown adverse effects on the fetus or the outcome of the pregnancy.
* However, arbitrarily MRI is NOT usually performed in the 1st trimester 2/2 to this being the period of organogenesis.
* When MRI is used, informed consent must include the possibility that a previously undiagnosed fetal abnormality may be found.

Appendicitis
Signs and Symptoms
* RLQ pain: Most reliable sx
* Anorexia and vomiting: Not sensitive nor specific.
* Direct RLQ tenderness: ~100%
* Rebound tenderness: 55-75% of pts
* Abdominal muscle rigidity: 50-65% of pts
* Psoas sign: Observed less frequently.
* All findings are less common in 3rd trimester due to laxity of abdominal wall muscles.

Adler Sign
Appendiceal Location
Laboratory Evaluation
1st Line Imaging for Appendicitis
2nd Line Imaging for Appendicitis
MRI
Risks for Mother and Fetus
Recommendations for Diffuse Peritonitis
Acute Cholecystitis
Pathophysiology:
Hormones and biliary disease
Epidemiology
Presentation and Diagnosis
Initial Management of Cholecystitis
* IV hydration
* Bowel rest
* Pain control
* Antibiotics
* Fetal monitoring
* Nasogastric decompression if necessary

Surgical Management of Cholecystitis
* Cholecystectomy is now recommended as the primary treatment for cholecystitis because of:
o Recurrence rate during pregnancy of 44-92%, depending on date of 1st presentation
o Reduced use of medications
o Shorter hospital stay and fewer hospitalizations
o Elimination of risk of subsequent gallstone pancreatitis
o Minimizing development of potentially life-threatening complications such as perforation, sepsis, and peritonitis

Other Indications for Cholecystectomy During pregnancy
* Choledocolithiasis (after ERCP)
* Gallstone Pancreatitis
* Recurrent symptomatic cholelithiasis

Laparotomy vs Laparoscopy?
Choosing Surgical Technique
Laparotomy
* Currently considered 1st line approach.
* Always preferred approach when diffuse peritonitis is present, as it is associated with a lower complication rate than laparoscopy in this setting.
Laparoscopy
* First offered in 1991 for pregnant patients for appendectomy and cholecystectomy.
* Many new studies show this technique to be safe in pregnancy for routine appendicitis, especially during the 2nd trimester.
Recommendations to improve safety of laparoscopy during pregnancy
* Obstetrical consultation should be obtained preoperatively.
* When possible, operative intervention should be deferred until 2nd trimester.
* Procedure should be performed with pt in supine, left lateral decubitus position and degree of reverse Trendelenburg should be minimized.
* Open Hasson technique should be used to prevent puncture of uterus.
* Pneumoperitoneum pressures should be minimized to 8-12 mm Hg with maximum 15 mm Hg.
* Administration of tocolytic agents and perioperative monitoring of fetal heart tones should be considered.
* Pneumatic compression devices should always be used as both pneumoperitoneum and the condition of pregnancy are a risk for venous stasis.

Optimizing Delivery
Use of Tocolytics for Preterm Labor
Types of Tocolytics I
Types of Tocolytics II
Use of corticosteroids to improve fetal outcomes in premature delivery
Steroids and peritonitis?
References

Acute Abdomen in Pregnancy.ppt

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Early pregnancy abnormalities

Early pregnancy abnormalities
Presentation lecture by:Angela F. Hawk

Goals of the talk:
* Differential diagnosis/work up for first trimester bleeding
* Different types of first trimester pregnancy loss
* Ectopic pregnancies: diagnosis and management
* Miscellaneous other oddities of the first trimester

First trimester bleeding
* Occurs in 20-40% women
* Etiology often unknown, goal = exclusion
* Prognosis: association b/w FTB and adverse outcome (SAB, PTD, PPROM, IUGR)
o Worse prognosis with heavier bleeding or extending into second trimester
o PTD frequency with no, light, or heavy FTB was 6, 9.1, and 13.8% respectively
o Spontaneous loss frequency prior to 24 WG was 0.4, 1.0, and 2.0 % respectively
o Vaginal bleeding in >1 trimester associated with 7 fold increased in PPROM
Evaluation – part I

* History
o Extent (amt, associated signs/sx, pain)
o Past history (previous ectopic, prior SABs, medical disorders, risk factors)
* Eval part II – physical
o Vital signs
o Tissue if available (clot vs POC)
o Abdominal exam (+/- dopplers)
o Speculum exam (external and internal) – look for lacerations, warts, vaginitis, cervical polyps, fibroids, ectropion, cervicitis, neoplastic process
o Bimanual exam – assess adnexal/cervical tenderness, adnexal masses, uterine enlargement

Ultrasound
* Cornerstone of evaluation
* Most useful with positive preg test where IUP not previously seen
* Uses: location of pregnancy (intra- or extrauterine), viability (+/- FCA), other rare findings (GTD, partial loss of multiple gestation)

