Department of Obstetrics and Gynecology Corina Cardaniuc, Stelian Hodorogea, Mihail Surguci

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1 Department of Obstetrics and Gynecology Corina Cardaniuc, Stelian Hodorogea, Mihail Surguci Surgical emergencies of gynecologic origin Acute surgical emergencies of gynecologic origin occur for the most part in women of reproductive age. The most common and most important conditions to be considered include pelvic inflammatory disease (PID) with abscess, ectopic pregnancy, hemorrhage from a functional ovarian cyst, and adnexal or ovarian torsion. Ectopic Pregnancy An ectopic pregnancy is a pregnancy that implants and develops outside the uterine cavity. This happens when the fertilized egg from the ovary does not implant itself normally in the uterus. Instead, the egg develops somewhere else in the abdomen. The products of this conception are abnormal and cannot develop into fetuses. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. Ovarian and abdominal pregnancies may be primary implantations on those sites or may follow a tubal abortion which reimplants. About 1% of pregnancies is in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes. In a typical ectopic pregnancy, the embryo does not reach the uterus, but instead adheres to the lining of the Fallopian tube. The implanted embryo burrows actively into the tubal lining. Most commonly this invades vessels and will cause bleeding. This bleeding expels the implantation out of the tubal end as a tubal abortion. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is locally irritant. Causes/Etiology The mechanism by which the fertilized ovum reaches the uterine cavity is dependent upon motility of the tube, the movement of the cilia of the fallopian tubes. - obstruction or dysfunction of tubal transport mechanisms - abnormalities of the fertilized ovum - Conception late in cycle - Transmigration of fertilized ovum to contralateral tube Common conditions that increase the risk of ectopic pregnancy include the following: - history of pelvic inflammatory disease - A prior history of ectopic pregnancy increases the risk of future occurrences to about 10%.

2 - Tubal surgery for damaged tubes - Tubal ligation can predispose to ectopic pregnancy. - Reversal of tubal sterilization carries a risk for ectopic pregnancy. - Endometriosis - Uterine or adnexal mass - smoking is associated with ectopic risk. - birth defects of the fallopian tubes, - complications of a ruptured appendix - previous pelvic surgery. - Taking hormones, specifically estrogen and progesterone (such as those in birth control pills), can slow the normal movement of the fertilized egg through the tubes and lead to ectopic pregnancy. - The presence of an intrauterine contraceptive device is associated with a higer rate of ectopic pregnancy. Symptoms Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. The early signs are: Abnormal vaginal bleeding (usually spotting, brown vaginal loss) Vaginal bleeding occurs as the decidua sloughs after the demise of the fetus. Amenorrhea (missed period) The period of amenorrhea is commonly between 6 and 8 weeks. Breast tenderness Low back pain Mild cramping on one side of the pelvis Nausea Pain in lower abdomen or pelvic area Pain while having a bowel movement Clinical examination may reveal peritonism with rebound on abdominal palpation, but often the findings are more vague with only tenderness in the lower abdomen. Gentle pelvic examination may reveal cervical excitation pain, because the tube is distorted by the enlarging ectopic pregnancy. It may be possible to feel a mass in the adnexal region. The uterus will be bulky due to the normal early pregnancy changes. Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms. External bleeding is due to the falling progesterone levels. Internal bleeding is due to hemorrhage from the affected tube.

3 A ruptured ectopic pregnancy is a true medical emergency. Common symptoms of a ruptured ectopic pregnancy include the following: Lightheadedness, dizziness, almost passing out, "falling out" Pale complexion, clammy-feeling skin Sweaty Fast heartbeat (over 100 beats per minute) Referred pain to the shoulder area Severe, sharp, and sudden pain in the lower abdominal area Internal bleeding due to a rupture may lead to shock. Abdominal palpation reveals a rigid abdomen and immediate laparotomy is necessary to control the hemorrhage. Diagnosis A pelvic exam may reveal tenderness in the pelvic area. A pregnancy test is usually positive. An ectopic pregnancy has to be suspected in any woman with lower abdominal pain or unusual bleeding who is or might be sexually active and whose pregnancy test is positive. An abnormal rise in blood βhcg levels may also indicate an ectopic pregnancy. In a normally sited pregnancy the doubling time for HCG levels is approximately 48 hours, so serial measurements of HCG may help in the diagnosis of an ectopic pregnancy. A vaginal ultrasound scan showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present. An empty uterus with levels lower than 1500 IU/ml may be evidence of an ectopic pregnancy. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. Culdocentesis may be used to check for blood in the pelvic/abdomen area. Any blood or fluid found there likely comes from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy. A laparoscopy, laparotomy, or D and C may be needed to confirm the diagnosis. Nontubal ectopic pregnancy 2% of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. - cervical pregnancy - ovarian pregnancy - abdominal pregnancy The differential diagnosis - miscarriage, - Pelvic Inflammatory Disease (PID). - appendicitis, - other gastrointestinal disorder, - problems of the urinary system,

