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
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.
Vincent K. Chronic pelvic pain in women. Postgrad Med J
2009; 85: 24-29 |