Surgical Procedures
Repair of Vaginal
or Vulvar Lacerations
These lacerations may result from childbirth, sexual assault,
accidents or hostile fire.
Because this area is quite vascular, primary closure is preferred in an
acute setting. In cases involving delayed treatment (>24 hours after the
injury), it may be preferable because of tissue inflammation and
infection to allow secondary healing followed, if necessary, by a later
repair.
Bladder Lacerations
Lacerations of the bladder can be diagnosed with retrograde
injection of dye through a Foley catheter. Repair should be in multiple
layers, using absorbable sutures, without tension. A very acceptable
alternative is simple drainage with a Foley or suprapubic catheter. Many
cases of small lacerations will close spontaneously over time with this
type of urinary diversion and those that don't may be closed electively
weeks to months later.
Rectal Lacerations
Lacerations of the rectum may be closed primarily with multiple
layers of absorbable suture. The need for fecal diversion should be
determined by the mechanism and magnitude of the injury. If treatment
has been delayed or there is evidence of significant inflammation of the
edges of the laceration, surgical closure should be delayed weeks or
months until the inflammation has subsided. During this time, fecal
incontinence will need to be tolerated.
If the rectal sphincter has been torn, it will retract back into the
surrounding tissue, creating a 1-2 cm. "crater." Identify this crater
with your finger, then grasp the retracted muscle with an instrument and
bring it back to the midline. Suture the edges of the sphincter
together, making sure to include the fibrous capsule of the muscle. This
will allow proper healing and promote subsequent fecal continence.
Failure to close the sphincter is not disastrous, but will usually
result in fecal incontinence to some degree and a later corrective
procedure.
Other Lacerations
Other soft tissue lacerations are usually easily repaired with such
absorbable sutures as 2-0 Vicryl or 0-Chromic. A simple running or
running locking stitch works well for most of these.
When the laceration involves the anterior vaginal wall, avoid deep
placement of sutures since the bladder and urethra are usually within a
few millimeters of the vaginal mucosa. Placing a Foley catheter in the
bladder prior to suturing will help to outline the important anterior
structures to be avoided.
If the laceration involves the posterior vaginal wall, remember that the
rectum can be within a few millimeters of the vaginal mucosa. Many
gynecologic surgeons find it advantageous to place the index finger of
the non-dominant hand in the rectum while suturing the posterior vaginal
wall.
Lacerations involving the lateral vaginal walls are best sutured with
good assistance (retraction) and good lighting. When these lacerations
are high in the vagina, they are both more difficult (because of
exposure and lighting problems) and more dangerous. The ureter courses
next to the cervix in the parametrial tissues but becomes accessible to
accidental vaginal suturing if the sutures are placed deep and high in
the vagina.
Vulvar Hematoma
Vulvar hematoma is common following a "straddle injury." These hematomas
are unilateral, painful and can be large (6-8 cm.). Place a Foley
catheter in the bladder and treat the hematoma with ice packs. Smaller
hematomas will resolve without surgery (the larger portion of the mass
is inflammatory tissue and not blood clot), but may require several days
for the swelling to reduce. Larger hematomas or expanding hematomas will
require surgical evacuation of the hematoma and primary reclosure. In
about half of these cases, the specific bleeding point is never
identified, but simple evacuation of the clot and closure with sutures
solves the problem. Hemovac drains may be placed if the hematoma bed is
still oozing.
Bartholin's Abscess
These painful, unilateral vulvar masses may be treated conservatively
with antibiotics if small, but will require incision and drainage if
large or persistent. For drainage, pick a site on the medial aspect of
the mass close to the introitus. If the mass is pointing, go through
that area straight into the abscess cavity. Local anesthetic may be used
but is often unnecessary if the skin is thin and attenuated.
After drainage of pus from the cavity, loosely pack the cavity with
narrow gauze (iodoform tape works well for this), primarily to keep the
incision open, allowing continued drainage over the next few days. The
cut edges of the drainage incision may need to be sutured for hemostasis
but this is usually unnecessary.
Rest, TID sitz baths, and antibiotics to cover gram negatives,
anaerobes, and gonococcus are all advisable in the operational setting.
These draining abscesses usually resolve over the next few days but may
return at a later time. Repeat I&D can be done multiple times, although
a marsupialization procedure may ultimately be required. It is
inadvisable to try to surgically remove an entire abscess on an emergent
basis. It is better to simply drain it.
