Gynecologic Emergencies
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| 6.0 Recommendations |
| 7.0 Summary |
| 8.0 Clinical Questions |
Introduction
General surgeons in the developing world have to be versatile in diagnosing
and managing abdominal disorders, not just involving the GI tract, but also
those of other organ systems such as the genitourinary tract. It has been
estimated that 30% or more of emergency abdominal operations in Africa are
for obstetric or gynecologic conditions (1 - 2).
Common gynecologic emergencies can mimic general surgical conditions such
as cholecystitis and appendicitis. Most patients with gynecologic emergencies
complain of pelvic pain and/or abnormal vaginal bleeding. A complete history
and physical exam will define the extent of the laboratory and radiologic
work up and the expediency of resuscitation. Most gynecologic emergencies
arise from benign rather than malignant etiologies.
Abnormal Pregnancies
2.1 Forms of abortion
2.11 Spontaneous abortion
Approximately 20% of known human pregnancies terminate in a recognized abortion
(3). Eighty percent of spontaneous abortions occur in the
first trimester and are usually a result of chromosomal or genetic abnormalities.
The risk factors for a spontaneous loss include prior pregnancy loss: history
of one abortion (13%); two prior abortions (25%); three prior abortions (45%)
and 4 prior abortions (54%) and rising maternal age (women 35-40 yr (21%);
women over 40 yr (42%).
2.12
Threatened Abortion
These women present less than 20 weeks’ gestation with crampy, abdominopelvic
pain, vaginal spotting, no cervical dilation or effacement and an intact intrauterine
pregnancy. The management includes restricting activities. There is no evidence
that progesterone or injectable HCG will improve outcome. Serial bHCG and
ultrasonography will aid in predicting outcome (4).
2.13 Inevitable and incomplete
abortion
Those women with an inevitable abortion present with an open cervical os on
pelvic examination but without a history of passing tissue (4).
The women with an incomplete abortion have evidence of retained products either
by examination or ultrasound. These cases usually occur between 8 and 14 weeks
of pregnancy, are incomplete and require surgical evacuation. If the woman’s
vital signs are stable, then treatment includes: CBC, group and screen and
possibly cross match, insertion of a large bore IV, oxytocin (10-30 units
in 1000ml of Ringers lactate), analgesia, and a paracervical block with 1%
lidocaine (10cc). The goal is to evacuate the uterine contents with suction
(vacuum aspiration) (4). Intercourse should be avoided for
2 weeks. Iron supplementation should be considered. If the mother is Rh negative
and father Rh positive, give 50 microgram of anti-D gamma globulin IM.
2.14
Septic Abortion
There is an extensive literature on complications related to abortions in
Africa. The World Health Organization estimates that the death rate from unsafe
abortions in Africa is 110/100,000 live births, the highest in the world.
In Mozambique, 22% of maternal deaths were in adolescents and septic abortion
was one of the 4 leading causes (6). In Nigeria, unsafe abortions
account for 40% of maternal deaths (7). In Kenya, the annual
number of women with abortion complications admitted to public hospitals is
20,893, with a case fatality rate of 0.87% (95% CI 0.71-1.02%) (8).
In the Central Republic of Africa, abortions accounted for 13.6% of gynecologic
admissions, 43.4% of which were from complications of self inflicted abortions
(SIA). This later type of abortion is more common in students and the main
reason is the financial inability to maintain the pregnancy and child. The
common methods for SIA are drug combinations (39.1%) and mechanical tools
(26%). Severe complications including infection and death seem to be confined
to this group (9).
When a patient presents to emergency, a history and subsequent physical exam is important. The investigations may include, if available, CBC, urinalysis, electrolytes and renal function tests, Gram stain of vaginal discharge, blood cultures, CXR and PTT/INR. An ultrasound will define retained products of conception.
The management begins with combination IV antibiotics (including gram positive, gram negative and anaerobic coverage) and evacuation of the uterus. If there are signs of septic shock, then CVP will guide the fluid resuscitation, (administer IV fluid according to CVP of > 4 and < 12, or 30 ml/hr urine output). Also important are placing a foley catheter, nasal oxygen, oxytocin or ergot as required to cause the uterus to contract (may effect the blood pressure). If sepsis persists despite these initial maneuvers or if there is evidence of visceral perforation (uterus or bowel) as a result of the abortion, a laparotomy may be required to repair the involved organ or remove the source of infection (hysterectomy).
A case control study from 4895 post abortion records in Zimbabwe showed that complete uterine evacuation and use of oxytocin are very important. Associated complications such as anaemia and sepsis were related to mortality. They recommended improved education of health care workers, in-service training, regular audits and changes in policies for managing abortions (10). In Ghana the government has responded to high rates of complications from abortions by providing training to community-based midwives especially in the technique of manual vacuum aspiration (11). A group from the Central Republic of Africa stressed the importance of making contraceptive methods more available in schools and universities (9). In Kampala, Uganda, a qualitative study was completed with 30 women who had a near death experience. Four of these women had a septic abortion. The themes included powerlessness to get help both within and outside of the hospital. Financial barriers and transport problems were pre-eminent. Other issues included overcrowding, long delays, shortages and inhumane care. (12).
