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Gynaecological causes of acute abdominal pain

Ectopic pregnancy

  • Gestation outside of uterine cavity
  • Occurs in 1% of pregnancies
  • 11,000 cases per year in United Kingdom and incidence is increasing
  • Mortality is less than 1%
  • Risk factors include:
    • Previous PID
    • Infertility
    • Tubal surgery
    • Intrauterine contraceptive device
    • Previous ectopic
  • PID increases risk of ectopic seven fold
  • Commonest site is in the tubal ampulla
  • Usually presents at 6-8 weeks amenorrhoea
  • Clinically patient has lower abdominal pain and slight vaginal bleeding
  • Cardiovascular collapse and shoulder tip pain suggest large intraperitoneal bleed
  • Examination will often shown abdominal and adnexal tenderness
  • Patient invariably has positive urinary pregnancy test
  • In cases of doubt sensitive serum beta-HCG is helpful
  • Ultrasound shows empty uterus and may identify ectopic
  • An intrauterine pregnancy on US almost invariably excludes an ectopic
  • If patient is shocked immediate laparotomy is essential
  • If no evidence of cardiovascular compromise laparoscopy is investigation of choice
  • Foetus can then be removed by salpingotomy or salpingectomy

Pelvic inflammatory disease

  • Pelvic inflammatory disease usually synonymous with acute salpingitis
  • Ascending sexually transmitted disease
  • Due to chlamydia (60%), Neisseria gonorrhoea (30%) +/- anaerobes
  • Untreated can progress to pyosalpinx or tubo-ovarian abscess
  • Presents with lower abdominal pain and vaginal discharge
  • Pelvic examination is uncomfortable
  • High vaginal and endocervical swabs essential
  • If doubt over diagnosis consider laparoscopy or ultrasound examinations
  • Often improves with antibiotics (tetracycline and metronidazole)
  • Surgery rarely required
  • 40% chance of tubal occlusion after three episodes
  • Increases risk of ectopic pregnancy by a factor of six
  • 20% develop chronic pelvic pain

Endometriosis

  • Functional endometrial tissue outside the uterine cavity
  • Results from either retrograde menstruation or celomic metaplasia
  • Usually affects ovaries, fallopian tubes, serosal surface of the bowel
  • Most commonly seen in women between 30 and 50 years
  • Presents with premenstrual lower abdominal pain
  • May also cause back pain, intestinal obstruction and urological symptoms
  • Large 'chocolate' cysts may rupture causing acute abdominal pain
  • Also a cause of infertility
  • Diagnosis can be confirmed at laparoscopy
  • Hormonal therapy may improve symptoms
  • Danazol is probably the first line treatment

laparoscopic appearance of endometriosis

Ruptured ovarian cyst

  • Ovarian cysts are either functional or proliferative
  • Cause abdominal pain if rupture, torsion or infarction occur
  • Patients present with sudden onset sever lower abdominal pain
  • Differential diagnosis includes ruptured ectopic pregnancy
  • Cyst may be palpable on bimanual examination
  • Diagnosis can be confirmed by ultrasound or laparoscopy
  • Treatment usually involves ovarian cystectomy

Bibliography

Ankum W M.  Diagnosing suspected ectopic pregnancy.  Br Med J 2000;  321:  1235-1236.

Cooke I D. The ovary as encountered by general surgeons. Curr Pract Surg 1996; 8: 34-39.

Giudice L C,  Kao L C.  Endometriosis.  Lancet 2004;  364:  1789-1799.

Tay J I,  Moore J,  Walker J J.  Ectopic pregnancy.  Br Med J 2000;  320:  916-919.

 

 
 

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