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Acute Abdominal Pain of Female Genital Origin: Diagnosis and Management
Acute Abdominal Pain of Female Genital Origin Diagnosis and Management PAUL O. KLINGENSMITH, M.D.*
THE female genital tract is a common site of origin of acute lower abdominal pain. These structures present an avenue to the peritoneal cavity for the entrance of infection. They are subject to neoplasms which may undergo acute changes. Not only are the complications of pregnancy numerous, but variants in otherwise physiologic cyclic phenomena may give rise to pain. Indeed, the wide variety of pattern offers a diagnostic challenge to the surgeon. The purpose of this clinic is to point out the basic methods of diagnosis and management which may serve as safeguards against error. THE APPROACH TO THE PATIENT: THE INTERVIEW
The circumstances surrounding the examination of the patient with acute abdominal pain often lead to confusion. The surgeon should take time to calm the patient and to seek an atmosphere conducive to sound observations. He will do well to keep an open mind, and not drive his questioning along preconceived lines. An adequate history is the foundation in the building of diagnosis. Methods of history taking are well known, but certain points bear repetition. Past medical events, especially previous operations and previous attacks of pain, should be noted, and documented if possible. The gynecologic and obstetric history should be reviewed. Recent therapy and instrumentation must not be overlooked. It is well to recall that women who want not to be pregnant may give false information. The menstrual history is of special significance. The most important points to note are the date of occurrence and character of the last menses, the presence of vaginal bleeding since the last normal period, and the sequence of appearance of vaginal bleeding in relation to abdominal pain. The amount of any abnormal external bleeding should be estimated as accurately as possible. The history of the site and character of onset of abdominal pain re-
* Assistant Profe8sor of Obstetrics and Gynecology, University of Pennsylvania School of Medicine; Assistant Obstetrician and Gynecologist, Hospital of University of Pennsylvania, Philadelphia. 1717
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PaulO. Klingensmith
quires special attention. The duration of the pain and its progression both in spread and intensity should be noted. The presence and sequence of gastrointestinal and urinary tract symptoms may be of significance. General phenomena such as fainting, chills and malaise should not be overlooked. Important points require checking from any available source, because the information obtained from acutely ill patients is often not reliable. THE PHYSICAL EXAMINATION
A good general survey of the patient must take precedence over local examinations. Accurate observation of the vital signs and general state of the patient is important. Special attention should be given to the presence or absence of constitutional signs of blood loss, or an inflammatory process. It is essential that the patient be catheterized prior to local examinations. Pelvic palpation should be deferred until the abdomen has been investigated. The abdominal examination will furnish the Surgeon with information concerning peristalsis, the presence of gaseous or fluid distention, the signs of peritoneal irritation, the localization of tenderness, and the occurrence of masses. Abdominal masses should be studied for the presence of a fetus. The accuracy of pelvic examination is enhanced by an unhurried and gentle technic. The lower genital tract is inspected for evidence of infection, instrumentation, and signs of pregnancy. Bimanual examination should be deferred until the vaginal fingers have tested the referral of pain from gentle motion of the cervix and explored the cul-de-sac and posterior pelvis. Rectovaginal palpation may permit more accurate definition and localization of masses and tenderness than the more customary vaginal examination. In any case, rectal palpation should not be omitted. LABORATORY EXAMINATIONS
Simple laboratory procedures meet the initial need, but there is a premium on the accuracy with which they are performed. The urine obtained by the original catheterization should be examined carefully. An accurate blood count is essential. In patients with suspected blood loss, or infection, serial counts are indicated. The basic electrolyte pattern should be determined in the seriously ill patient. Pregnancy tests may be required. The type of pregnancy test depends on. the available laboratory, but it is apparent that the shorter tests have advantages. Roentgen examination of the abdomen and pelvis is indicated when the surgeon suspects bowel involvement, foreign body, or pregnancy over four months' duration. DIAGNOSTIC POSSIBILITIES
When the historical and physical data have been collected, the diagnostic possibilities should be reviewed. The following list includes only
Acute AbMminal Pain of Female Genital Origin
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those conditions germane to this discussion of acute abdominal pain of female genital tract origin. A. No_evidence of pregnancy r. Variants in 'physiologic mechanisms a. Ruptured follicle h. Ruptured corpus luteum c. Primary dysmenorrhea 2. Inflammatory disease a. Acute salpingo-oophoritis b. Acute pelvic cellulitis c. Ruptured tubo-ovarian abscess 3. Neoplasms a. Uterine myoma b. Adnexal tumors and cysts 4. Endometriosis B. Evidence of pregnancy 1. Abortion a. Spontaneous b. Induced 2. Extrauterine pregnancy 3. Late placental accidents 4. Rupture of the uterus 5. Neoplasms a. Uterine myoma b. Adnexal tumors and cysts.