Laboratory evaluation
* HCG levels – useful only with serial measurements
* No role in monitoring once viable IUP has been verified by ultrasonography
* Less useful: progesterone, estrogen, inhibin A, Papp-A)
* Always get type and screen and give rhogam if applicable

Differential diagnosis
* Abortion (threatened, inevitable, complete, incomplete, missed)
* Ectopic pregnancy
* Vanishing twin
* Trauma, wounds, vaginitis, vaginal/cervical neoplasia, warts, polyps, fibroids, ectropion
* Physiologic/implantation (diagnosis of exclusion)

Miscarriage

* SAB = most COMMON complication of early pregnancy
* 8-20% of clinically recognized pregnancies under 20 wks undergo SAB, 80% of these will be <12 wks
* Low risk of loss after 15 wks (0.6%) if fetus chromosomally normal
* Loss of unrecognized/subclinical pregnancies occurs in 13-26% of all pregs
o Unlikely to be recognized without daily UPTs

Early loss – the data
Types of miscarriage
* Threatened: closed cervix, uterus appropriately sized, FCA present if gestational age sufficiently advanced
* Inevitable: cervix dilated, increased bleeding with cramps/ctx, POC can be at os
* Complete/incomplete
* Missed: in utero death of embryo prior to 20th wk with retention of pregnancy for prolonged period of time. Cervix closed, +/- bleeding
* Septic abortion: rare with SABs, foreign bodies ie IUDs, invasive procedures, legal EABs; common complication of illegal EABs.

Ultrasound and SABs
* Definitive diagnosis of SAB when:
o Absence of FCA with CRL >5mm
o Absence of fetal pole when mean sac diameter >25 mm (TAUS) or >18 mm (TVUS)
o Absence of yolk sac 32 days post IVF
* Promising findings for lack of SAB
o Yolk sac b/w 22-32 days from IVF associated with +FCA in 94% pregs
o Positive FCA…. But age matters! Women <36 +FCA associated with SAB in only 4.5% pregs. 36-39 y/o SAB rate 10%, women >40 y/o SAB rate 29%.

You might worry when…
* YS abnormal (irregular, LGA, free floating)
* Slow fetal heart rate (ie HR <85 bmp at 6-8 wks associated with 0% survival)
* Small sac (MSS-CRL <5 mm)
* Subchorionic hematoma (ie double SAB rate with women with large -- >25% of gest sac volume -- subchorionic hematomas in study of first trimester bleeders)
* Management
* Threatened: expectant
* Complete: ideally nothing, but difficult to distinguish clinically/ radiologically so consider D&C
* Septic: stabilize pt, obtain blood and endometrial cultures, broad spectrum Abx (gent + clinda +/- amp), D&C
* 3 options for incomplete, inevitable, and missed ABs
* Surgical: D&C – use this if bleeding heavy, suction curettage is best. Data on Abx (doxycycline) post SABs limited. Has shown 42% decrease in infection with EABs
* Medical: Miso (some studies show expulsion in 71% by day 3, 84% by day 8)
* Expectant: use if stable vital signs, no evidence of infection. Can be used for up to one month

Ectopic pregnancy
* 3 classic symptoms: abdominal pain (99%), amenorrhea (74%), vaginal bleeding (56%)
* Occur with both ruptured and unruptured cases
* Clinical manifestations often appear 6-8 wks after LMP but can appear later
* Often see above symptoms with breast tenderness, frequency urination, and nausea
* Shoulder pain (blood irritating diaphragm), urge to defecate (blood pooling in cul-de-sac) can also be seen with ruptured ectopic pregnancies
* 50% women asymptomatic before rupture with no identifiable risk factors

Differential diagnosis abdominal pain (a very limited list)
* UTIs
* Nephrolithiasis
* Diverticulitis
* Appendicitis
* Ovarian neoplasms
* Endometriosis
* Endometritis
* PID
* IBS
* Fibroids
* Gastroenteritis
* Interstitial cystitis
* Pregnancy miscellaneous!

Risk factors - high
Risk factors – moderate
Risk factors - low

Initial evaluation
Ectopic preg: ultrasound pics
hCG monitoring
Discriminatory zone
Management – above the DZ
Management: below DZ
Uncommon ectopic cases
Cervical pregnancy
Natural history
Management
Gestational trophoblastic disease
Epidemiology
Clinical manifestations
* Vaginal bleeding
* Enlarged uterus
* Pelvic pressure/pain
* Theca lutein cysts
* Anemia
* Hyperemesis gravidarum
* Hyperthyroidism
* Preeclampsia prior to 20 wks gestation
* Vaginal passage of hydropic vesicles
Complete moles
Partial moles
Management
References

Early pregnancy abnormalities.ppt

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