Acute Pelvic Pain ainisd?nM"ad6ouLiluainifiwu~n"~'au1uam"s~u $ 0 * 11?tlJ$~6' ~ ~ ~ ~ ~ f l ~ ~ l n l ~ ~ ~ l ~ d ? ~ ~ l ~ ~ ~ ~ ~ ~ & 6audijiltlJuilunis;jS~a'umnamuniss'nwi uidswaw 4 ds ~flu~unsiun~sl?m m~~~~~lii~~w~~iiiulnd~:li~mui t a n i a ~ i ~jud n? u a d i ~ ~ n u 1 u d ? ~ d d s : n a u a i ~ w ~ ~ w ~ 6 adidlsn'miu ?nuinisluil~~Y'uln"d~ulfini~;j~~a'u nis s'nw1ijds:3~tniwuiniu u i n ~ s i a i u i s n ~ n ~ 1 i u m ~ i u ~ .r d ~udiulnnlii1:lfluds:Pusl6adid~d omi~?n~ad~aud~ai~uy~in~~m fin% ~idu"s~?sl d?nui~~mAniia:i;a (lower abdomen) 6id?wngnnfin f I I 3 ~ I J ~ ~ a l ~ l l < I J(Pathways da~1 of pain perception) f q:d?nm~ u i ~ ? m ~ u i r a u i a l6i i n u i ~ a n i w a i d i l n niss'u$~m~?iu~;ud?n ~~L~MEIMI]W~~IS~Q~S:L f Ad * , ungnun:h~rni~:d?nu?~?m~u~a~iu~usl"aa:~wn~uui Zo ds:ai~niss'u%"nmaiun"ud?nl4uniu~~uu LLLIYM~YMU~ ~ ~ d n i n ~ u ligament i n a ~ ni~ioinisd~ms"i~1.d6iuuEui~m n"nttn:~fludusus'u n'uuin~oCartesian Model d i i n i s Y f r' sacrum i i i a ~ n s i i u u l i ~ d d ? n ~ ~ ~ ~ % u ~nis u ~ ~ n%~?Iu%~~L;'u~?A iia:~o ui~inni~l6SYYuin~~u~~~ d?n~ufinliln"iiaiLuyqinlsmMidu"sL~sl uan.pin:nio bd1$o~uiu'odnis@nm?iu~1"ud?m~~uu~~uuwn'u (acute pain) d ~ m M " o a 6 o u d ~ i i n ~ i n ~ s m ~ i ~ u " s ~ ? ~ ~ u ~ : ~ a iIn"; nisd?nuin d A A 4 ~dirriu~riunitiirnPi~u~u6' <~ai~~fluainisrii~~~vii2fi Ir C - Gate control theon/ Lfl~~nM~~~~~dMs'u~~a m?iu~dnm?iu~~ud?n~iu~duds:~i~d?udniu waiuh @huuiwuuwnd ~,dn'yaisu~m?iu~mnn'd?n uio'Jds:aiMd?unni~ qin n i s d i r r u n . a G ~ u ~ ~ a i n i s d ~ ~lud%q: ~)M'~~u '~~ 424 A ~~i~onn 2 "an;o ~ilu M ~ W ~ M I ~ L ~ ~~U?~1~~I 1 1 " ~ d ? LL~:Anl ~ M ~?:MId ~nl aisumFimk nnan~unsounhun:mswziu: ~fluilq.~ud 1. nisd?rnM"od6nu~~uu~~uuw~u (Acute pelvic pain : A' Qd~uijoinisd~m~uuiM'u~M'u1m fin6adnism?iGu i~rdlunis;jQ~a'us'u~a:lfiniss'nwifin~:inisd~nuiuiulai APP) L ~ 72 M &IU~ 2 2. n1sd?mM"nd6nu~sasYJ(Chronic pelvic pain : CPP) Nociceptive stimuli dd~a~uu~ad~uu~~dndniss'u~~dm?iu~1"ud?m1n" k2ddl 14atuiu16in~~nisd~nLLuu~as'~ (chronic pain) U?.JA!JWY i i ~ ~ a n i s u i n i ~ u i i ~ n i ~~i6dmaijninisd?mia uuiu~~~~ I d l G n u7ahubldd~ndii u u l i ~ &dniald ~~ +============= + Patient's perception of pain Social determinant Psychologic state nl~dsna:uad%:al~~odn1%%'~1~~al91!~~1danspinal (Nociceptive signals of pelvic pain) cord 447ziji4 sympathetic L L Bparasympathetic ~ systems tj7u Franken hauser's plexus LLaz uterovesical ganglion 6 9 ~ ~dai74n7ul6Fuu7nGu lzinq~d4nsz~~adsza7wq7n da7udszfi7nldG4aua~Pmuld4q7nuterus, cervix ~aza?YU?z daih4ide4+~~1ur~uri uterosacral ligaments , broad ligaments ~ ~ L H ~ v Q s ~ % ~ ~ w ~ ' Q (Acute ~ ~ ~ 'pelvic Q U L pain ~ U P I : APP) LLaz round ligaments W5-I inferior LLaz superior hypogastric plexuses 1sympathetic chain D(I4 TI0 - TI2 IU spinal cord 2" 4 ufln~1nuu4uu74dau77n pelvic floor ld4ldG4 S2-S4 lu 1snw74 d l ? q U ~ I & R dd~ ' l i l d f ? 