D&C
In the operational setting, D&C (dilatation and curettage) is often
required to resolve complications of early pregnancy loss, such as an
incomplete abortion. Rarely would it be necessary in a non-pregnant
woman with intractable uterine bleeding.
Under anesthesia, the bladder is catheterized and a pelvic exam
performed so the surgeon can feel the orientation of the uterus. Of
particular importance is noting whether the cervix leads directly into
the uterus or whether there is any angulation anterior or posterior.
Equally important is determining the size of the uterus as this will
guide the surgeon in inserting the instruments.
The cervix is grasped with a tenaculum or a ring forceps on its anterior
lip. (This works the best for most patients, but the posterior lip works
better in a women whose uterus is tilted posteriorly.)
The cervix is then dilated by inserting "dilators" of gradually
increasing diameter until the cervix is open about 1-2 cm. Fortunately,
in the case of incomplete abortion, the cervix will already be dilated
and no additional dilation will be necessary.
Polyp forceps or Ring forceps are then inserted through the cervix into
the uterus to grasp and remove any large pieces of pregnancy tissue.
This is a time when gentleness is required because it is relatively easy
to perforate the soft walls of the uterus and cause damage to the
surrounding structures (bladder, bowel, ureters). Then a curette is
gently inserted and used to scrape any remaining tissue off the uterine
walls. Excessive scraping at this time can result in too much tissue
being removed and later infertility.
After an uncomplicated D&C, patients are advised to rest in bed with
bathroom privileges for a day or two and then may return to their normal
activities. Prophylactic antibiotics may be given (particularly in an
incomplete abortion situation) as well as ergotamine 0.2 mg PO TID for 2
days to stimulate uterine contractions and reduce blood loss.
Salpingectomy
Ectopic pregnancy, ruptured or unruptured, will usually require surgical
intervention. Salpingectomy (removal of the fallopian tube) is uniformly
effective, safe, simple, fast, and well within the capabilities of an
abdominal surgeon. its only important disadvantages are that it results
in the loss of the tube and may be more surgery than is needed.
After opening the abdomen (lower midline incision is fast and gives
excellent exposure), identify the fallopian tube containing the ectopic.
Grasp the tube with Babcock clamps and elevate the tube. This spreads
out the mesosalpinx (the blood supply of the tube). Using hemostats,
clamp across the mesosalpinx, starting at the fimbriated end and working
toward the uterus. Clamp across the tube where it enters the uterus.
Then remove your specimen and suture the clamped tissue with 0 or 2-0
Vicryl, Chromic or other such material.
Evacuate from the abdomen any large clots (removal of all free blood
from the abdomen is both unnecessary and laborious), and close the
abdomen. Surgical drains are usually not necessary.
In the face of a large ectopic pregnancy and significant bleeding, this
approach of salpingectomy is probably the wisest course. With smaller
ectopics, you may conserve some or all of the tube performing a
"segmental resection" in which only the middle portion of the tube is
removed. This offers the advantage of conserving some of the tube for
tubal reconstruction at a later date if necessary.
Another technique which works well for small ectopic pregnancies (2-3
cm. in diameter) is the "linear salpingostomy." A scalpel makes a linear
incision along the anti-mesenteric border of the tube, directly over the
ectopic pregnancy. The pregnancy is extruded through the incision and
the tube observed for further bleeding. Often, the bleeding will simply
stop. The tube may be reclosed with very fine absorbable suture or
simply left open (the defect will close spontaneously.)
While a linear salpingostomy may be preferable in some fully-equipped
and fully-staffed medical facilities, there are important drawbacks to
its use in isolated settings, primarily the limitations of diagnostic
techniques to follow these patients over time. Surgeons in these
isolated settings might be better advised to perform the definitive
therapy (salpingectomy, partial or complete) which will assure
hemostasis and avoid the possible need for reoperation.
Oophorectomy
Ovarian torsion is the most common reason for emergency removal of an
ovary. After opening an acute surgical abdomen, you find the
strangulation of one ovary (usually involves the fallopian tube as well)
due to a twisting of the blood supply to these structures.
Place a clamp of any appropriate size or type across the twisted
pedicle, and excise the effected ovary and tube. Suture the pedicle to
secure the blood supply and then close the abdomen. The only important
structure close to where you will be clamping and suturing is the
ureter. This may be avoided by keeping the clamp and suture within the
twisted pedicle itself and not going too deep below the twisted portion.