4 Treatment Nonsurgical treatment If administered early in the pregnancy, methotrexate can disrupt the growth of the developing embryo causing the cessation of pregnancy. Surgical treatment If hemorrhaging has already occurred, surgical intervention is necessary. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). Complications The most common complication is rupture with internal bleeding that leads to shock. Infertility occurs in 10-15% of women who have had an ectopic pregnancy. Prevention Avoiding risk factors for pelvic inflammatory disease (PID) such as multiple sexual partners, intercourse without a condom, and sexually transmitted diseases (STDs) Early diagnosis and treatment of STDs Early diagnosis and treatment of salpingitis and PID Torsion of Ovarian Cyst: The characteristic symptom of ovarian torsion is the sudden onset of extreme lower abdominal pain that radiates to the back, side and thigh. Nausea, vomiting, diarrhea, and constipation can accompany the pain. The patient may also experience tenderness in the lower abdominal area, a mild fever and tachycardia.if torsion leads to infarction, the pain becomes more severe and constant. There is pyrexia, tachycardia and leukocytosis. Clinical Significance: It is difficult to differentiate torsion from acute appendicitis, ectopic pregnancy and rupture of the adnexal cyst. Laparotomy is mandatory. The necrotic cyst should be clamped and removed avoiding the risk of embolization. Adnexal Torsion: This is an acute emergency as prolonged torsion leads to infarction of the tube and ovary. Solid tumors like dermoid cyst are prone for torsion. Clinical Significance: Patient presents with acute severe pain, lateralized to the right or left lower quadrant of abdomen accompanied by nausea and vomiting. Pelvic examination may reveal tender mass on the affected side. Pain is described as knife like and is proportional to the degree of venous interruption. Low grade fever and leukocytosis may occur. If necrosis and infection of the twisted organ occurs then high grade fever may ensue. Laparoscopy has become the preferred surgical approach both for diagnosis and treatment. Hemorrhagic Functional Ovarian Cyst: Rupture of a follicular cyst may cause acute onset of pain. Corpus luteums are very vascular and life threatening hemorrhage may ensue if they rupture. The acute pain associated with ruptured of corpus luteum is often confused with ruptured ectopic pregnancy. Clinical Significance: If hemorrhage is

5 severe, it may produce abdominal distension and shock. Emergency laparotomy is indicated when patient is hemodynamically unstable. Diagnostic and therapeutic laparoscopy is appropriate if patient is hemodynamically stable. Pelvic Inflammatory Disease and Tubo-Ovarian Abscess: Patients with tuboovarian abscess present with history of pelvic or abdominal pain and fever associated with leukocytosis. Pelvic examination reveals extreme pelvic and cervical motion tenderness with adnexal mass. If rupture has occurred, typical symptoms of peritonitis may ensue. Clinical Significance: If there is evidence of rupture of tuboovarian abscess immediate surgical intervention is recommended. Drainage of the abscess with CT or ultrasound guidance and drainage via laparoscopy are other available modalities. In patients who have completed childbearing, total abdominal hysterectomy with bilateral salpingo-oopherectomy is the standard therapy. References 1. Page EW, Villee CA, Villee DB. Human Reproduction, 2nd Edition. W. B. Saunders, Philadelphia, p ISBN WHO: Maternal and perinatal health Accessed Dec 3, Shaw JL, Dey SK, Critchley HO, Horne AW (January 2010). "Current knowledge of the aetiology of human tubal ectopic pregnancy". Hum Reprod Update 16 (4): doi: /humupd/dmp057. PMC PMID Farquhar, C.M. Ectopic Pregnancy, Lancet 366 (2005), p Bogdanskiene, G.; Berlingieri, P.; Grudzinskas, JG. (Feb 2006). "Association between ectopic pregnancy and pelvic endometriosis.". Int J Gynaecol Obstet 92 (2): doi: /j.ijgo PMID Tay JI, Moore J, Walker JJ (2000). "Ectopic pregnancy". West J Med. 173 (2): doi: /ewjm PMC PMID Dicker, D. Feldberg, D. Samuel, N. and Goldman, JA. (1985). "Etiology of cervical pregnancy. Association with abortion, pelvic pathology, IUDs and Asherman's syndrome.". J Reprod Med 30 (1): PMID "emedicine - Surgical Management of Ectopic Pregnancy: Article Excerpt by R Daniel Braun". Retrieved Hurd A. B., William W.; Falcone T. (2007). Clinical reproductive medicine and surgery. St. Louis, Mo: Mosby/Elsevier. pp ISBN