64lltW14lflu ~ 7 ~ 7 41; Table 1 Causes of Acute Pelvic Pain Complication o f pregnancy - Gastrointestinal tract Abortion Ectopic pregnancy Ovary - - Rupture of a cyst Torsion of a cyst - Appendicitis - Mesenteric lymphadenitis - Bowel obstruction Diverticulitis Urinary tract Cystitis Mittelschmerz - Ovarian hyperstimulation - Nephrolithiasis - Mesenteric vascular disease - Aortic aneurysm Bleeding of corpus luteum syndrome Fallopian tubes - Torsion - Infection Pyelonephritis Vascular Musculoskeletal Metabolic Uterus - Degeneration of leiomyoma Torsion of a fibroid Pyometra - Porphyria Sickle cell crisis N o evident organic abnormality Endometritis Acute pelvic inflammatory disease - From : Porpora MG, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Fertil Steril 1997; 68 : 767. ~ n W ~ Z d m ? 9 7 W ~ ~ 1 7 7 n n 7 9 d f l ~ n d f l 4 n 7 4 . d ~ 4normal n " ~ 4 pelvis(l8.9%) 1 1 n n l ? ~ n ~ 7 1 ~ ? 7 ~ n.H. 4 7 1996 d (laparoscopy) L R U ~ S ~ U ~A.H. ~ U1983 ~ M(Cunanan ~ RG Jr, (m797.d 2) W L I ~ ~ ~ ? I . Jacute ' ~ Msalping~ophoritis ~~U (22.8%) Courey NG, Lippes J. Laparoscopic findings in patient with pelvic adhesion (22.8%) LLaz ectopic pregnancy (19.0%) d ? ~ pelvic pain. Am J Obstet Gynecol 1983;146:589.) WU~I~?M normal pelvis W U L ~ 7.5% U ~ l M ~ l f h 4pelvic adhesion (31.5%) endometriosis (21.8%) U ~ Z Table 2 Laparoscopic findings in patients with APP and CPP 1. Salpingo-oophoritis 2. Pelvic adhesions 3. Ectopic pregnancy 4. Endometriosis 5. Hydrosalpinx 6. Ovarian cyst 7. Polycystic ovaries 8 (1.1) 72 (4.4) 80 (3.4) 8. Misplaced IUD 3 (0.4) 2 (0.1) 5 (0.2) 9. Normal finding 55 (7.5) 391 (24.0) 446 (18.9) 736 (100.0) 1629 (100.0) 2365 (100.0) Total From : Kontoravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, Zourloas PA. The diagnostic value of laparoscopy in 2365 patients with acute pelvic pain and chronic pelvic pain. Inr J Obstet Gynaecol 1996; 52 : 245. n ? o i w u normal pelvis qin laparoscopic findings $flu a~lun1s8nmluszuzwn'~~~1q~?!u~ws~z urethral syndrome du61.J L L a z ~ d i s i u J 7 u i 7 f l l ~ i ~ ~ w 1 ' ~ 1 7 psychiatric disorders ~ ? ~ t $ ? u I. !n7s~wu7~Rdsa.r!or~az;j1n7~~'7 Iaparoscopy 3 S W " ~ f l s z ~ m 7 n ~ w ~ ~ u a ~ u ~ s n w s ~ ~ w ~ w u ~ 7 a n ~ wq ~i n6nui si8nn~a u7 n " m u ~ 7 u u 1996 " Y 2. n77h;uL~fl (biopsy) Ldfln7??~qT% endome- &wuil@hu$u7 t$?u APP ~~azZ6QunisM'i operative laparoscopy d ? u l w y l t $ Y u1nauM'?~fifiiuisn~fin1~3Cq~u endometriosis$tI s'Elnis3Gq5ui1tdu ectopic pregnancy s a d a d u i ~ f l upelvic z d d mnau a~~uoriouu'nqz1Pjfi1uisnlfinis;jC~5uZn"n"iwin adhesions k a z endometriosis . 7 ~ & 6 ~dlu~d?udu11;1u CPP triosis endometriotic lesion l?!uda7? aLw?ifld w%lfil fin7:lW"nls lesion id& 1 2 7 ~ 7 a nn ?U~GUIU~~?J~"S 3 M f l n q l n M n I T w u normal pelvis q i n laparoscopic findings ~ u S i u & ? 6 ? ~APP !~&d 7.5% h U n j i CPP id! ~~azb%'un~rnvh operative laparoscopy q z ~ P n n q ~pelvic n adhesions ~ f l d a d ~ i endometriosis ~ ? ! ~ (F17~7dd3) d ? ~ operative procedure k L ? ! l d operative laparoscopy ~?q:L?!ld conservative surgery (Fi'l~idfi' 4) a 11.1 24% iufl7qLdaduqqin~diun"LfluCPP !fi7~wyq?nlsm laparoscopy ififluuin d?w ,u!