2.2
Gestational trophoblastic disease (GTD)
Molar pregnancies occur in 1 out of 1000 pregnancies (3).
They are usually associated with abnormal chromosomal complement of the fetus.
In a complete mole, there are only paternal chromosomes present (usually 46XX
, occasionally 46XY). In a partial mole, triploidy is common (ie., XXX, XXY).
The Mandela School of Medicine, Durban (13) studied the
referral pattern of 98 women with GTD over a 5-year period. There was no trend
of referral of patients from specific geographic areas.
Women with GTD present with a history of amenorrhea, hyperemesis, vaginal spotting, and possibly passing grape like tissue. On physical exam there may be tachycardia. This results from the elevated ßHCG. The common portion of the ßHCG and TSH molecule results in the body reacting to the elevated ßHCG as if TSH were elevated. One can also see tremors, elevated blood pressure, respiratory distress and blood in the vagina. The respiratory distress occurs as a result of trophoblastic embolization and congestive heart failure secondary to anemia, hyperthyroidism, preeclampsia or fluid overload need to be ruled out. Uterine size is enlarged for dates in 50% of cases, and/or palpable ovarian mass from theca lutein cysts may be present. Investigations include CBC, PTT, INR, Blood type, antibody screen and cross match, serum ßHCG, (see below) and CXR. An ultrasound shows a snowstorm pattern. You may consider sending renal, liver and thyroid function tests.
Treatment begins with starting an IV. If the woman is hypertensive it is important to stabilize the blood pressure. If she shows evidence of hyperthyroidism, use ßblockers to prevent thyroid storm and the associated delirium, convulsions, atrial fibrillation and cardiac collapse. Evacuate the uterus in the operating room using suction D+C. Start oxytocin (10u per 1000 cc NS) once dilatation is completed. Rhogam should be given if mother is Rh negative and a form of reliable contraception started. Serial weekly ßHCG should be taken until normal then q2-4weeks for 6 months. If ßHCG plateaus over 3 weekly values or rises refer for treatment with chemotherapy (ie. methotrexate or actinomycin D)
2.3
Ectopic Pregnancy
Any pregnancy not in the uterus is considered ectopic. Ninety-five percent
of ectopic pregnancies are tubal, less commonly on the ovary or the peritoneum.
Population based incidence of ectopic pregnancy in Cameroon was 0.79% (95%
CI 0.72%-0.88%) with a mortality rate of 0.94% (95% CI 0.32%-2.72%) (14).
A twenty year review of the African literature showed that the ectopic pregnancy
case fatality rate is 1-3% (15), which is more than 10 times
higher than that reported in industrialized countries. Late diagnosis leading
to major complications and the necessity of emergency surgical treatment are
the key causes (16). A case report of ectopic pregnancies
in Ile-Ife Nigeria showed that the incidence was 10.5 per 1000 live births.
In 10% of cases, the initial diagnosis was wrong and this led to 5/38 deaths.
This death rate was very much higher than the rate among those correctly diagnosed
(2/342) (17).
We will specifically discuss tubal pregnancies. These pregnancies account for 1.3-2% of all pregnancies. Mortality rates from ectopic pregnancy fell from 35.5 to 3.8 per 10,000 from 1970 to 1986 in the USA. The condition should be suspected in all women of childbearing age who experience abdominal pain or abnormal vaginal bleeding, even those who are over 40, have had a tubal ligation or use other means of contraception such as pill or IUD (3). A case-control study in Lagos, Nigeria showed that the risk factors for ectopic pregnancy were early age of sexual debut (OR 1.93, 95% CI 1.71-2.93), multiple lifetime sexual partners, induced abortions, PID (17, 18), STD, miscarriage (18, 19), prior induced abortions (19), pelvic surgery, IUD (OR 3.76, 95% CI 2.12-6.69) (18, 20). A case series completed at the Nigeria Teaching Hospital in Enugu, showed that ectopic pregnancy was most common in young single women who had previously undergone an induced abortion with resultant pelvic infection (21). Other risk factors include: prior ectopic pregnancy, infertility, prior pelvic inflammatory disease (PID) or sexually transmitted disease (STD), intrauterine devise (IUD), past or present smoker, documented tubal pathology, or multiple sexual partners.
Only one third of patients are diagnosed on initial evaluation (22,
23). Any woman with pelvic pain and vaginal bleeding should
be screened with serum or urine human chorionic gonadotrophin (ßHCG).
Quantitative serum bHCG is an extremely valuable tool for assessing pregnancy.
Produced by the syncytiotrophoblast 8 days after fertilization, bHCG rises
progressively to reach a peak 65 days after conception reaching levels as
high as 100,000mIU/ml. HCG has a half life of 1.5 days. Its quantitative value
plays an important role in the diagnosis and decision making around a number
of emergency gynecologic conditions: abortions, GTD and ectopic pregnancy.
Sadly, quantitative tests are not available in the majority of hospitals in
the developing world and physicians are obliged to make decisions using qualitative
urinary tests with a higher level of false negatives (16).