RECOGNITION AND MANAGEMENT OF A SURGICAL EMERGENCY OF GENITAL ORIGIN
True surgical emergencies are limited to conditions which are asso~ ciated with progressive, severe hemorrhage. Hemorrhage from abortion and placental separation has self-evident characteristics which will be discussed later. However, the etiology of intraperitoneal hemorrhage may be difficult to discern. It is more important to be able to recognize the signs of this catastrophe than to make an exact diagnosis of its cause. Prompt action is indicated for a patient who gives a history of lower abdominal pain of sudden onset and rapid progression, and who exhibits diffuse peritoneal irritation, abdominal distention of nongaseous character, and signs of restlessness, pallor, pulse hurry, and hypotension. Occasionally, a similar clinical picture may be produced by a ruptured tubo-ovarian abscess. Fortunately, the initial treatment for ruptured tubo-ovarian abscess is essentially similar to that of hemorrhage. The essence of treatment in massive intraperitoneal hemorrhage is the control of shock and hemostasis. The patientshou,ld be prepared rapidly, and the administration of narcotics omitted. She can be moved tp the operating room while a large volume of suitably matched blood is being secured. The operating team devotes its attention to the establishment of at least two ample avenues of blood administration. The anesthetist begins the administration of oxygen and prepares to give an agent which will permit continued high oxygen intake and minimum hypotensive effect. No other procedure is begun until the patient exhibits signs of recovery from shock. The actual operation will depend on the findings,
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but the object is to carry out the minimum procedure that will secure adequate hemostasis. . . Postoperative care should include careful observation of vital signs, and urinary output. The patient must not be overloaded with fluids. Gastric or intestinal suction is used if abdominal distention develops. Prophylactic antibiotics are indicated. ACUTE LOWER ABDOMINAL PAIN OF GENITAL ORIGIN IN THE ABSENCE OF PREGNANCY
Physiologic Variants
The principal clue to the diagnosis of ruptured follicle is the coincidence of unilateral lower abdominal pain with the midcycle time of a normally menstruating woman. The pain is sudden in onset and may be severe. It tends to diminish in severity over a space of several hours unless the rupture has been complicated by continuing hemorrhage. Signs of local peritoneal irritation are present with unilateral pelvic tenderness. There may be slight vaginal bleeding. Pelvic mass or signs of pregnancy are absent. There is no general evidence of an inflammatory process. The immediate management is rest, mild sedation, and observation for signs of blood loss. Rarely, there may be evidence of progressive blood loss, but usually the symptoms and signs progressively diminish over twentyfour hours. Should blood loss require laparotomy for control, simple local hemostasis of the bleeding site, not oophorectomy, is the treatment of choice. Rupture of a corpus luteum may present a clinical picture essentially similar to that of ruptured follicle except that the time of onset in relation to menstruation is different, and there is almost always some menstruallike uterine bleeding due to the hormonal withdrawal from the endometrium. When rupture occurs just prior to or coincident with menstruation, the pain is usually mild and short in duration. However, the corpus luteum may persist and delay the expected menses, and subsequent rupture produce signs which closely simulate those of early tubal pregnancy. A positive pregnancy test will exclude simple corpus luteum rupture, but a negative test does not exclude ectopic gestation. In patients suspected of corpus luteum rupture, direct visualization of the adnexa must be considered when the signs do not subside progressively after the first twenty-four hours. The method of visualization is a choice conditioned by experience, but culdoscopy or cul-de-sac exploration will often avert the need for laparotomy. The basic management of corpus luteum rupture is the same as that described for ruptured follicle. Primary dysmenorrhea should rarely present a problem in diagnosis, but occasionally in young girls the pain may be so acute as to suggest an intra-abdominal accident. The patient lies doubled over with pain and exhibits apprehension, pallor, and pulse hurry. Nausea and vomiting and urinary urgency may be present. Determination of the fact that menstruation is in process, and normal as to time and character, furnishes the major clue to the correct diagnosis. Demonstration of the uterine origin of pain with otherwise normal pelvic structures, the absence of
Acute Abdominal Pain of Female Genital Origin
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general or local signs of inflammation, and negative urine will make the diagnosis clear. Treatment is reassurance, adequate sedation and continued observation. Inflammatory Disease