$'t~ ulf M"~ri1d~snm7du"sL?"11u7nni7 1 6 ~ "irritable bowel syndrome, R ~ M Z Bole7Uu f l 7 8 1 ~ 4d ? major ~ complications L ? ~ A ~ s ~ u diverticular disease of the colon, chronic bladder infection, d h d ~ ?emergency ~ laparotomy (w75'lJd 5) Table 3 minor complications riu Diagnostic andlor therapeutic procedures in patients with APP and CPP Diagnostic laparoscopy Operative laparoscopy Total Laparotomy Conservative treatment Total No treatment From : Konroravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, Zourloas PA. The diagnostic value of laparoscopy in 2365 patients with acute pelvic pain and chronic pelvic pain. Int J Obsret Gynaecol 1996; 52 : 245. Table 4 Type of operative laparoscopy treatment (n=315) Ectopic pregnancy Salpingotomy Salpingectomy Endometriosis Ablation Coagulation Tubal sterilisation Ligation Bipolar diathermy Unipolar diathermy Pelvic adhesions Adhesiolysis Fimbrioplasty Ovarian cyst Enucleation Misplaced IUD Retrieval From : Kontoravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, Zourloas PA. The diagnostic value of laparoscopy in 2365 patients with acute pelvic pain and chronic pelvic pain. Int J Obstet Gynaecol 1996; 52 :246. Table 5 Complication during diagnostic and operative laparoscopy in patients with APP and CPP Nausea and vomiting 36(1.8) Postoperative shoulder pain 29(1.4) Postoperative bleeding Small intestine perforation Bladder perforation Total 65(3.2) From : Kontoravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, Zourloas PA. The diagnostic value of laparoscopy in 2365 patients with acute pelvic pain and chronic pelvic pain. Int J Obstet Gynaecol 1996; 52 :246. ni%32~5u 1Pd.dadn"ad 3 ~umou~in'~1unisitq.a'u~snM"i~ufiiitl~~a;Inin]~m n"idoinisd?mmaq (dull pain) 6n~?mqinnisCn~fiu n"n;lCou iiiio dszGnisd9m ainiqdwui?ug?u uaznis n"iiininisd?m~~dEu (sharp pain) 6n~?m~innisiimn w n s a q i i ~ n i u6 d i l ti"s~~mn'Pdslfidfl?"u7=ldu ruptured cyst tl?a dl!dqm"YM 1. dszZnisdam (gut obstruction) lflufiu 1. ~n~nwmzk?!d~odaini?d? m (Nature of pain) 2. ~ ~ i ~ ~ U l l ~ d (severity) ~ ~ d ~ i n i ~ d ? ~ u n n ~ i n n i s ~ n n i u ~ i n ~ d ~ u i i ~ tiiiioini?d?m~flu$nq(intermittent) dam?nq (colicky pain) ~ n q z ~ f i i r v l ~ q i n n i ~ ~ m s ' m n ' ? n a ~ d i ! ~ ainisd?mu6~nisld~inm~n'nwmzniuuan~o~Bfl~uqzn'i'lr i i i i i a i n i q d ? m $ u u i v i u ~ n a z a i n i s d a n i i l u a ~ i n f i i u i r o n s i u i i ~ ~ ~ i ~ ~ ~ u i i s du ~ ~ u~!umq "i u~d~du naamL?ai (constant pain) 6n~fii~vl?qinniss:miu~~o~noda i n i q d ~ m ~ u u t d u [email protected] n wqziirinamdm d a u d~ o~ ~ ~ i o ~ d a d bd8dqinuuo.r .r Isam bowel contents d o d vi?~n'? 3. oinis~4ud~m~dar"sufi~ (onset) ni?nimltlom (ischemia) nodaiu?rdo~~udodl'i.rn~iu~?o 2 n"7iioinisd?nauuiKu~Kuln (sudden onset) Pelvic Inflammatory Disease (PID) .r ~ a i ~ u y ~ i n Z n i ~ ~ ~ m n ~ ~ : ~ a ~ ~ ~ ? Y~Zon, U ~ zuuoq G i l f i u ' G i , PID ~ilulsnGn~~oluo~u~z3uw'u~d~uuuluam lnu 3 bowel contents ~ ~ n u i s ~ n i u ~ i i a ~u?oiinis ~ i ~ ~ ~ Du I .