In a report from Ghana in 1999, in only 6% of women diagnosed with ectopic
pregnancy was urinary HCG used.
The woman may have no symptoms (22). If symptoms are present they may include abnormal vaginal bleeding (in 50-80% of patients) (21, 19), abdominal pain (in 90-100% of patients) (22,19), shoulder tip pain (which reflects blood in the peritoneal cavity), and amenorrhea (19).
On exam, an adnexal mass is present in only one-third of patients (22). The presence of peritoneal signs, cervical motion tenderness and lateral or bilateral abdominal or pelvic tenderness increases the likelihood of an ectopic pregnancy (23). Hypotension strongly suggests a ruptured ectopic (22, 19). In Benin City, Nigeria, 49.3% of women with ectopic pregnancy were in shock at the time of diagnosis (19). Tachycardia unfortunately is only seen in half of the patients. In the other 50% of patients with hypotension and a normal heart rate (22), the hematoperitoneum has triggered a parasympathetic response preventing increase in the heart rate despite significant volume loss. The Nigerian group showed that the frequency of ectopic pregnancy was 2.32% of all pregnancies. They used culdocentesis to make the diagnosis in 80% of cases (24). In Dakar, Senegal, mini-pfannenstiel laparotomy under local anaesthesia was the management approach in view of difficulties with laparoscopy in their unit (25).
Investigations
ßHCG: this serum lab value will increase by 66% every 48 hours
in normal intrauterine pregnancy. If the value does not rise appropriately,
the patient may have either an ectopic pregnancy or a failing intrauterine
pregnancy.
Pelvic Ultrasound: An intrauterine pregnancy is confirmed by a gestational sac, fetal pole or a fetal heart beat within the uterus. An ectopic pregnancy is confirmed by evidence of an adnexal mass with extrauterine fetal heart beat. The intrauterine findings are only visible on transabdominal ultrasound when the ßHCG is above 6000 mIU/mL and on transvaginal ultrasound when the ßHCG is above 2000 mIU/mL. When the ßHCG is below these levels, ultrasound may not be reliable. In Botswana, the addition of ultrasound improved case management. The service was felt to be affordable for the health care system (25).
Decision for Surgery
Watch and wait: When hemodynamically stable, one may watch the patient
either at home or in the hospital with serial ßHCG.
Surgery is preferred: when the ßHCG > 5000 mIU/mL, or there is positive
cardiac activity on ultrasound, or the mass is greater than 4 cm, or the patient
is unstable or there is free fluid in the cul de sac. In Benin City, Nigeria
(19), 80.3% had ruptured tubal pregnancy at diagnosis; in
Senegal, 95% had ruptured (15).
Some of the advantages of a surgical approach are: confirming the diagnosis
of ectopic pregnancy, effective and prompt treatment, and visual inspection
of the pelvis and both fallopian tubes. Laparoscopy has replaced laparotomy
for routine management of ectopic pregnancy in many centers.
Linear salpingostomy, which involves making a linear incision on the antimesenteric side of the fallopian tube through which the pregnancy is removed by suction is recommended for distal (ampullary) ectopics less than 4 cm in size. Closing the tube is unnecessary as it will close spontaneously in the vast majority of cases. Larger tubal pregnancies, and those involving the isthmic portion of the tube, may require partial or total salpingectomy. A review of 3 randomized controlled trials showed that salpingostomy by laparotomy has an increased rate of elimination of the pregnancy compared to laparoscopic technique. However, the 2006 Cochrane review recommends laparoscopic salpingostomy even though there is a slightly higher rate of persistent trophoblast rate (RR 3.6, 95%CI 0.63-21) (27). There was no difference in tubal patency, rates of subsequent intrauterine pregnancy or ectopic. Operative blood loss was higher in open cases and laparoscopy is cheaper. Salpingostomy should be considered instead of salpingectomy particularly when the contralateral tube is diseased. Due to the risk of persistent ectopic tissue with salpingostomy, ßHCGs need to be followed. Persistent elevations in ßHCGs can be managed by an ultrasound to rule out another site for pregnancy and, if confirmed that there is no intrauterine pregnancy, methotrexate given in the stable patient or repeat surgery in those that have failed medical management. Salpingectomy is at present the most common treatment in Africa, occurring in 89.5% of cases (19) – 100% (15, 28). Autotransfusion is an option in severe hemorrhage and occurs at rates of 54.6% of cases in Nigeria (19, 29).
Medical Management of Ectopics
Methotrexate has been used for many years in the management of gestational
trophoblastic disease. It interferes with DNA synthesis causing destruction
of trophoblastic activity. It inhibits dihydrofolate reductase and therefore
the synthesis of thymine and purine. Stovall (3, 30,
31) has reported on 100 outpatients treated with methotrexate
for an unruptured ectopic 3.5 cm or less in size. The regimen was alternate
day methotrexate until the serum ßHCG decreased by greater than 15%
over 2 consecutive days. 96 patients were successfully treated and 4 required
surgery for ruptured ectopics. Tubal patency was present by hysterosalpingogram
in 84.5% of the cases. Stoval has also reported using a single dose of methotrexate
(50 mg/m2 IM) in 120 patients with 7 requiring surgery and 82.3% tubal patency.
