Published on 10/04/2015 by admin
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Last modified 10/04/2015
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CHAPTER 22 Gynaecology
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.
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.
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.
Salpingectomy or salpingostomy by laparoscopy or laparotomy.
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.
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.
Churchills Pocketbook of Surgery
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