~ d~ a~ ~~ L~~ ~Dsalpingitis, ~L O U oophoritis, parametritis, pelvic 1 ain~~onan~nTuazGu~n"Gilfiijainisdan~uuiKu~ln" peritonitis, 4. s:uzL?aidd?n(duration) iiainisCiiim'rya; 6iu'oinisd?nuiuiu~~bq ninird?niinis 1. Lower abdominal tenderness ~ d i u u ~ ~ d a q ~ n ~ l j ~ ~ a ~6iiini~~d~uu~~daqn"qz ?ai~jiul,d 2. Cervical motion tenderness d ? u l f i l ? i ~a~l i $a ~ n i~~ ' j i i q ~ u ~ i uL i ~u ~usiudiinis U 3. Adnexal tenderness ~~mnao~oTuazludn~fi'i3~ oin?sdanI1UYn~u~~~~uinlum~u f ~ u n ' ~ n i s n s ~ ~ w u 6 ~ i a l d ? asnsioui~rflndlldriun~~u moudZnirumn ~ ~ h a i n i s d w ~ 1. Temperature of fever > 38'c 4- Y C ~iuldu~~~inoTuazGu~~mnLera~z~~~n"? 5. 2. Pelvic mass ninisd?n&uw'ufi'n'un?~ii~au~zq (relation to the 3. Leukocytosis (WBC > 10,500 cells1pL) 4. ESR > 15 mmlh menstrual cycle) am~luTu~~?~~ufi'nisa'nniuoini~d~nii&uw'u~ 5. Presence of N. gonorrhoeae and/or C. trachormatis rYurourquiaLi Z n ~ i u d i ~ u ~ i nw s i : Z l r n & u ~ a u ~ in the endocervix ~iioinisd?n&uw'ufi'n'usau~:~ ~dldendometriosis Go Mittelschmerz (nisd~n$Liin~inni~mnli) $8 oinisd?n$u 2 l i i n a u u ~ 4 ~ i n i i n i r I i n ~(missed zq period) ai1iiai~uy 6. Mucopurulent cervical discharge (WBC > 5 cells per oil immersion fields on gram's stain of endocervical discharge) 7. Presence of purulent material in the pouch of ~ i n n i t b n s s n ' d Z n i ~ z ~ ~ ~ ~ n a " a u ~ E n ~Glai u f n u ~Douglas y"d~u Differential diagnosis I X L L ~ ~ ~riuiimu~o~m'\lnssn' 6. ainisiu7 d w u i ~ u f i a i n i s d moisd?ulfi~si 1. Acute appendicitis ~siuai~uyanqnisdanL ~ Uiiainisdaai~::~~au$n 2. Ectopic pregnancy d a a i ~ z i a a wui~aniwririnq:adds:uu$u~iu~aai~z 3. Ruptured corpus luteum cyst or other ovarian acci(urinary tract) hu'ainisniuld BIL%IU f i ~ q f af?udi?u ~ dents nisd~n6uu'n~En~inwu~~aniwM"di~d~~um"u 4. Septic abortion 2. Jsz%nis~8"uilau'Lu&i6il 5. Torsion of adnexal mass L, oi~wud~l'u~idu~aa~nitd~nfia46~u~ZuuwCulu6. C A T I ~ ~"d ~n u ~ f l u Q ~ ~ ? ~ n~nufinsshnnunqn ~iu~n~au 7. Endometriosis Lnuejl,~,ldi41qum"u P q Degeneration of leiomyoma C 8. Acute urinary tract infection 3. nisnsaqhilniu 9. Diverticulitis dsznauhu nisms~~fi~niulnuY1"~'ld nismsaqcr61 10. Regional enteritis &sz6oqms~qhanirq ndi mi: 4.1 qin$u hnismr?qniulu 11. Ulcerative colitis k q i i ~ ~ i n ~ ~ l l j a i u i s n 1 f i n i t ; j ~ ~ a ' u l n " o i ~qinnitAnuilnu m"n~~glnlssn?7~~u Ultrasound l ~ u ~ ? uG o laparoscopy sellers Lraznmr qiny"l1qudii clinical findings dfi~&flil'~z~gld PID (preoperative diagnosis of n i ~ a ~ d ~ ~ u ~ ~ i ~ l u n i s c r i a i ~ u ~ a ~ ~suspicious n i ~ d aPID n )f Li a~ D~~6I ~~I u~ ILaparoscopy w u i i ~ g uPID L%IQ .r ~Zaunh'ulir6qdd 2 . 