No side effects from the medication were noted. 60% of patients treated this
way will develop pain. If the patient is seen for increased abdominal pain,
an ultrasound and Hct should be done. Patient can be observed if there is
no large accumulation of blood in the cul de sac. Success rates of medical
management were at 92% with a ßHCG less than 5000 IU/L and 98% with
ßHCG less than 1000 IU/L. Multiple doses appear to be superior (31).
Repeat ectopics are seen in 10% of cases.
3.0 Infectious Gynecologic
Diseases
3.1. Bartholin’s Gland Infection
The Bartholin’s glands are located at the 4 and 8 o’clock position
of the entrance to the vagina. About 2% of women develop enlarged Bartholin’s
glands (3). This is due to cystic dilation of the duct with
obstruction and resultant adenitis or abscess. Usually the infection is a
polymicrobial, necrotizing, subcutaneous infection. Bartholin’s gland
infections usually occur during the reproductive years (32).
The symptoms include acute vulvar pain that develops rapidly over 2-4 days, dyspareunia, and pain during walking or movement. The signs include vulvar erythema, acute tenderness, edema and cellulitis of the surrounding tissue. For a symptomatic abscess, this is treated by creating a marsupialized tract by removing an elliptical wedge of skin over the abscess and suturing the edges of the abscess to the skin. An alternative treatment is to place a Word catheter through a stab incision into the abscess. The balloon tip is inflated to break up all the loculations and left it in place for 4-6 weeks (32). This allows epithelialization of the tract. Antibiotics are not necessary unless there is surrounding cellulitis. If the abscess recurs, or presents in a woman over 40 years, excision of the gland or biopsy of the gland is important to rule out an adenocarcinoma of the Bartholin’s gland.
3.2. Pelvic Inflammatory Disease (PID)
Pelvic inflammation is usually caused by an ascending infection to the upper
genital tract not associated with pregnancy or intraperitoneal
pelvic operations. This inflammation may include infections of the endometrium
(endometritis), oviducts (salpingitis), ovary (oophoritis), uterine wall (myometritis),
uterine serosa and broad ligaments (parametritis) and pelvic peritoneum. The
most important sequela of PID is the destruction of the tubal architecture
(3).
The most important issue with PID is prevention. Primary prevention includes education of the cause of PID and use of condoms and chemical barrier methods. Secondary prevention involves screening women at high risk for chlamydia and gonorrhea, screening for acute cervicitis, treating sexual partners and education to prevent recurrent infection. PID is rarely seen in women who are not menstruating (prepubertal, pregnant or postmenopausal women). When an infection is seen in a postmenopausal woman one should consider genital malignancies, diabetes, concurrent intestinal disease.
Pelvic inflammatory disease is usually a polymicrobial infection with aerobic and anaerobic bacteria. N. gonnorhoeae and C. trachomatis cause acute PID in the majority of cases. These are usually cultured in the first 48hrs of the disease. Later, anaerobic bacteria tend to be seen.
Risk factors
PID is seen in menstruating young women. 75% of cases occur in women less
than 25yr of age. The risk of PID in a sexually active adolescent is 1 in
8 versus 1 in 80 for women over 25 yr (3). Exposure to multiple
sexual partners increases the risk of PID by 5 times (3).
Living in an area of high prevalence of sexually transmitted diseases increases
the risk of acquiring PID. Known cervical colonization with C. trachomatis
increases the PID risk.
Douching increases the risk of PID by 3-4 (3). Intrauterine device is associated with an increased risk especially during the first 3 weeks from the time of insertion. Risk of PID is 9.7 per 1000 women-years in the first 20 days after insertion versus 1.4 per 1000 women-years during the next 8 years (2). Prior episode of PID is associated with a subsequent risk of PID. 25% of women with one episode of PID will develop another episode (33). This may be related to microscopic tube damage or an untreated male partner. 1 in 200 cases of therapeutic abortion will develop PID. A history of recent instrumentation is associated with PID.
Methods for minimizing or preventing PID include monogamy, low number of partners (decreases likelihood of exposure to the causative agent), barrier methods [condoms, diaphragms, spermicidal preparations (ie., nonoxynol 9)], oral contraceptives (the progesterone in the OBCP thickens the cervical mucus which inhibits sperm and bacterial penetration and decreases menstrual flow which shortens the interval for bacterial colonization), vaccine for Hepatitis B, and tubal ligation.
Symptoms of PID may be nonspecific. The timing is usually after menstruation. Other symptoms include fever (34.4%), dull and constant lower abdominal pain [may be made worse with sexual activity (99.3%)], vaginal discharge (69.3%), irregular bleeding (40%), urinary symptoms (19.8%), and vomiting (10.4%).