Don't try to untwist the ovary or tube since you may release clot or
cellular toxins into the general circulation. In operational settings,
when ovarian torsion is encountered, the ovary and all effected tissue
should be simply removed.
Drains are not necessary. Watch for signs of metabolic acidosis during
the recovery as the necrotic tissue may have released enough tissue
toxins to cause this problem.
Ovarian Cystectomy
Emergency removal of an ovarian cyst is usually necessitated because of
either severe pain or hemorrhage. In either case, the cyst can often be
"shelled out" from the ovary allowing ovarian conservation. With most
cysts, there is a very nice dissection plane between the cyst and the
ovary that will allow you to quickly and easily separate the cyst from
the ovary.
After removal of the cyst, close the ovary in two layers...a deeper
layer to assure hemostasis, and a second superficial layer to
approximate the edges of the ovarian capsule.
In the case of endometriosis (with "chocolate cysts" and "powder burns"
in the pelvis), surgical dissection planes are less clear and removal of
just the cyst is more difficult. Usually, the chocolate cyst ruptures
while you are trying to remove it. Just do the best you can and
remember:
1. You will probably not cure the endometriosis surgically, no matter
how much you remove.
2. Take care of the problem you came to fix (hemorrhage, torsion, etc.)
and leave the rest to medical therapy.
Hysterectomy
It would be a very unusual situation that would require an emergency
hysterectomy. Most bleeding can be controlled with lesser procedures
(D&C or hormonal management), and most infections respond to
antibiotics.
Hysterectomy consists of clamping across the supporting structures of
the uterus and its blood supply followed by removal of the uterus. The
most difficult part (and the part which leads to the most complications)
is removal of the lowest portion of the uterus and cervix. The reason
for this difficulty is the close proximity of bladder, ureters and
bowel. In an emergency setting, it is very acceptable to avoid those
problems by performing a "supracervical hysterectomy."
Clamps are placed across the fallopian tubes close to the body of the
uterus. Then working stepwise, the parametrial tissues are clamped
(again, very close to the body of the uterus.) When the uterus narrows,
(above the level of the bladder and ureters), a scalpel cuts across the
lower uterine segment, resulting in the removal of the upper portion of
the uterus and the leaving in place of the lower portion of the uterus
(primarily the cervix). The raw, cut edge of the cervix and lower
uterine segment is sutured for hemostasis. This part of the uterus can,
if necessary, be removed electively at a later time.
The advantages of this supracervical hysterectomy are:
1. It can be performed more easily, particularly by surgeons with lesser
amounts of gynecologic surgical training.
2. It is safer in the short run because it greatly reduces the chance of
inadvertent injury to the bladder, bowel or ureters.
3. It is faster than a complete hysterectomy.
4. Because the cervix remains in place, there is less chance of
long-term vaginal support problems since the supporting structures
(cardinal and uterosacral ligaments) remain intact.
The disadvantages to the supracervical hysterectomy are several, but
relate more to the elective or semi-elective hysterectomy setting than
the emergency hysterectomy performed in an operational setting. Because
the cervix remains and may develop cervical malignancy at some time in
the future, the patient has not derived maximum benefit from her
surgery. If malignancy is present in the uterus, an incomplete procedure
has been performed. Further, if infection is present, some infected
tissue may be left behind.
In the operational arena, none of these disadvantages seem persuasive,
and the advantages in speed, safety and simplicity suggest supracervical
hysterectomy is preferable when needed.
Post-operatively, bedrest with bathroom privileges for a day or two
followed by steadily increasing ambulation gives good results.
Prophylactic antibiotics covering gram negative and anaerobic bacteria
is an excellent idea in the operational environment.
Threatened Abortion
Any pregnancy complicated by any form of bleeding from the uterus during
the first 20 weeks of pregnancy is considered a "threatened abortion."
The bleeding may be heavy or light, spotting or just brown discharge. It
may or may not be accompanied by uterine cramping. If pregnancy tissue
is passed, it is reclassified as either an incomplete or complete
abortion. Inevitable abortion means the cervix has begun to dilate and
bleeding is so heavy that spontaneous abortion must occur.