4690 (n = 95) l d ~ n 7 i n ~ l dtubal 7 ~ pregnancy 1 ~ ~ 5.2% Ovarian a i a q r ( i 6 ~ r a . r APP dwuiau ais~iluCumsiu cyst 4.2% hemorrhagic corpus luteum cyst 2.1 % appendicitis 2% pyelonephritis 1% irritable bowel syndrome 1% \ahWi'lu' FiaTim ~ ~ a z ~ o u $ i ~ i j d ~ u i l u n i tIXuri ~ i i ~ apelvic 'u nmuijndni 39.5% n ~ i u ~ ~ l j u ~ i a a ~ n i s ; j S ~ a ' u ~ inflammatory disease (PID) LLaz ectopic pregnancy 44; dsz~n"u$tiiaul~n'~< ~ ~ a n d ~ i ~ ~ ~ ~ a : n i o m ~ ~54nriidi.rh ~i~fia~d~ 4 0 Y Acute abdominal pain Within 72 hours I Probe pain pattern and undertaken physical examination included vaginal examination I I Associated with signs of without signs of peritonitis, peritonitis, bleeding, or bleeding, or shock shock I CBC, UA, pregnancy test $. Consider 1 CBC, UA, pregnancy test + diagnosis acute - UTI abdominal - Gastroenteritis emergency - Sickle cell crisis - Porphyria - Other nonsurgical '-4 pelvic mass I clinically and laboratory studies are unrevealing w abdominal disorder Ultrasonography I - Adnexal accident - TOA - Ectopic pregnancy - Salpingitis - Uterine myoma - endometriosis v Assess need, emergency, timing for undertaking surgical procedure Rule out - Dysmenorrhea - Dyspareunia - Psychosomatic pain - Malingering - Gastrointestinal, urinary, orthopedic, or neurologic, L condition ~ ~ i]n?q~l? 4 7 (sensitivity) 52.3% 4 P~??u<?Lw?: (specificity) d (sensitivity) 61.4% A ? ~ u < ~ L w ~(specificity) : 52.9% LUB 44 84.3% L ~ D ? U ~ C B ( I ~ ~ ( I ? ¶ ~ ~ ~ L ~ ~ M ~ ~ L ?ir4tillmuuwnu~~1d L ~ ~ O ' L L ~ : ~ ~(nm.rd ? ~ U ~61? Table 6 Performance of clinical diagnosis by gynecologists and primary care physicians for presence or absence of PID. GYN vs ALL-PID 52.3 GYN vs PATH-PID 40.6 PCP vs ALL-PID 61.4 PCP vs PATH-PID 59.4\ GYN, gynecologists; PCP, primary care physician; PPV, positive predictive value ;NPV, negative predictive value. From : Sellers J, Mahony J, Goldsmith C, Rath D, Mander R, Hunter 6, Taylor C, Groves D, Richandson H, Chernesky M. The accuracy of clinical findings and laparoscopy in pelvic inflammatory disease. Am J Obstet Gynecol 1991 ; 164 : 115. ~dn.rqqnnqs?Qqa'uqqnBqnqsunznqnqsrran.rii c;irmda~wuYkm' Y n??urriuu'?cBu 6.rCu~aparoscopyfid'll~u Gold standard Fallopian tube 98.3% Iun?s?%a'u PID ~ m u ~ ~ w ~ : a d ~ . r d . r n ~ s ? ~ ~ a ' u ~ u s ~ u d u ' ~ ~ i uJIq ~ d ? u d a ~ q k ~ a u i a ~ n ~ s ~ v m s u i a l u ~ ~ u n " l ~ n ~ s f n m 4 i l u u ~ d l j h u : u i ~ a ~ n ~ ~ l i ~ < l48-72 d n ~ 4u9l u1 ~ 4 lunqsn'q laparoscopy MYMn?s~n"uiqluda.rn"a.rd.r Ovary 0.1 5% Y A4 Y ~w?:~¶a~rnzn'? biopsy l u i ~ ~ ~ u d . r n m ~ ~ ¶ a m " ~ u ~ ~ a l f iAbdominal i i n ~ ~ ~1.4% ., Y ~ u s ' l f l n " ~mild ~ ~to ., - Fimbrial part 6.2% Ampullary part 79.6% lsthmic part 12.3% lnterstital part 1.9% Y ~wsq:uq.rnknqsqm"?umq~ddq moderate ~nwm:un.r Cervical 0.15 inflammation 7: iY~~uil~uam'eni%ldpdl%w Y km' li%lil~qun=Ilfinqs?Qqa'uEnwnqnl6 n q s h laparoscopy q:d?ulfinqs?Qqa'u~i3uldm"?u E 2 Y n m u ~ ~ i u i q r ? m n u ~.~rd?ulfiid?ul);funqsQnwqn" nu Luuq:au~~bwis:u:usnna.r~sn Gnm:unmriauviq.r 7 2. Tubal sterilization d~17UUln"7:~R~.llm"m"?flL ~ pelvic U adhesion, infertility, ec- 4. DES exposure ~i3uhuadq.rlsn"mq~u'ln~m"iiL~u?n'l~ ? Q q ~ i l l d kn"oqsd?ulu?irs&Us?m~??