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1- DD OF PELVIC PAIN

1- ACUTE
1.1. Gynecological:
*ectopic pregnancy
*acute pelvic inflammatory disease
*rupture of an ovarian cyst
*adnexal torsion
*threatened,inevitable,or incomplete abortion
*degenerating fibroids or ovarian tumors
1.2. Non-gynecological
* Appendicitis
* diverticulitis
* urinary tract disorders
* mesenteric lymphadenitis

2- Chronic pelvic pain


2.1.gynecological causes:
* Dysmenorrheal
* Endometriosis
* Adenomyosis
* Fibroids
* Retained ovarian syndrome
* Genital prolapse
* Chronic pelvic inflammatory disease
2.2. Non-gynecological causes:
* Adhesions
* Gastrointestinal disturbance
* Musculoskeletal problems

1
2- Non-dysfunctional abnormal uterine bleeding
1-Iatrogenic:
* exogenous estrogen, OCP
* Progesterone-only contraceptive
* Hormone replacement therapy
* aspirin
* heparin\coumadin
* tamoxifen
* steroids
* intrauterine device

2-dyscrasias" blood diseases"


* thrombocytopenia
* increased fibrinolysins
* autoimmune disease
* leukemia
* von willebrans disease

3-systemic disor ders


* hepatic disease (impaired estrogens metabolism)
* renal disease (hyperprolactinemia)
* thyroid disease
* Sepsis

4-trauma
* laceration
* abrasion
* foreign body

5- complications of pregnancy
* Miscarriage
* Ectopic pregnancy
* Gestational trophoblastic disease

6- Neoplasm
* Cervical dysplasia / carcinoma
* endometrial hyperplasia / polyp / carcinoma
* uterine leiomyomas
* Estrogen-producing ovarian tumors
* adenomyosis

7- Infections
* endometritis
* cervicitis

2
3- Dysfunctional uterine bleeding (anovulation)
Physiological
- Adolescence
- Perimenopause
- Lactation
- Pregnancy
Pathologic
- Hyperandrogenic state
- Hyperprolactinemia
- Hypothyroidism
- Low estrogen status (estrogen withdrawal)
- Premature ovarian failure
- Bilateral oophorectomy
- Radiation of mature follicles
- Cessation of exogenous estrogen therapy
- Very high estrogen level (estrogen breakthrough)
- Polycystic ovary syndrome
- Obesity
- Progesterone breakthrough
- long-acting progesterone-only contraceptive
- Progesterone withdrawal
- After stop progesterone such as contraceptive

4- DD OF UTERUS LARGER THAN EXPECTED


- full urinary bladder
- external maternal obesity
- wrong calculation of gestational age
- multiple pregnancy
- molar pregnancy (complete mole)
- macrosomic fetus (ex: diabetic mother)
- polyhydromnios
- Diabetic mother
- Hydrops fetalis
- Fetal abnormalities (ex: esophageal or doudenal atresia)
- Fibroid (leiomyoma)
- adenexal pathology (ex: ovarian cyst)

3
5- DD OF UTERUS SMALLER THAN EXPECTED
- wrong calculation
- oligohydramnions
- single dead fetus
- IUGR
- anencephaly
- shoulder presentation
- missed abortion

6- DD OF EARLY PREGNANCY BLEEDING


- Threatened abortion
- incomplete abortion
- missed abortion
- ectopic pregnancy
- gestational trophoblastic disease (molar)
- implantation bleeding "at the time of 1st missed menstrual period"
- Cervicitis or Vaginitis
- Cervical or vaginal neoplasia
- Chorionic cyst or subchorionic hemorrhage

7- DD OF LATE PREGNANCY BLEEDING


- placenta previa
- abrptio placenta
- vasa previa
- Cervicitis or other genital tract infection
- Bloody show (may indicated Preterm Labor)
- Cervical polyp
- Cervical Cancer
- Cervical Ectropion
- Vaginal trauma
- uterine rupture
- fetal vessles ruptuer

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8- DD OF ABDOMINAL PAIN DURING PRGNANCY
A- due to pregnancy
Early - ruptured ectopic
- Septic abortion with perotonitis
Late
- Labor pain
- Red degeneration of fibroid
- Torsion of pedunculated fibroid
- Ruptured uterus
- Abrupto placenta
- Polyhydramnions
- Chorioamnitis
- HELLP syndrome

B- Acute abdomen associated with pregnancy


- acute pyelonephritis
- acute cystitis
- acute fatty liver of pregnancy
- rupture of rectus abdominus muscle
- torsion of pregnant uterus & stretched round ligament

C- Incidental acute abdo men


* GIT
- Acute Appendicitis
- Acute pancreatitis
- Acute cholecystitis
- Peptic ulcer
- Gastroenteritis
* Vascular (ex: SMA syndrome)
* Respiratory (pneumonia, pulmonary embolism)
* Others
- intraperitoneal hemorrhage
- splenic rupture
- abdominal trauma
- acute intermittent porphyria
- DKA
- SCA (vaso-oclusive crisis)

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9- DD OF Vaginal discharge
A- Blood
- pregnant
*1st trimester
> Normal pregnancy: implantation bleed, abortion
> abnormal pregnancy:
!! Intrauterine> molar
!! extrautrine: ectopic
* 2nd & 3rd trimester
APH due to the causes of APH or PPH due to causes of PPH