Pain is usually bilateral in 90% of women distinguishing PID from appendicitis, diverticulitis or postsurgical abscess (3). Temperature is over 38°C. The abdominal/pelvic exam shows direct tenderness with or without rebound (95.4%); tenderness with motion of cervix and uterus and adnexal mass or tenderness (47.8%). Purulent cervical discharge is present in 75% cases.
Investigations should include:
Culture the endocervix: looking for C. Trachomatis and N. gonorrhoeae.
WBC >10,000 (50%)
Elevated Erythrocyte Sedimentation Rate: greater than 15 mm per hr
(75%)
Elevated C-reactive protein
Endometrial Biopsy: looking for endometritis with 5 or more neutrophils
per 400 high- power field and 1 or more plasma cell in the stroma. (Usually
only used in research protocols as it takes 48 hours to get a result).
Purulent material (WBC) from peritoneal cavity by culdocentesis or
laparoscopy
Ultrasound: Early stages – no findings. Later stages –
endometrial thickening with or without endometrial fluid and gas, ovarian
enlargement with indistinct ovarian borders, uterine enlargement with indistinct
uterine contours, free intraperitoneal fluid (30, 34,
35). Ascending extrauterine disease may cause tuboovarian
complexes with dilated inflamed fallopian tubes and enlarged inflamed ovaries
or frank tuboovarian abscess (10%).
Laparoscopy: Several conditions (ie. appendicitis) may mimic PID
and laparoscopy will allow inspection of the tubes, collection of culture
material and better define the situation. However, laparoscopy is an expensive
invasive technique and many women do not undergo this assessment. Indications
for laparoscopy include: impending septic shock, acute surgical abdomen, complicated
differential diagnosis in a postmenopausal woman. At the time of scope, there
is the opportunity to lyse adhesions, irrigate the pelvic cavity and drain
the abscess. The classic findings for PID include: the pelvic organs appear
red, indurated, edematous oviducts, pockets of purulent material, large pyosalpinx,
tuboovarian abscess. Useful, especially if the patient is not responding to
treatment
Culture the urethral secretions from the male partner: frequently an overlooked
investigation
Management
Goals:
1. Resolution of symptoms and
2. Preservation of tubal function.
Early treatment (ie. within 3 days of symptoms) will minimize occurrence of
tubal infertility or ectopic pregnancy. PID is usually a polymicrobial so
treatment should cover N. gonorrhoeae, C. trachomatis, anaerobic rods and
cocci (i.e, bacteroides, peptococcus, peptostreptococcus, clostridium, actinomyces
species), gram-negative aerobic rods and gram-positive aerobes (ie., streptoccous,
staphylococcus, haemophilus, E. coli).
| Minor Criteria (need one) | |
| Major Criteria (need all three) | Oral Temperature > 38.3 C |
| Lower abdominal tenderness | Mucopurulent cervical or vaginal discharge |
| Bilateral adnexal tenderness | Elevated ESR |
| Cervical motion tenderness | Elevated C-reactive protein |
| Positive swab | |
CDC recommendations for treatment (36, 37,
38, 32)
Outpatient:
Ofloxacin 400mg PO q12hr + Metronidazole 500mg PO q12h both for 14 days
or
Cefoxitin 2gm IM + Probenecid 1 g PO + Doxycycline 100mg PO q12h for 14 days
or
Ceftriaxone 250mg IM + Doxycycline 100mg PO q12hr for 14 days or
Ofloxacin 400mg PO q12hr + Clindamycin 450mg PO qid both for 14 days
Re-examine the patient within 3 days to ensure that she is improving. Reculture
the cervix 4-6 weeks after treatment to ensure microbiologic cure.
Inpatient;
If a patient is not improving with oral antibiotics she should be hospitalized.
Indications for hospitalization and use of intravenous antibiotics to get
maximum levels of antibiotics include an adolescent with her first episode
of PID, adnexal mass, associated pregnancy, immunodeficiency (especially with
HIV and low CD 4 counts), when the diagnosis is in question (differential
includes appendicitis, ectopic, cholecystitis if there is acute right upper
quadrant tenderness). PID with an IUD in place or after instrumentation is
usually from anaerobic bacteria. IUD should be removed and patient treated
in hospital.
CDC recommendations for antibiotics for the in hospital patient are
(31, 39):
Regimen A: Doxocycline 100 mg IV or PO q12hr plus cefotetan 2 gm
IV q12hr or cefoxitin 2g IV q6hr. May discontinue parenteral therapy 24 hr
after improvement and complete a total of 14 days of doxycycline.
Regimen B: Clindamycin 900mg IV q8hr plus gentamicin load with 2gm/kg
followed by a maintenace dose of 1.5 mg/kg q8hr. (May use single day dosing
of gentamycin)
Alternate regimens: 1. Ofloxcin 400mg IV q12hr plus metronidazole
500mg IV q8hr or ampicillin/subactam 3g IV q6hr plus doxycycline 100mg IV/orally
q12hr.
2. Ciprofloxacin 200mg IV q12h plus doxocycline 100kg IV/PO q12hr plus metronidazole
500mg IV q8hr.
There are a series of articles from several African countries including Ghana,
Addis Ababa, Gambia and Morocco. They all indicate the importance of following
algorithms for determining treatment, and the problem of availability of high
cost antibiotics (40, 41, 42,
43).
Surgery
An operation is indicated if there is life-threatening infection, ruptured
tuboovarian abscess, pelvic abscess, persistent mass in an older woman where
childbearing is not a concern, or a persistent symptomatic mass.
Percutaneous drainage of an abscess under ultrasonic or computer tomography
guidance is an option which shows favorable short terms outcomes in the order
of 90% (2). When the abscess is 4-6 cm 15% will need drainage.
If the abscess is greater than 10cm, 70% will need drainage. In this situation
the induration may be of such a degree that you may only be able to culture
the pus, biopsy the lesion and drain the abscess.
Complications of PID:
Disseminated peritonitis can be complicated by serositis of adjacent bowel,
peritoneal adhesions and small-bowel obstruction or perihepatitis (Fitz-Hugh-Curtis
syndrome 5-10%) (33). With Fitz-Hugh-Curtis syndrome there
can be right upper quadrant tenderness or pleuritic pain with radiation to
the shoulder or into the back. Liver transaminases may be elevated (39).
Tubo-ovarian complex, abscess and pyosalpinx can occur. Rarely is gonorrhoeae
or chlamydia isolated from the abscess. Usually peptostreptococcus, bacteroides
or E.Coli are isolated (39). HIV positivity is more common
in Africa than in other regions. Research done with patients who have HIV-1-seropositivity
and acute salpingitis show that tubo-ovarian abscesses are more common (OR
2.8 95%CI 1.2-6.5) and this finding is related to the CD4 count (ie. the lower
the count, less than 14, the higher the rate of TOA). Treatment needs to include
treatment of the PID and the HIV (44). The abscess may rupture
in 15% of cases causing a surgical emergency (32).
Long term sequelae include increased risk of infertility related to a tubal
factor (10 fold more common if there is a history of PID), recurrent PID,
chronic pelvic pain (in 20% of patients with PID) and ectopic pregnancy (7-10
fold more common in women with a history of PID).
3.3 Toxic Shock
Septic shock can be seen in the following gynecologic circumstances: post-delivery,
surgical abortion, retained tampon, recent pelvic surgery and medical abortion
with misoprostol within one week of medication (45). Management
involves removal of any foreign body, a diligent attempt to culture bacterial
agents, broad spectrum antibiotics and supportive medical care including ICU
care where available.
Severe septic shock has a mortality rate approaching 50% (46). In Tunisia, septic shock syndrome was one of three poor prognosis factors for outcomes related to gram negative bacterial septicemia from 1996-1998. In this hospital population, 18% of patients with gram negative sepsis died (47). Sepsis is defined as the presence of an infection accompanied by evidence of systemic response. This systemic inflammatory response is defined as the presence of at least two of the following:
| 1. General | |
| a. Altered mental status | |
| b. Significant edema or positive fluid balance (>20mL/kg in 24 hours) | |
| c. Hyperglycemia (plasma glucose > 120 mg/dL or 7.7 mmol/L) in the absence of diabetes. | |
| 2. Inflammatory variables | |
| a. Plasma C-reactive protein >2SD above the normal value | |
| b. Plasma procalcitonin > 2SD above the normal value | |
| 3. Hemodynamic variables | |
| a. Arterial hypotension (SBP<90 mm Hg, MAP <70 mmHg, or an SBP decrease > 40 mmHG in adults or >2SD below normal for age) | |
| b. SvO2 > 70% | |
| c. Cardiac Index > 3.5 L/min/m2 | |
| 4. Organ dysfunction variables | |
| a. Arterial hypoxemia (PaO2/FIO2 < 300) | |
| b. Acute oliguria (urine output < 0.5 mL/kg/h for at least 2 h) | |
| c. Creatinine increase > 0.5 mg/dL | |
| d. Coagulation abnormalities (INR> 1.5 or a PTT>60s) | |
| e. Ileus (absent bowel sounds) | |
| f. Thrombocytopenia (platelet count <100,000/?L) | |
| g. Hyperbilirubinemia (Plasma total bilirubin > 4mg/dL or 70 mmol/L) | |
| 5. Tissue perfusion variables | |
| a. Hyperlactamia (>2mmol/L) | |
| b. Decreased capillary refill or mottling | |
Severe sepsis is the presence of sepsis and 1 or more organ dysfunction (i.e., acute lung injury, coagulation abnormalities, thrombocytopenia, altered mental status, renal liver or cardiac failure, or hypoperfusion with lactic acidosis). Septic shock is defined as the presence of sepsis and refractory hypotension. Bacteremia is the presence of viable bacteria in the blood and is only found in 50% of cases of severe sepsis and septic shock.
The initial reaction to infection is a neurohumoral, pro and anti-inflammatory response. The vascular endothelium is the site for the interaction of cellular activation (ie. monocytes and macrophages), host response (ie. cytokines) and activation of complement and the coagulation cascade. Diffuse endothelial disruption will result in organ dysfunction and tissue hypoxia.