About 1 in every 3 or 4 pregnancies demonstrates some evidence of
bleeding. The majority of these women will continue the pregnancy
uneventfully and the remainder will ultimately abort.
Bedrest will usually slow the bleeding temporarily, but will not change
the final outcome of the pregnancy.
Incomplete Abortion
When some pregnancy tissue has been passed, but more remains inside the
uterus, this is an "incomplete abortion."
These patients have moderate to heavy bleeding, uterine cramping,
uterine tenderness and sometimes low-grade fever.
If tissue is seen protruding through the cervix, you may grasp is gently
with sponge forceps and ease it the rest of the way out of the cervix.
The goal of treatment is to convert the "Incomplete Abortion" to a
"Complete Abortion".
Definitive treatment is D&C (dilatation and curettage). If D&C is not
available, bedrest and oxytocin, 20 units (1 amp) in 1 Liter of any
crystalloid IV fluid at 125 cc/hour may help the uterus contract and
expel the remainder of the pregnancy tissue, converting the incomplete
abortion to a complete abortion.
Alternatively, ergonovine 0.2 mg P.O. or IM three times daily for a few
days may be effective.
If fever is present, broad-spectrum antibiotics are wise, particularly
if D&C is not imminent. Rh negative women should ideally receive Rhogam
(Rh immune globulin) within 3 days of a completed miscarriage to prevent
Rh sensitization, but it may still be effective even 7-10 days later.
If hemorrhage is present, bedrest, IV fluids, oxygen, and blood
transfusion may all be necessary.
Complete Abortion
A complete abortion is the passage of all pregnancy tissue from inside
the uterus.
Typically, these patients complain of vaginal bleeding and cramping
which leads to passage of tissue. Then, the bleeding and pain subside.
It is sometimes difficult to know whether the abortion is "complete" or
"incomplete." To resolve this issue, some gynecologists recommend D&C
for all patients who miscarry, while others recommend D&C only for those
who obviously have an incomplete abortion, and those who continue to
bleed and cramp.
Bedrest for a day or two may be all that is necessary to treat a
complete abortion. Ergonovine 0.2 mg PO TID may be given for two days to
stimulate the uterus to contract and reduce bleeding. Some physicians
give a broad-spectrum oral antibiotic for a few days to protect against
infection. If fever is present, IV broad-spectrum antibiotics are wise,
to cover the possibility that the complication of sepsis has developed.
If the fever is high and the uterus tender, septic abortion is probably
present and you should make preparations for D&C.
Save in formalin any tissue which the patient has passed for pathology
examination.
Continuing hemorrhage suggests an "incomplete abortion" rather than a
"complete abortion" and your treatment should be reconsidered
Inevitable Abortion
An early pregnancy which is destined to miscarry or abort is known as an
inevitable abortion.
These pregnancies are complicated by bleeding and cramping and dilation
(opening) of the cervix at the internal os. Such a pregnancy will not
survive and can be considered in the same category as an incomplete
abortion. Unless hemorrhage is present, patients can safely wait up to
six weeks for definitive treatment (D&C).
Septic Abortion
Infection may complicate any abortion. Such infections are characterized
by fever, chills, uterine tenderness and occasionally, peritonitis. The
responsible bacteria are usually a mixed group of strep, coliforms and
anaerobic organisms.
Usual treatment consists of bedrest, IV antibiotics, utero-tonic agents
(such as ergotamine or pitocin), and complete evacuation of the uterus.
If the patient does not respond to these simple measures and is
deteriorating, surgical removal of the uterus, fallopian tubes and
ovaries may be life-saving.
If your patient responds well and quickly to IV antibiotics and bedrest,
you may safely continue your treatment. Remember, though, that she has
the potential for becoming extremely ill very quickly and transfer to a
definitive care facility should be considered.
Evacuation of the uterus can be initiated with oxytocin, 20 units (1
amp) in 1 Liter of any crystalloid IV fluid at 125 cc/hour or ergonovine
0.2 mg P.O. or IM three times daily. If the patient response is not
favorable, D&C is the next step.
