CHAPTER 22 Gynaecology Ectopic pregnancy 482 Ovary 483 Pelvic inflammatory disease 484 Dysmenorrhoea 484 Endometriosis 484 Uterine fibroids 485 Mittelschmerz 486 Between 10% and 20% of patients admitted with acute abdominal pain have a gynaecological cause. It is therefore important for the surgeon to be able to distinguish between surgical causes and gynaecological causes of acute abdominal pain. Gynaecological conditions which may be admitted as surgical emergencies include ectopic pregnancy, ovarian cyst (torsion or rupture), salpingitis, dysmenorrhoea, endometriosis, Mittelschmerz and complications of fibroids. Ruptured ectopic pregnancy is a life-threatening condition and requires urgent gynaecological referral. Ectopic pregnancy This occurs when the conceptus implants outside the uterus, e.g. fallopian tube, ovary or abdominal cavity. Over 95% occur in the fallopian tube. Risk factors for ectopic pregnancy include use of IUD, after pelvic inflammatory disease, after pelvic surgery and increasing maternal age. Symptoms and signs In the early stages, there may be no symptoms. Vaginal bleeding and iliac fossa pain are the commonest symptoms. Later, a mass may be palpable arising out of the pelvis associated with abdominal pain. Ruptured ectopic pregnancy presents with sudden severe pain gradually spreading across the abdomen. Signs of shock may be present with sweating, tachycardia and hypotension. Shoulder tip pain may be present due to irritation of the diaphragm by intraperitoneal blood. Investigations • Hb: may be low or may be normal after sudden bleed • βhCG elevated • USS: foetus in fallopian tube, intraperitoneal free fluid • Laparoscopy. Treatment Salpingectomy or salpingostomy by laparoscopy or laparotomy. Ovary Ovarian cyst An ovarian cyst is any collection of fluid within an ovary. The classification of ovarian cyst is beyond the scope of this chapter and the reader is referred to a textbook of gynaecology. Most ovarian cysts are benign. Symptoms and signs May be found incidentally during routine abdominal or pelvic examination. Dull ache in the lower back or thighs. Pressure, fullness or pain in the abdomen. Dyspareunia. Painful periods and abnormal bleeding. Severe pain may arise from rupture, torsion or haemorrhage into a cyst. Intraperitoneal bleeding may occasionally mimic ruptured ectopic pregnancy. An abdominal mass is palpable when the cyst becomes large. Pressure effects on the bladder may cause frequency of micturition and, on the colon, constipation. Rarely, there may be hormonal symptoms due to secretion by the tumour of androgens or oestrogens. Rarely, ovarian cysts may become massive and fill the whole abdomen. Examination may reveal a mass arising out of the pelvis which it is impossible to get below. Maybe shifting dullness of ascites (malignancy or Meigs syndrome). Bimanual examination: mobility, consistency, nodules in the pouch of Douglas (with malignancy). Hard, irregular fixed mass likely to be malignant. Investigations • Hb: ↓ bleeding, malignancy • WCC ↑ infarction due to torsion • CA125: ↑ ovarian carcinoma • USS: abdominal or transvaginal • CT/PET: assess extent of condition especially if malignancy suspected. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Like this:Like Loading... Related Related posts: Management of malignant disease An introduction to surgical techniques and practical procedures Abdominal wall and hernia Orthopaedics Stay updated, free articles. Join our Telegram channel Join Tags: Churchills Pocketbook of Surgery Jun 14, 2017 | Posted by admin in GENERAL SURGERY | Comments Off on Gynaecology Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access %d
CHAPTER 22 Gynaecology Ectopic pregnancy 482 Ovary 483 Pelvic inflammatory disease 484 Dysmenorrhoea 484 Endometriosis 484 Uterine fibroids 485 Mittelschmerz 486 Between 10% and 20% of patients admitted with acute abdominal pain have a gynaecological cause. It is therefore important for the surgeon to be able to distinguish between surgical causes and gynaecological causes of acute abdominal pain. Gynaecological conditions which may be admitted as surgical emergencies include ectopic pregnancy, ovarian cyst (torsion or rupture), salpingitis, dysmenorrhoea, endometriosis, Mittelschmerz and complications of fibroids. Ruptured ectopic pregnancy is a life-threatening condition and requires urgent gynaecological referral. Ectopic pregnancy This occurs when the conceptus implants outside the uterus, e.g. fallopian tube, ovary or abdominal cavity. Over 95% occur in the fallopian tube. Risk factors for ectopic pregnancy include use of IUD, after pelvic inflammatory disease, after pelvic surgery and increasing maternal age. Symptoms and signs In the early stages, there may be no symptoms. Vaginal bleeding and iliac fossa pain are the commonest symptoms. Later, a mass may be palpable arising out of the pelvis associated with abdominal pain. Ruptured ectopic pregnancy presents with sudden severe pain gradually spreading across the abdomen. Signs of shock may be present with sweating, tachycardia and hypotension. Shoulder tip pain may be present due to irritation of the diaphragm by intraperitoneal blood. Investigations • Hb: may be low or may be normal after sudden bleed • βhCG elevated • USS: foetus in fallopian tube, intraperitoneal free fluid • Laparoscopy. Treatment Salpingectomy or salpingostomy by laparoscopy or laparotomy. Ovary Ovarian cyst An ovarian cyst is any collection of fluid within an ovary. The classification of ovarian cyst is beyond the scope of this chapter and the reader is referred to a textbook of gynaecology. Most ovarian cysts are benign. Symptoms and signs May be found incidentally during routine abdominal or pelvic examination. Dull ache in the lower back or thighs. Pressure, fullness or pain in the abdomen. Dyspareunia. Painful periods and abnormal bleeding. Severe pain may arise from rupture, torsion or haemorrhage into a cyst. Intraperitoneal bleeding may occasionally mimic ruptured ectopic pregnancy. An abdominal mass is palpable when the cyst becomes large. Pressure effects on the bladder may cause frequency of micturition and, on the colon, constipation. Rarely, there may be hormonal symptoms due to secretion by the tumour of androgens or oestrogens. Rarely, ovarian cysts may become massive and fill the whole abdomen. Examination may reveal a mass arising out of the pelvis which it is impossible to get below. Maybe shifting dullness of ascites (malignancy or Meigs syndrome). Bimanual examination: mobility, consistency, nodules in the pouch of Douglas (with malignancy). Hard, irregular fixed mass likely to be malignant. Investigations • Hb: ↓ bleeding, malignancy • WCC ↑ infarction due to torsion • CA125: ↑ ovarian carcinoma • USS: abdominal or transvaginal • CT/PET: assess extent of condition especially if malignancy suspected. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Like this:Like Loading... Related Related posts: Management of malignant disease An introduction to surgical techniques and practical procedures Abdominal wall and hernia Orthopaedics Stay updated, free articles. Join our Telegram channel Join Tags: Churchills Pocketbook of Surgery Jun 14, 2017 | Posted by admin in GENERAL SURGERY | Comments Off on Gynaecology Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access
