1. Christopher R. Graber, MD Salina Women’s Clinic 15 April 2011

2.  Definitions and Symptoms  Acute OB/Gyn Pain Complication of pregnancy Acute infection Adnexal disorders  Other GI, GU, Musculoskeletal, other

3.  Acute pain Sudden onset, sharp rise, short course  Cyclic pain Definite association with mestrual cycle Dysmenorrhea – painful menstruation  Primary or secondary  Chronic pelvie pain Greater than 6 months duration

4.  Rapid onset Perforation of hollow viscus or ischemia  Colic or severe cramps Muscular contraction, obstruction of hollow viscus such as uterus or intestines  Entire abdomen Generalized reaction to irritating fluid within the peritoneal cavity

5.  Complications of pregnancy Ectopic, abortion, leiomyoma degeneration  Acute infections Endometritis, PID, TOA  Adnexal disorders Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst Ruptured cyst – functional or neoplastic

6.  Ectopic pregnancy – implantation in a site other than the uterus (95% in tube) Acute pain due to tubal dilation If rupture  localized changes to generalized peritonitis (due to hemoperitoneum) hCG less than expected or abnormal rise Use ultrasound to locate pregnancy  Heterotopic pregnancy rare (both uterine and ectopic)

7.  Treatment Methotrexate  50 mg/m 2 IM x1  Multiple-dose regimen an alternative Surgery  Linear salpingostomy  Partial salpingectomy Follow quant hCG if no fetal tissue recovered  MTX: quant on days 4 and 7, expect 15% drop

8.  Absolute contraindications Breastfeeding, immunodeficiency Chronic liver disease, active pulmonary disease Leukopenia, thrombocytopenia, anemia Peptic ulcer disease, renal dysfunction Known sensitivity to methotrexate  Relative contraindications Gestational sac >3.5 cm, embryo cardiac motion Elevated hCG quant

9.  Abortion (loss of pregnancy <20w) Threatened – any vaginal bleeding Inevitable – bleeding plus dilation Complete – spontaneous expulsion Incomplete – passage of some tissue Missed – no expulsion of tissue for 8w Induced – medical or surgical

10.  Degeneration of leiomyoma Rapid growth during pregnancy, outgrowing blood supply If pedunculated, can cause torsion Increased progesterone Degeneration sometimes seen on imaging Supportive care unless torsion or not pregnant

11.  Complications of pregnancy Ectopic, abortion, leiomyoma degeneration  Acute infections Endometritis, PID, TOA  Adnexal disorders Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst Ruptured cyst – functional or neoplastic

12.  Endometritis (postpartum uterine infection) Fever, abdominal pain, leukocytosis Vaginal delivery  Overall risk 1%, increased after prolonged labor or rupture of membranes  13 % risk if chorioamnionitis during labor Cesarean delivery  Decreased by single-dose pre-op abx  Increased risk with manual extraction of placenta Treatment – Abx: amp, gent, clinda

13.  Pelvic inflammatory disease Acute salpingo-oophoritis Pain, fever, purulent vaginal/cervical discharge Cervical motion tenderness, adnexal tenderness Outpatient vs. inpatient mgmt  Inpatient if: acute abdomen, pregnancy, vomiting, no response to PO abx, TOA http://www.cdc.gov/std/treatment/2010/STD- Treatment-2010-RR5912.pdf

14.  Tuboovarian abscess (TOA) Sequela to PID May be palpated on exam, seen on imaging Treatment with IV abx Exploratory surgery may be needed, especially if rupture occurs

15.  Complications of pregnancy Ectopic, abortion, leiomyoma degeneration  Acute infections Endometritis, PID, TOA  Adnexal disorders Hemorrhagic functional cyst, ovarian torsion, torsion of paratubal cyst Ruptured cyst – functional or neoplastic

16.  An ovarian cyst that is not torsing, rapidly expanding, infected, or leaking does not cuase acute pain

17.  Ovarian cysts – leaking, hemorrhagic May be mittleschmertz Similar symptoms as a ruptured ectopic  Increasing abd pain, dizziness if hemoperitoneum  May be a surgical abdomen Diagnosis: hCG, CBC, ultrasound Treatment: supportive or surgical

18.  Adnexal torsion Ischemia from twisting of the vascular pedicle of an ovary, tube, or paratubal cyst May be constant or intermittent pain Onset may coincide with physical activity Diagnosis – sono: rapidly increasing mass Treatment – surgery, with possible removal Benign cystic teratoma is most common neoplasm to undergo torsion

20.  GI Gastroenteritis, appendicitis (can be similar to PID), bowel obstruction, diverticulitis, IBS  GU Cystitis, pylonephritis, ureteral lithiasis  Musculoskeletal Abdominal wall hematoma, hernia  Other Acute porphyria, pelvic thrombophlebitis, aneurysm, abdominal angina

21.  Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, 2010. MMWR 2010;59.  Comprehensive Gynecology. Stenchever MA editor. Mosby Inc., St. Louis, MO. 2001.  Novak’s Gynecology – 13 th edition. Berek JS editor. Lippincott, Williams, and Wilkins, Philadelphia, PA. 2002.  Williams Obstetrics – 22 nd edition. Cunningham FG editor. McGraw-Hill, New York, NY. 2005.