IV antibiotics should be started immediately. Reasonable antibiotic
choices include (American College of OB-GYN Tech. Bull. #153, 1991):
Clindamycin 900 mg IV every 8 hours, plus
Gentamicin 2.0 mg/kg IV, followed by 1.5 mg/kg every 8 hours,
or
Metronidazole 500 mg IV every 6-8 hours, plus
Gentamicin 2.0 mg/kg IV, followed by 1.5 mg/kg every 8 hours,
or
Cefoxitin 2.0 gm IV every 6 hours
Second Trimester Abortion
Middle trimester abortions are uncommon and usually uncomplicated. They
typically involve a labor-type experience for the patient, with delivery
of a non-viable fetus.
After delivery of the fetus, be prepared to wait as long as several
hours for the placenta (afterbirth) to separate and be delivered. While
waiting, clamp and cut the umbilical cord and remove the fetus so as not
to distress further the mother.
After delivery of the placenta, cramping and bleeding usually stop or
reduce to a minimal amount. Pitocin, 10 units IM or 20 units in 1 L of
crystalloid at 125 cc/hr are helpful in reducing postpartum blood loss.
Pitocin at reduced dosage (same IV mixture, but at 2-10 drops/minute)
can be useful in stimulating the uterus to contract in the case of a
retained placenta, but has the potential of overstimulating the uterus.
If the placenta remains inside longer than 6 hours, D&C is indicated to
remove it. This surgery is among the more dangerous types of procedures
because of the relatively large amounts of placental tissue left inside
and the extreme softness of the uterus which lends itself to perforation
and injury.
In the presence of vaginal hemorrhage, D&C is indicated immediately,
although you might attempt a manual removal of the placenta. If you can
grab a portion of the placenta (assuming a part of it is extruded
through the cervix), you sometimes can tease the rest of the placenta
out through the cervix without resorting to D&C.
If D&C fails and hemorrhage continues, hysterectomy may be life-saving.
Third Trimester
Delivery Complications
Cesarean Section
In the face of intractable hemorrhage in
an undelivered patient or totally obstructed labor, emergency cesarean
section will probably be life-saving. For those abdominal surgeons with
lesser amounts of training in cesarean section, a midline lower
abdominal incision and midline uterine incision are the wisest.
Continue in a midline fashion through the wall of the uterus until the
uterine cavity is entered. ("low cervical vertical Incision) You may
extend the uterine midline incision as high as necessary to gain the
needed exposure for delivery of the infant and the placenta. Avoid going
too low and risking entering the bladder. Close the uterus in two or
three layers.
Manual Removal of the
Placenta
After delivery of the infant, the placenta normally separates within a
few minutes. At this time, if hemorrhage occurs, you may need to
manually remove the placenta. Insert your hand through the vagina into
the uterus and grasp the placenta. Gently tease it out.
Immediate Post Partum
Hemorrhage
This is generally caused by the uterus failing to contract. After
manually exploring the uterus to make sure no placenta was left inside,
manually massage the uterus to encourage it to contract. Give Oxytocin
(10-20 units in 1 L crystalloid...run briskly) or ergotamine 0.2 mg IM.
Post Partum Hysterectomy
This is performed for uncontrollable hemorrhage. Typically, this is a
supracervical hysterectomy (subtotal hysterectomy) even in experienced
hands because of the difficulty in easily identifying the soft,
attenuated cervix. By staying well away from the bladder, these
hysterectomies usually go quite well.
Unruptured Ectopic Pregnancy
A woman with an unruptured ectopic pregnancy may have the typical
unilateral pain, vaginal bleeding, and adnexal mass described in
textbooks. Alternatively, she may have minimal symptoms. The pregnancy
test is positive. For all practical purposes, a negative sensitive
pregnancy test rules out ectopic pregnancy.
Patients with a positive pregnancy test and unilateral pelvic pain or
tenderness may have an unruptured ectopic pregnancy and should have an
ultrasound scan to confirm the placement of the pregnancy. If ultrasound
is not available, then it is best to arrange for MEDEVAC.
Alternative diagnoses which can cause similar symptoms include a corpus
luteum ovarian cyst commonly seen in early pregnancy, or occasionally
appendicitis. PID is characterized by bilateral rather than unilateral
pain. With a threatened abortion, the pain is central or suprapubic and
the uterus itself may be tender.
While awaiting MEDEVAC, the following are wise precautions:
1. Keep the patient on strict bedrest. She is less likely to rupture
while lying still.
2. Keep a large-bore (#16) IV in place. If she should suddenly rupture
and go into shock, you can respond more quickly.