~nm"a.rlfinnq.r ~~ u i . r i . r a q s f i p M ~ i ~ ~3 d d 5. IUD topic pregnancy 1. Tubal pathology 3. Previous ectopic pregnancy 6. Infertility 7. Life style eg., multiple sexual partner, cigarette smoking, vaginal douching Ectopic pregnancy a~-~qsun:nv-~~sufim.r y"d?uu'nuqn"?u aqnqsd?m q u ~ n ~ s n o . r n ~ s ~ . r n s s f i u a n ~ m O n i i ~P.rlisu ~ u ~ f f aqmrrq i ~ ~ ~ ~ a~nqnawqs~3u~Som ~u lunuludq: 9: i a u 7 URLn?l'duii?m91nnltkP139fiMBnUp10nnU~nmnpI lfin~s?CGiulfiiu7nl l d ~ d ? u B 7 9 ~ a 7 n 7 ? ~ n : ~ 7 n 7 3 ~ ~ f i n.rdau 7 ~ . r ~ a ~ ~ ~ i 3 u ~ w s ~ : f i ~ ~ ~ s n l f i n ~ s ? Q dumnviq.r~u~rjiuqn ~a'ulm"k~~~D n'~ufim.rlumqsq.rd i 7 un: 8 a w 6 l f i i i s:u:iuiudu'~liiinqsmn~~am ~m:fiquqsnlfinqsQnwqlm" ilyu~'lun~s?Q~a'ulm"u~n adwiids:antnqw L ~ M nqsi4a.rnia.r n~sri~mYPlnq.ruflq n"a.rdiin~~:unsn4auama.r Ell Patient with Suspicion of Salpingitis History of pelvic pain and its pattern, fever, relation to menstrual pattern, periodic recurrence, prior sexually transmitted disease, intrauterine device use, infection after abortion or delivery, associated urinary tract manifestations, and gastrointestinal symptoms Examine physically in detail for signs of peritonitis, Adnexal masses, or induration J, Investigate objectively with CBC, differential, erythrocyte sedimentation rate, urinalysis, smears and cultures for sexually transmitted diseases, C-reactive protein, beta-Subunit hCG, and pelvic ultrasonographic scanning Ensure the presence of objective findings Exclude diseases of uterine or extrapelvic origin Determine existence of inflammatory adnexal disease Consider laparoscopy if diagnosis is unclear Diagnose and manage Adnexal accident , Ectopic pregnancy, Dysmenorrhea , Endometriosis , Pyometra , Urinary tract infection , Degenerating leiomyoma , Premenstrual syndrome, Inflammatory disease, Or acute appendicitis Diagnose pelvic inflammatory disease ilsqY'uiinirl8 ultrasound &rilu?2nism~qdii !m"s?mi?!im"a4r~um'9iifiiuisnunn!n"ii1ziini?~ heme ~n~4~fiiuisnms~q~iiij~nud~ peritoneum u~olai Table 7 symptoms of ectopic pregnancy %# Abdominal pain (adnexal mass) maanlums?1uinis~4Anssn'niu~uPws4 Amenorrhea Vaginal bleeding unqn!dlu~ani~"nu?n'M n'~unis$iculdocentesis %r;an 18~owizluns~dZiri ultrasound Q J ? u D ~ I ~ ~ I ? : L ~ ~ ~ ? u Dizziness, fainting m"a4Mnis?fiq<ui~azfnwiPnu~? w Urge to defecate 2. Ultrasound (UIS) Pregnancy symptoms nisms~~ii~niu~zms~~wun"nu1n"~~n~u 2 3 ~du.r r i U/S f i i u i ~ n m ~ ~ ~ w u ! n " k ~ r1r i.I~ U.u i~u!d n Passage of tissue From : Weckstein LN. Current perspective on ectopic pregnancy. Obstet Gynecol Surv. 1985 ;40 :262. 3 uan~inuu'fiiuisnlfisiuazPaun"o~~nw~z~n~n"~u1n"n u u a n ~ ~ u ' J m s ~ ~ u i n i s K ~ ~ s s n 1 u C w s ~ms?qni?z un~nuaz 4 '~dw~~urh!n"n'nii?