The goal in septic shock is to delivery oxygen systemically through volume (preload), blood pressure support (afterload) and optimizing stroke volume (contractility) (46). Management options include: continuous monitoring of vital signs, pulse oximetry and urine output; lab tests to identify infection type and organ system status; fluid resuscitation with NS to a CVP of 8-12 mm Hg; foley catheter; vasoactive agents to maintain mean arterial pressure of 65-90 mm Hg (Norepinephrine, Dopamine, Phenylephrine, vasopressin, epinephrine, nitroglycerine); blood transfusion to Hct>21%; inotropes (dobutamine); intubation, sedation and paralysis to achieve a ScvO2>70%. Use low tidal volume to maintain end-inspiratory plateau pressure less than 30 cm H2O; antibiotics for an abdominal or pelvic source such as Piperacillin/tazobactam 3.375g q6h and gentamicin 5mg/kg q24h; use radiologic techniques to help locate the source; if patient not responding to rescuscitation consider Hydrocortisone 50mgIV q6h and 9æ-fludrocortisone 50µg orally once a day for 7 days as 20% of patients have adrenal insufficiency and randomized trials show decreased rates of mortality (46).
3.4 Necrotizing Fasciitis
There is a high mortality rate with this condition, 20% if the operation happens
within 24hr and 75% if the operation is delayed 48hr or longer (49-59).
Some of the situations where this is seen include penetrating trauma, paracentesis
and laparoscopic or open abdominal or vaginal surgery. The risk factors include
advancing age, diabetes, obesity, hypertension, arteriosclerosis, malnutrition,
renal failure, immunosuppression, and trauma.
The classic bacteria include Group A beta Hemolytic strep and clostridium perfringens. The infection can be polymicrobial including Proteus mirabilis, E. Coli, Candida albicans, Pseudomonas, Klebsiella, Staph aureus, Bacteroides, Enterobacter.
The patient presents feeling generally unwell and has pain greater than expected from the visualized area of concern. Findings on exam include a dull redness around the wound, crepitus in the area of the wound, and dirty dishwater coming from wound. Investigations include: CBC and diff; electrolytes including HCO3 and blood sugar; cross Match; blood Cultures; urine Culture; cross table flat plate to determine if there is gas in the subcutaneous tissue; and CT Scan.
Initial treatment includes: ICU admission; 2 Large bore IVs; tetanus booster;
foley catheter; central Line; arterial line; continuous cardiac monitoring;
Blood sugar qid; culture wound drainage. Patient needs to start broad spectrum
antibiotics – including coverage for gram positive (for Clostridium
and ßHemolytic strep), gram negatives and anaerobes.
Antibiotic regimens include:
Consult plastic surgery and infectious diseases if available.
Urgent wide debridement of necrotic tissue back to healthy muscle or until you
get bleeding is necessary. Leave the skin open and pack with saline gauze. Consider
hyperbaric oxygen if available. When the wound starts granulating, use a skin
graft or myocutaneous graft.
4.0 Ovarian Masses
4.1 Tubo-ovarian Torsion
Acute adnexal torsion accounts for 3% of all emergent gynecologic surgeries
(35). Complete or partial torsion of the ovarian vascular
pedicle compromises the lymphatic and venous drainage (presents as unilateral
tender adnexal mass) with eventual loss of arterial perfusion (low grade fever
and leukocytosis). The risk factors include: pregnancy, ovarian stimulation;
and ovarian enlargement.
Symptoms include acute abdominal pain (stabbing (70%), sudden and sharp (59%), radiate to the back, flank or groin (51%)), nausea and vomiting (70%), peritoneal signs (3%), and age under 50 yr in 80%. Signs are those of an acute abdomen and cervical motion tenderness when the torted side is put on stretch.
Investigations include CBC (fall in Hgb with hemorrhage and an increase in WBC with necrosis), electrolytes (especially if there has been persistent vomiting), ultrasound. In children a torted ovary may be normal. In adults a torted ovary may have a large cyst (up to 80%) (35). With time the ovary enlarges and may be solid (hyperechoic) or fluid filled (hypoechoic) (56). Free intraperitoneal fluid in the pelvis results from lymphatic and venous congestion or infarction with intraperitoneal hemorrhage. Intra-ovarian artery flow usually reflects partial torsion resulting from extrinsic compression and occlusion of the ovarian vein with an intact arterial supply (56, 35). Blood flow usually indicates a viable ovary. Doppler ultrasound will document arterial flow.
Detorsion can be used in young women to preserve ovarian function. 93% of detorted ovaries will regain normal ovarian function. Salpingo-oophorectomy should be completed if there is a concern of malignancy or if the tissue is clearly gangrenous. There is a 10% risk of recurrent torsion. Methods to prevent this include oral contraceptives to decrease development of ovarian cysts. Ovariopexy fixes the ovary to the uterus or pelvic sidewall. Ovariopexy is preferred if the problem is seen in childhood (3).
4.2 Hemorrhagic Ovarian Cyst
Physiologic ovarian cysts from corpus luteal or follicular origin can become
hemorrhagic (60). The woman may present with acute pelvic
pain or a dull constant lower abdominal pain. If you take a menstrual history,
she will likely be at the time of ovulation. Rupture of a blood-filled corpus
luteum cyst usually gives abdominal pain with guarding and possibly rebound.
There is diffuse pelvic tenderness on vaginal exam. The pain is more pronounced
on the side of the ovarian cyst. A mass may or may not be palpated. If the
hemorrhage is severe, then the abdominal is distended and there can be hypovolemic
shock.
Ultrasound may show a heterogeneous, hypoechoic mass with internal echoes, thin and thick septations, fluid debris level, echogenic retracting clot or irregular nodular wall. Acute intracystic hemorrhage may appear isoechoic to the ovarian stroma and mimic an enlarged ovary (61). There will be free fluid in the cul de sac and sometimes in the upper abdomen. A ßHCG or urine pregnancy test is negative.
Culdocentesis will reveal free blood in the abdomen.
When there is significant hemorrhage, a laparotomy is indicated to confirm the diagnosis and excise the cyst. The ovarian defect should be closed in layers with fine absorbable suture. Laparoscopy could be considered in a hemodynamically stable patient, however, it is often difficult to see well in the presence of a significant amount of intra-abdominal blood.
5.0 Trauma
5.1 Vulvar Hematoma
Straddle injuries may result in vulvar hematomas (ie. falling on the cross
bar of a bicycle). Symptoms include increasing vulvar pain. Signs include
expanding vulvar mass and purplish discoloration of the skin. Treatment begins
with IV, CBC, Cross match, ice packs and pressure dressings (62).
These hematomas can become quite large as blood dissects through the soft
tissue planes. Ensure that the patient is able to void. It may be necessary
to incise and drain the hematoma if it continues to expand.
5.2 Sexual Assault
Sexual assault is motivated by power and control issues rather than sexual
gratification (63). In keeping with this statement a 10
year review of vaginal injuries in a teaching hospital in Calabar, Nigeria
showed that 68% were related to sexual assault usually in a nulliparous patient,
toddler or teenagers (64). Coital injuries made up 0.7/1000
gynecologic emergencies at that unit. A retrospective review of the literature
from 1980-2003 showed that 10-67% of children with STD had been sexually abused,
while 15-30% of sexually abused incidents were associated with STD. The alleged
child abusers were adult males known by the child (family member (30-60%),
teachers, household personnel, neighbor). The extent of this problem in sub-Saharan
Africa is not well documented (65). A report on post-coital
injuries at the Addis Ababa Fistula Hospital in Ethiopia from 1991-1997 showed
that 78 of 91 women were sexually abused under the cover of marriage and 9
were kidnapped, raped then discarded. Once the fistula occurred, 59 women
were divorced and 19 were abandoned. They advocated for changes which include
education, amended polices and laws from government and health care workers
(66).
The initial evaluation includes an appropriate history to detect life-threatening injuries, the state of the victim’s overall health (including tetanus status), gynecologic and assault history. The physical exam must be thorough with clear documentation of any signs of trauma and proper evidence collection. The exam usually shows anal or genital injuries, trauma to the perineum or lower third of vagina, vesico-vaginal or recto-vaginal fistula, vaginal bleeding and sometimes shock. In contrast to other centers, 32 cases of vaginal injuries due to coitus are seen annually in a Dakar hospital. The most common location of injury was the posterior upper third of vagina and this was managed with suturing (67).
Management includes vaginal cultures for sexually transmitted diseases (chlamydia, gonorrhea), blood work for CBC, pregnancy test and possibly cross match. HIV antibody testing should be done initially and repeated at 6 weeks, 3 months and 6 months. For HIV prophylaxis, the patient should receive zidovudine 300mg bid and lamivudine 150mg bid for 28 days (63). The CDC recommends sexually transmitted disease prophylaxis for hepatitis B ( Hep B vaccination and repeat at 1 and 6 months and Hep B immune globulin 0.06 mL/kg IM), Bacterial vaginosis and trichomoniasis (Metronidazole 2g PO), Gonorrhea (Ceftriaxone 125-250mg IM or Ciprofloxacin 500mg PO) and Chlamydia (Azithromycin 1g PO or Doxycycline 100mg PO bid for 7 days) (63). There are a few options for preventing an unwanted pregnancy. These include the morning after pill (thinly estradiol 100µg and levonorgestrel 0.5 mg and repeat in 12 hours) or 2 Ovral tablets and repeat in 12 hours or placement of a copper IUD within 5 days of the assault (62). Counseling is necessary and reporting to legal authorities in keeping with the laws of the country. Prior to discharging the patient, there must be plans for follow-up in 1-2 weeks and again in 2-4 months. Patient should be informed to return if her menses is more than 2 weeks late. She then requires a pregnancy test and her options need to be reviewed with her.
Laurie Elit MD MSc FRCS(C)
Associate Professor, Department of Obstetrics and Gynecology
McMaster University
Division of Gynecologic Oncology
Hamilton Health Sciences Centre – Henderson site and Juravinski Cancer
Centre, Hamilton, Canada