3. Know her blood type and have a plan for possible transfusion.
The vibration during a helicopter ride or the jostling over rough roads
in an ambulance or truck may provoke the actual rupture. Try to minimize
this risk and be prepared with IV fluids, oxygen, MAST equipment, etc.
If she develops peritoneal symptoms (right shoulder pain, rigidity, or
rebound tenderness), she may be starting to rupture and you should react
appropriately.
Ruptured Ectopic Pregnancy
Women with a ruptured ectopic pregnancy will nearly always have pain,
sometimes unilateral and sometimes diffuse. Right shoulder pain suggests
substantial blood loss. Within a few hours (usually), the abdomen
becomes rigid, and the patient goes into shock. Serum pregnancy tests
are positive.
Treatment is immediate surgery to stop the bleeding. If surgery is not
an available option, stabilization and medical evacuation should be
promptly arranged. While awaiting MEDEVAC:
1. Give oxygen, IV fluids and blood according to ATLS guidelines.
2. Keep the patient at absolute rest.
3. Monitor urine output hourly with a Foley catheter and take frequent
vital signs to detect shock.
4. Consider MAST trousers.
If abdominal surgery is not an available option, the outlook for a
patient with a ruptured ectopic pregnancy is not totally bleak.
Aggressive fluid and blood replacement, oxygen and complete bedrest will
result in about a 50/50 chance of survival. If this approach is
necessary:
1. Maintain the urine output between 30 and 60 ml. /hour.
2. If the pulse is >100 or urine output <30, she needs more fluid.
3. If she becomes short of breath and the lung sounds become "crackly,"
slow down the fluids as she probably is becoming fluid overloaded.
(Central monitoring is helpful if available.)
4. If she becomes short of breath and the lungs sound dry, increase the
fluids and give blood as she is probably anemic and in need of more
oxygen carrying capacity.
5. As she loses blood into the abdomen, she will become distended. If
she becomes so distended she can't breath, put a chest tube into the
abdomen through a small, midline incision just below the umbilicus to
drain off fluid or blood so she can breathe.
6. A MAST suit can be very helpful in tamponading the internal bleeding.
7. She may require as many as 15 or 20 units of blood.
Ovarian Cyst
These cysts are common and generally cause no trouble. Each time a woman
ovulates, she forms a small ovarian cyst (3.0 cm. in diameter or less).
Depending on where she is in her menstrual cycle, you may find a small
ovarian cyst. Large cysts (>7.0 cm.) are less common and should be
followed clinically or with ultrasound.
Occasionally, ovarian cysts may cause a problem by:
Delaying menstruation
Rupturing
Twisting
Causing pain
Bleeding
95% of ovarian cysts disappear spontaneously, usually after the next
menstrual flow. Those that remain and those causing problems are often
removed surgically.
Ruptured Ovarian Cyst
This cyst has ruptured and spilled its contents into the abdominal
cavity. If the cyst is small, its rupture usually occurs unnoticed. If
large, or if there is associated bleeding from the torn edges of the
cyst, then cyst rupture can be accompanied by pain. The pain is
initially one-sided and then spreads to the entire pelvis. If there is a
large enough spill of fluid or blood, the patient will complain of right
shoulder pain.
Symptoms should resolve with rest alone. Rarely, surgery is necessary to
stop continuing bleeding.
Unruptured Ovarian Cyst
While most of these cysts are without symptoms, they can cause pain,
particularly with strenuous physical activity or intercourse. Treatment
is symptomatic with rest for those with significant pain. The cyst is
expected to rupture, usually within one month. Once it ruptures,
symptoms will gradually subside and no further treatment is necessary.
If it doesn't rupture spontaneously, surgery is sometimes performed to
remove it. This will relieve the symptoms and prevent torsion. This
surgery is done electively.
Torsioned Ovarian Cyst
A torsioned or twisted ovarian cyst occurs when the cyst twists on its
vascular stalk, disrupting its blood supply. The cyst and ovary (and
often a portion of the fallopian tube) die and necrose.
Patients with this problem complain of severe unilateral pain with signs
of peritonitis (rebound tenderness, rigidity). This problem is often
indistinguishable clinically from a pelvic abscess or appendicitis,
although an ultrasound scan can be helpful.
Treatment is surgery to remove the necrotic adnexa. If surgery is
unavailable, then bedrest, IV fluids and pain medication may result in a
satisfactory, though prolonged, recovery. In this suboptimal,
non-surgical setting, metabolic acidosis resulting from the tissue
necrosis may be the most serious threat to the patient.