~~6? ii~finis;jfi1?h nisk4~ssriuanun~niinisrdduurLda4~dndi4uinuiu nisIr uw d o m r ~ ~ a i i u i n i s l ~ s s f i n i u ~ u ~ w s ungntesok ~inniM'nn?iuuuim endometrium WU~I 61; hemoperitoneum Table 8 Signs of ectopic pregnancy Adnexal tenderness 7590 Abdominal tenderness 80-95 viable intrauterine pregnancy A?lUHul91Q4 endometrium 1 : 3 u ulnnil 6 Nu. 91uZd Q I I m S ? I W U gestational sac P h L r i 2-3 Adnexal mass 50 &dnititrg4linij implantation ~ifiun4!ail{u embryonic (20% present on side opposite ectopic) structures r % n ~ q i n o ' ~ ~ u i n r ~ n u i n 20-30 Uterine enlargement nisZ4 transvaginal u/S d?ulflnis?Sqa'uectopic pregOrthostatic changes 10-15 nancy ! ~ ~ u i n u a z u i n 1 8 i ~ u n ' u ?1 ~ ~ n'szui u Fever 5 10 dsz~ntniw1unififiqb!ausiudfi4!1jijninis sign dwu~lm"1rri From :Weckstein LN. Current perspective on ectopic pregnancy. - empty uterus 90.5 % Obstet Gynecol Surv 1985 ;40 :263. - intrauterine pseudogestational sac 9.4% - adnexal mass 81.1% - free pelvic fluid 96.2% 4-i w w i i u c MRI M~SD CT scam uvl~~du~uuin niqdnnl%i f i i 4 'lusiud U/s k!rifiiuionlfldafi~dhnis~~~<u!n" um'n'u'nqzr7nnl8 laparoscopy nYMuinnii~z~70nZ'a" MRI 1. Culdocentesis u% CT Culdocentesis U%I colpocentesis nis~~iz~$i1,dZu culhemoperitoneum LL~?<I de-sac ~in!n"r&n ~4I.i4~finiiij 3. Endocrine m a r k e r s fii~u~d?uZuqj~fin~in ectopic pregnancy uin'aiqriinqin 3.1 hCG (human chorionic gonadotropin) filnrqdu7 16 idu rupture ovarian cyst. spontaneous abortion. Lilusas~uuu~nnun.rnisi4ntsn'i4fir?41nu trophoblast menses, intestinal pathology k4kihd6 ~ ~ 4 d f i f i d f i l u l ~ n ~ ~ ~ w u ~ ~ ~ b~rsilo ?u u & ~ i n i n i njru; l uazij~6u~4~nlu?ud ' 3 nisi? culdocentesis LW'n9~9~f.l ectopic pregnancy ~SZUIN 50-70ug471n ovulation U ~ ~ I S L ~ U S I ~ L ? ~2. ~rVi1 (doubling time) ' 3 8590% lrazg positive predictive value dszulf1.4 80-95 % drzuiru 48-72h ~ u a LL~:R~PLRUUM~I.IIJO~ 66 % I n 48 n"7~~iz~i~!ailn"~ijn[il (negative results) ~11rflu)1Ei[u h1u4 Ga 114% zu72 &E.N siudGnnnnnfi41aiuin Gnujlai rupture 6~~ufi~qizlailn" filuin maternal serum HCG ~ i n n i800 i mlU/ml I? A?IU~? (sensitivity) L L ~ ~ A ? I U ~ ' ~ L W(specificity) I~ 91D4 d r s rijanlai~iuisnuanln"ii1ai~3u ectopic pregnancy niqws?qwunisk4fissn'n"?uU/S ln"rrd? filtlln B-hCG IJlnnjl 3,000 mlU/ml 7:h~\lfilu75'llm5'~~wlJ intrautenine gestational sac 'ln"tt6?n"?tItransvaginal ultra- sound ~ \ l m l s l \ l d9 Table 9 Gestational age and serum hCG concentration for different probabilities of detecting gestational sac by endovaginal sonography From Kadar N, Bohrer M, Kemman E, Sheldon. K. The discriminatory human chorionic gonadotropin zone for endovaginal sonography :a prospective, randomized study. Fertil Steril 1994; 61 : 1018. 3.2 Progesterone sK :u progesterone du1nn41 25 ndml f%J viable intrauterine pregnancy 7:83JfifiLI fin~:8u%u8 ~a:fili7n'lnjl 5 ndml fin nonviable pregnancy filflf,i5':~jl4 525 ndml u'fiqd'li'ln" i\llflun~r;jCqa'uectopic pregnancy 'ln"u7n 4. Dilatation and curettage (D&C) 1. Buck P. Pelvic pain In : Luesley DM, editor. Common conditions in gynaecology : A problem solving approach. London : Chapman & Hall Medical, 1998 : 81-97. 