- non-pregnant
1st of all u should put in mind the normal menses or variation of menses like menorrhagia, mid
cycle spotting or obviously menarche!!!
*according to age groups:
> adolescents
Anovulatory, Exogenous hormone use, coagulopathy, Trauma, Breakthrough bleeding of OCP
> Perimenopause -around menopause
Anovulatory, Fibroid, endocervical & endometrial polyp, Thyroid dysfunction, Trauma, HRT
incorrect use
* Or according to:
>reproductive:
anovulatory, Exogenous hormone use , Fibroid, endocervical & endometrial polyp,
Thyroid dysfunction , Trauma , Breakthrough bleeding of OCP
> Post menopausal:
Endometrial cancer, endometrial hyperplasia, endometrial cervical polyp, DUB, exogenous
hormone
use, atrophic vaginitis (most common), other tumor (vulvar, vaginal, cervical), trauma

B- Non blood
- physiologic discharge & cervical mucus production.
Many women will have a consistent, slightly clear, non-odor-producing discharge, either
midcycle or premenstrually, particularly if they are on oral contraceptives
A change in odor, consistency, or color of discharge may signify that evaluation is
necessary increased discharge is associated with pregnancy

-non physiologic:
*genital tract infection
> vulvovaginitis with it's causes, chlamydia/ gonorrhea, pyosalpinx, salpingitis
*non-infectious genital tract inflammation
> Local: chemical irritants, douches, sprays, forign body, trauma, atrophic vaginitis,
desquamative inflammatory vaginitis, focal valvitis.
> neoplasia: vulvar, vaginal, cervical, endometrial >>> consider esp with blood
>systemic: toxic shock syndrome, collagen disease, dermatologic (e.g. lichen sclerosis).
>Drugs: IUD (Mirena), OCP.

C- Urine
Fistula like in IBD esp. crhon's & diverticulosis.

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10- DD OF PELVIC- ABDOMINAL MASS
GYNECOLOGICAL CAUSES
Uterus
- pregnancy
- fibroid
- carcinoma
- adenomyosis
Lower quadrants:
- ovarian cyst
- ovarian neoplasm
- ectopic pregnancy
- hydroslpinx
- tubo-ovarian abscess

NON GYNECOLOGICAL CAUSES


- bladder "urine retention"
- feaces
- appendicular mass or abscess
- cecum or colon cancer
- cecal volvulus
- diverticular mass
- sigmoid volvulus
- iliac art aneurysm
- lymphadenopathy

11- Bleeding in postmenopausal women


- Atrophy (59 percent)
- Polyps (12 percent)
- Endometrial cancer (10 percent)
- Endometrial hyperplasia (9.8 percent)
- Hormonal effect (7 percent)
- Cervical cancer (less than 1 percent)
- Other (eg, hydrometra, pyometra, hematometra: 2 percent)
- Disease in adjacent organs — Inflammation of neighboring organs, such as
diverticulitis, can occasionally cause a corresponding inflammation of the female upper
genital tract.
- Diseases of the urethra (eg, urethritis), bladder (eg, cancer or urinary tract infection), and
bowel (eg, inflammatory bowel disease or hemorrhoids) may cause bleeding that is
mistaken
for genital tract bleeding.
- Post radiation therapy
- Anticoagulant therapy.
- Infection.

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12- DDx of loss or decreased fetal movements:
- Normal sleep phase
- Physiological (toward the end of pregnancy)
- decrease maternal perception (idiopathic or distraction)
- Sedative drugs given to mother (barbiturates)
- Intrauterine asphyxia (fetal distress)
- abrptio placenta
- Ruptured uterus
- Fetal death
13- Postpartum fever:
1- endometritis (most common cause)
2- pyelonephritis
3- mastitis
4- breast engorgement
5- respiratory complications
6- wound infections
7- infection of CS incision
8- infection of episiotomy repair
9- infection of spontaneous obstetric lacerations
10- thrombophlebitis
11- septic pelvic thrombophlebitis
12- thrombophlebitis of the lower limb
13- bacterial endocarditis

14- DDx of PROM:


1- membrane infection
2- polyhydraminos
3- incompetent cervix
4- cerclage placement
5- abruptio placenta
6- amniocentesis
7- low socioeconomic status
8- Hx of STD's
9- prioer preterm delivery
10- cigarette smoking
11- multiple gestation
12- trauma
13- decreased collagen content in the membrane
14- vaginal bleeding
15- local infections that will results in weakning of membranes

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15- DDx of fever during pregnancy:
- Cystitis
- Acute pyelonephritis
- Septic abortion
- Amnionitis
- Pneumonia
- Infections: malaria
Typhoid
Hepatitis

17- Recurrent pregnancy loss


1-idiopathic (> 50 %)
2-endocrine factors (10 – 15 %)
- luteal phase deficiency, metabolic disorders, Hypothyroidism, poorly controlled DM
3-anatomical factors (10 -15 % )
- congenital as :
Mullerian fusion abnormalties or less commonly inutero exposuer of DES.
- aquired as:
Uterin fibroid – Ashermane $ - cervical incompetence.
4- genetic factors ( 5 – 10 % )
- parental chromosomal abnormalties, fetal chromosomal abnormalties
5- immunological factors ( 5 – 10 % )
- antiphospholipid antibody $, alloimmunity
6- infection (5 % )
7-others ( 5% )
- enviromental : smoking – alcohol …
- drugs : valproic acid , warfarin