Other surgical conditions which may resemble a twisted ovarian cyst
(such as bowel obstruction, appendicitis, ectopic pregnancy) may not
have a good outcome if surgery is delayed. For this reason, patients
thought to have a torsioned ovarian cyst should be moved to a definitive
care setting where surgery is available.
PID
Pelvic Inflammatory Disease (PID) is a bacterial inflammation of the
fallopian tubes, ovaries, uterus and cervix.
Initial infections are caused by single-agent STDs, such as gonorrhea or
chlamydia. Subsequent infections are often caused by multiple non-STD
organisms (E. Coli, Bacteroides, etc.).
Mild PID
Gradual onset of mild bilateral pelvic pain with purulent vaginal
discharge is the typical complaint. Fever <100.4 and deep dysparunia are
common.
Moderate pain on motion of the cervix and uterus with purulent or
mucopurulent cervical discharge is found on examination. Gram-negative
diplococci or positive chlamydia culture may or may not be present. WBC
may be minimally elevated or normal.
Treatment consists of:
Doxycycline 100 mg PO BID x 10-14 days, plus one of these:
Cefoxitin 2.0 gm IM with probenecid 1.0 gm PO,
or
Ceftriaxone 250 mg IM
or
Equivalent cephalosporin
Moderate to Severe PID
With moderate to severe PID, there is a gradual onset of moderate to
severe bilateral pelvic pain with purulent vaginal discharge, fever
>100.4 (38.0), lassitude, and headache. Symptoms more often occur
shortly after the onset or completion of menses.
Excruciating pain on movement of the cervix and uterus is characteristic
of this condition. Hypoactive bowel sounds, purulent cervical discharge,
and abdominal distension are often present. Pelvic and abdominal
tenderness is always bilateral except in the presence of an IUD.
Gram-negative diplococci in cervical discharge or positive chlamydia
culture may or may not be present. WBC and ESR are elevated.
Treatment consists of bedrest, IV fluids, IV antibiotics, and NG suction
if ileus is present. Since surgery may be required, transfer to a
definitive surgical facility should be considered.
ANTIBIOTIC REGIMEN: (Center for Disease Control, 1989)
Doxycycline 100 mg PO or IV every 12 hours, plus either:
Cefoxitin, 2.0 gm IV every 6 hours,
Or
Cefotetan, 2.0 gm IV every 12 hours.
This is continued for at least 48 hours after clinical improvement. The
doxycycline is continued orally for 10-14 days.
ALTERNATIVE ANTIBIOTIC REGIMEN: (Center for Disease Control, 1989)
Clindamycin 900 mg IV every 8 hours,
Plus
Gentamicin, 2.0 mg/kg IV followed by 1.5 mg/kg IV every 8 hours
This is continued for at least 48 hours after clinical improvement.
After IV therapy is completed, doxycycline 100 mg PO BID is given orally
for 10-14 days.
Tubo-Ovarian Abscess
These patients are very ill, with severe PID. In addition, they have
palpable pelvic masses from dilated, abscessed fallopian tubes.
An initial course of IV antibiotic therapy is warranted even if surgery
ultimately is necessary. With the antibiotics, the patient will either
improve and stabilize, allowing definitive surgery at a later, more
elective time, or they will not stabilize and instead follow a downward
clinical course. These failing patients require laparotomy.
At surgery, removal of the abscessed fallopian tubes is necessary, along
with all affected tissue. This typically includes the ovaries and the
uterus. This surgery may be difficult because the considerable
inflammation will obscure anatomic landmarks and the edematous tissues
will be friable and difficult to manipulate. In such a setting,
supracervical hysterectomy may be a wise course even considering the
leaving behind of a possibly infected cervix.
After removal of the affected tissues, locally irrigate with crystalloid
and place multiple surgical drains.
Once the infected tissues are removed, recovery is usually brisk,
although return of GI function may be prolonged.
Abnormal Vaginal Bleeding
Overview
Occasionally, abnormal bleeding will be due to a laceration of the
vagina, a bleeding lesion, or bleeding from the surface of the cervix
due to cervicitis. Much more commonly, abnormal bleeding arises from
inside the uterus.
There are really only three reasons for abnormal uterine bleeding:
