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Gynaecological abdominal pain

Clinical Discipline(s)/Organ System(s)
Obstetrics & Gynaecology, General Surgery, Reproduction & Development, Genitourinary System
Progress Test Topic(s)
Women's health
Description
A 29 year old NZ European/Māori woman presents to the Emergency Department with lower abdominal pain and some vaginal bleeding.
Applied Science for Medicine 
   - Anatomy of the female reproductive tract
   - Physiology of the normal menstrual cycle and early pregnancy
   - Physiological mechanisms for compensating acute haemorrhage
   - Pathology in early pregnancy: ectopic pregnancy, miscarriage and molar pregnancy
   - Pathophysiology of tubal ovarian disease: ovarian cysts, pelvic inflammatory disease
   - Pathophysiology of isoimmunisation, haemolytic disease of the newborn (HDN) and role of anti-D
   - Pharmacology of methotrexate (for medical management of ectopic pregnancy), misoprostol (for medical management of miscarriage), folate (peri-conceptual) and iodine (supplement in pregnancy)
Clinical and Communication Skills 
   - History from a woman presenting with abdominal pain and vaginal bleeding including information on contraceptive use and risk factors for ectopic pregnancy and miscarriage
   - Examination including speculum and bimanual examination, including Chadwick sign, status of internal os and estimated size of pregnant uterus
   - Differential diagnosis of acute abdominal pain in a pregnant and a non-pregnant woman
   - Recognise importance of considering pregnancy in all reproductive age women with abdominal pain and get a pregnancy test
   - Correct technique to perform endocervical and vaginal swabs
   - Interpret full blood count, blood group, endocervical/vaginal swabs, ultrasound scan, midstream urine, cervical smear, serum beta-HCG
   - Management of acute haemorrhage: classify its severity, noting that increase in pulse rate is an early and hypotension a late sign, especially in young patients
   - Medical and surgical management of a miscarriage or ectopic pregnancy
   - Management of an ovarian cyst accident and pelvic inflammatory disease
   - Recognise and manage Bartholin cysts
   - Appropriate prescribing of anti-D
   - Pre-pregnancy medications e.g. folic acid and iodine
   - Recognise recurrent miscarriage and refer to specialist
   - Effect on future fertility of ectopic, and of pelvic inflammatory disease
   - Appropriate follow-up of benign ovarian cysts
Personal and Professional Skills 
   - Intimate examination and use of a chaperone
   - Counselling regarding early failed pregnancy
   - Importance of patient choice in management of a miscarriage and ectopic pregnancy
   - Discussing future pregnancy plans and fertility
   - Counselling regarding contraception options after ectopic pregnancy
   - Importance of communication with primary care provider
Hauora Māori 
   - Consideration of access to cultural / spiritual support for patient and whānau
   - Ability to cater to differential health literacy needs of Māori patients and whānau
Population Health 
   - Understanding the clinical implications of recurrence of miscarriage and ectopic
   - Importance of communication back to GP
   - Epidemiology of miscarriage, ectopic pregnancy and pelvic inflammatory disease and their recurrence risks
   - Role of smoking on etiology of ectopic pregnancy
   - Role of ectopic pregnancy as cause of maternal mortality
   - Pelvic inflammatory disease as risk factor for ectopic pregnancy and chronic pelvic pain
   - Pelvic inflammatory disease and ectopic pregnancy as risk factors for infertility
Conditions to be considered relating to this scenario
Common
ectopic pregnancy, ovarian cyst accident (torsion, rupture, haemorrhage), benign ovarian cysts, corpus luteum cyst, pelvic inflammatory disease, tubo-ovarian abscess,non-gynaecological causes of abdominal pain, foreign body in vagina, vaginal trauma, cervix (cervicitis, polyp), implantation bleed, illegal abortion, miscarriage (threatened, recurrent, spontaneous, complete or incomplete)
Less common but 'important not to miss'
molar pregnancy
Uncommon
cervical cancer, coagulopathies, thrombophilia
Related Scenarios
[Acute abdominal pain]