2. Hewitt G. Pelvic pain. In : Stenchever MA, editor. Atlas of clinical gynecology : Vol.1 Pediatric and Adolescent gynecol- d ~ ~ 1 ~ n l ? ~ ~ ~ ~ d l n l ? ~ J A O O n " ~ ~ ~ ~ 9 \ogy. l ~ lPhiladelphia i l ~ n t l ": Appleton s B ~ ~ & Lange, 1998 : 8.1-8.14. ~ ~ n oD&C ~ under d ~ general l anesthesia 1L~:filul~ll~l 3. Kontoravdis A, Chryssikopoulos A, Hassiakos D, Liapis A, I n "n " ~ : ¶ ~ t 1 ~ ~ 6 l ~ l ?surgical o n ' l l treatment Zourlas PA. The diagnostic value of laparoscopy in 2365 ~n'ld'ln"~auluns~a~~uan'uin~sanw~wui~ n l f ~ ?frozen ~ patients with acute and chronic pelvic pain. Int J Gynecol frozen section section ?ksensitivity 78.3% specificity 98.4% positive predic- tive value 94.7% ua: negative predictive value 92.6% Obstet 1996, 52 : 243-8. 4. Porpora MG, Gomel V. The role of laparoscopy in the management of pelvic pain in women of reproductive age. 5. Laparoscopy Fertil Steril 1997 ; 68 : 765-79. n~sdo~n6a~~:¶au'lm"u7ntl~nn~s;jC~Gu~u~u~~~i Sellors J, Mahony J, Goldsmith C, Rath D, Mander R. Hunter ~ilududlqf i ~ n " o a n ~ s m s a ~ ectopic u ~ i ~pregnancy i tl?o'li B, et al. The accuracy of clinical findings and laparoscopy in d a\lfiamo~Lilu;uLLsnrinun'7 laparotomy fi~~Gu\lhn\ln~smnq pelvic inflammatory disease. Am J Obstet Gynecol 1991 ; liiudlqi~iiectopic pregnancy 9% 'linam0l laparotomy ~ilu 164 : 113-20. Rhu unLluluntrididaunf,iluiu;jnqm Friedman EA. Pelvic pain. In : Friedman EA, Borten M, Chapin Diagnostic algorithms iIqCuduqntrn\l practice guideline M% medicine DS, editors. Gynecological decision making. 2& ed. Philadelprotocoldriven phia : B.C. Decker Inc., 1988 : 51. 7. Lichter ED. Salpingitis. In : Friedman EA, Borten M. Chapin ~1niin1n1~~~wu~umnun19?Cq~~'lm'~n'~:dau1.~' Y uwnB i~Ku%umnun~smsaqhu (investigation) 'lmY~~u~:fiu DS, editors. Gynecological decision making. 2& ed. Philadephia Y u ~ n t r u I m u ~ u ~ ~ n n ~ n ~ s u aua:n~sd\lmsaqiu : n ~ n ~ r ~ ~ ~ n ~ : B.C. Decker Inc.. 1988 : 187. L & ~ i ~ ~ r i n ~ s n~ nCqGLu L~ ~ ~ ~ I ~ L L N ~ ~ I ~8. ~Graczykowski U ~ ? ~ W JW, ~ . Seifer U ~ UDB. Diagnosis of acute and mn'ld tl~nC\l'li~~Jlq n'n1~l~n1r~~1m1un1n1s~Llau1.upersistent ectopic pregnancy. Clin Obstet Gynecol 1999; ruria'ld kefi@al~i~umaulun~s;jC~a'um'~~dd 4 429-22, Initial Evaluation Symptoms Gestational age Endocrine testing : serum PhCG level, progesterone level, other Physical exam findings Sonographic findings I Hemodynamically stable Hemodynamically unstable Pregnancy location unknown Pregnancy location ectopic Follow-up sonograms Surgical or medical treatment Hemodynamically stable Serial PhCG measurements stabilizing Non-viable Pregnancy Viable pregnancy D&C Villi Villi Surgical or medical Absent Present treatment Ectopic Spontaneous Pregnancy abortion Surgical or medical treatment tdi Surgical treatment and 4 ~mn.r~umaulunwiir48 imtn?r%m ectopic pregnancy
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