A12. Acute abdomen in gynecology
Ectopic pregnancy
Ectopic pregnancy is a pregnancy in which the fertilised egg attached in a location other than the uterine cavity. It can be lethal and as such must be excluded in all cases of acute abdomen in women of reproductive age. Symptoms usually begin in week 6 – 8.
95% of ectopic pregnancies occur in the fallopian tube, most commonly in the ampulla. Other potential locations include the ovary, abdomen, hysterotomy scar, and cervix.
Etiology
- Pelvic inflammatory disease
- Previous ectopic pregnancy
- In vitro fertilisation (IVF)
- Surgery involving fallopian tubes
- Intrauterine device (IUD)
Clinical features
Ectopic pregnancy may present with abdominal pain or vaginal bleeding. As with any pregnancy, there is often amenorrhoea.
However, the fallopian tube (or other implanted structure) may suddenly rupture, causing sudden onset severe, persistent abdominal pain with haemodynamic instability or haemorrhagic shock.
Diagnosis and evaluation
Acute abdomen is evaluated in an emergency department. Ruptured ectopic pregnancy should be suspected in case of typical clinical symptoms together with evidence of echogenic fluid (blood) in the Douglas pouch or abdomen on ultrasound.
In case of non-acute cases, the combination of positive hCG and no intrauterine pregnancy on ultrasound is suspicious for ectopic pregnancy. Adnexal mass on physical examination or ultrasound is also suspicious. If an extrauterine gestational sac can be visualised, the diagnosis is confirmed.
Treatment
Suspected ruptured ectopic pregnancy must be treated with emergency surgery, either with laparoscopy or laparotomy. The ectopic pregnancy may be removed without removing the whole fallopian tube (salpingostomy) or we may remove the whole fallopian tube (salpingectomy). In case of ruptured tube, salpingectomy is usually required.
Uncomplicated ectopic pregnancy may resolve itself. In some cases, we can watch and wait, but in most cases we use methotrexate to terminate the pregnancy. If methotrexate is contraindicated, we can perform salpingostomy or salpingectomy. If the contralateral ovary and tube are intact, salpingectomy is usually performed. If not, salpingostomy can be performed instead (in an attempt to maintain fertility).
Ovarian torsion
Ovarian torsion is the complete or partial rotation of the ovary around the ligaments which hold them in place. The fallopian tube may also twist, called adnexal torsion. These decrease the blood flow to the two organs, causing necrosis and acute abdomen.
Risk factors
- Ovarian cysts
- Ovarian tumour
- Prior tubal ligation
- Longer than normal ovarian ligament
Clinical features
The patient presents with severe abdominal pain, nausea, and vomiting.
Diagnosis and evaluation
Physical examination may reveal adnexal mass and uterine tenderness. Doppler ultrasound is the initial investigation used, in which the following can be seen:
- Hypoechoic or hyperechoic ovary
- Free pelvic fluid
- Ovarian cyst or tumour
- Little or no venous and arterial blood flow in the ovary – (not always present)
Treatment
The treatment is emergency surgery, mostly with laparoscopy. If the ovary is not infarcted, we can untwist it. If it is infarcted, salpingo-oophorectomy is necessary.
Tubo-ovarian abscess
Tubo-ovarian abscess is a late complication of pelvic inflammatory disease. It can be life-threatening if it ruptures, which can cause sepsis. The pathogens of tubo-ovarian abscesses are usually E. coli, peptococci, and streptococci.
Approximately 15% of these abscesses rupture.
Clinical features
The main complaint is acute lower abdominal pain, sometimes with fever. If the abscess has ruptured, sepsis may be present.
Diagnosis and evaluation
Physical examination may reveal adnexal mass, cervical motion tenderness, uterine tenderness, and sometimes vaginal discharge.
Transvaginal ultrasound is essential and reveal:
- Enlarged ovary and fallopian tube
- Multilocular complex retro-uterine or adnexal mass with echogenic debris
- Free fluid in pelvis
Treatment
The treatment is intensive antibiotic therapy with or without drainage. Antibiotic therapy is usually intravenous and involves broad-spectrum antibiotic combination. In severe cases, ultrasound-guided drainage or surgical drainage can be performed.
Surgery, usually laparoscopy, is required in cases of ruptured abscess.
Corpus luteum haemorrhage
Bleeding into the corpus luteum is physiological and mild, and occurs after every ovulation. However, in some cases the corpus luteum can form a cyst which can rupture, causing severe bleeding into the abdominal cavity.
Clinical features
The patient presents with acute abdomen at mid-menstrual cycle, sometimes with signs of hypotension like dizziness and syncope.
Diagnosis and evaluation
Physical examination may reveal fluid in the Douglas pouch. Transvaginal ultrasound also finds fluid in the pelvis. A CBC should always be performed to look for anaemia.
Treatment
The treatment is surgical, either laparoscopy or laparotomy. The bleeding can be stopped by suturing, cauterisation, or wedge resection. Sometimes, due to the heavy bleeding, transfusion is necessary.