The typical picture of acute salpingo-oophoritis is well described in standard textbooks. Numerous difficulties arise, however, in the differential diagnosis of this condition and appendicitis, and also between inflammatory disease and noninflammatory conditions which give acute bilateral abdominopelvic pain and tenderness. The differential diagnosis of appendicitis and acute salpingo-oophoritis in the typical early acute stage is easily recognized. Difficulties may arise in atypical forms, however, in appendicitis with perforation, or when the course of salpingo-oophoritis has been altered by inadequate antibiotic therapy. Even in such instances, the history of onset may give the major clue to proper differentiation. The onset of pain in patients with acute salpingo-oophoritis is bilateral and low in the pelvis, subsequently spreading up over the entire lower abdomen. In contrast, appendiceal pain is unilateral and higher at the onset, and tends to come down to localize in the low right abdomen or right pelvic area. Anorexia and nausea often appear before significant pain in the course of ,appendicitis, whereas patients with acute salpingo-oophoritis usually do not exhibit upper gastrointestinal symptoms until they have been ill at least six to twelve hours. An estimate of the relative severity of the illness may also prove helpful in the differential diagnosis. Given the same duration of symptoms without treatment, most patients with acute salpingo-oophoritis look more ill, have higher temperatures, exhibit more diffuse peritoneal irritation, and run higher leukocyte counts than those with appendicitis. Two points on pelvic examination should be given particular attention, namely, the evidence of infection of the lower genital tract, and the referral of pain on gentle motion of the cervix. This later maneuver is especially helpful in distinguishing the unilateral character of appendicitis from the bilateral one of inflammatory disease. Many women with acute bilateral pelvic pain do not have "P.I.D.," at least not 'in an active inflammatory stage. Those with ovaries altered by endometriosis, cystic change, old burned-out inflammation or previous operative procedures may exhibit acute bilateral pelvic pain in the mid cycle or premenstrual time as a result of cyclic stimulation or follicle rupture. They do not show significant malaise, fever or leukocytosis; careful examination demonstrates lack of true peritoneal irritation, but, instead, localized ovarian tenderness. The management is quite different from that of patients with acute inflammatory disease. The treatment of acute salpingo-oophoritis should not be instituted until cultures from the urethral meatus and cervix are taken for bacteriologic control. Cultures for gonococcus must be planted immediately on a suitable medium, and not allowed to stand around. Blood should be drawn for a base line serology before antibiotics are given. The patient is put to bed with head and trunk elevated, and begun on parenteral
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antibiotics. Penicillin, aureomycin and terramycin have each proved to be effective if dosage is adequate. Inadequate dosage is uneconomic in the long run, and increases the chance for residual damage. In severely ill patients, aqueous penicillin, 100,000 to 200,000 units, every three hours intramuscularly, or 0.5 gm. of aureomycin, or terramycin intravenously in 5 per cent glucose in water every eight hours is a good beginning. Full dosage should be maintained until the clinical improvement is evident and continued until the temperature has been normal for at least twenty-four hours. Fluid and electrolyte balance requires close supervision, especially if gastrointestinal suction is needed to help control ileus from pelvic peritonitis. If improvement is not evident in forty-eight hours, several possibilities must be reviewed, namely, incorrect diagnosis, ineffective therapy or the appearance of a pelvic abscess. Should the diagnosis seem to be correct, the antibiotic in use is checked against the cervical culture, and a change considered. The possibility of a pelvic abscess is investigated. This complication is rare, but a progressively enlarging abscess is one of the few indications for surgical drainage. In those patients in whom the correct diagnosis is recognized only at the time of laparotomy, cultures should be taken, the abdomen closed without drainage or other manipulation, and treatment begun as outlined earlier. Pelvic cellulitis is seen most frequently in puerperal patients. It may, however, occur in nonpregnant patients after uterine or cervical instrumentation, either because of faulty technic, or because the procedure was done in the presence of unrecognized cervical infection. The prophylactic management is self-evident, whereas the care of active pelvic cellulitis is essentially similar to that described for acute salpingo-oophoritis. Intraperitoneal rupture of a tuba-ovarian abscess is a major catastrophe. The patient mayor may not have been known to have had salpingooophoritis. The onset of lower abdominal pain is sudden, and rapidly progressive both in intensity and in diffusion to the entire abdomen. Constitutional signs of an inflammatory process are obscured by a shocklike state exhibited by pallor, restlessness, pulse hurry and hypotension. The abdomen is tense, rigid and exquisitely tender. Peristalsis is absent. Pelvic examination contributes little except for confirmation of the diffuse tenderness. The initial management is similar to that described previously under Surgical Emergency. After treatment of shock, laparotomy is begun with the principal aim of establishing intraperitoneal drainage. The temptation to carry out extensive pelvic surgery should be resisted, but if the abscess can be excised easily, the patient's recovery may be hastened. The type of intraperitoneal drainage may vary with the preference of the surgeon, but a sump type of drain is most useful. The value of the introduction of antibiotics intraperitoneally is questionable, but adequate doses should be given parenterally in the postoperative period. In view of the mixed infection in these abscesses, both penicillin and either aureomycin or terramycin should be administered. A suggested dosage schedule is aqueous pencillin, 200,000 units intramuscularly every three hours, and aureomycin or terramycin, 0.5 gm. intravenously every
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eight t,o twelve h,ours. C,ontinu,ous intestinal sucti,on sh,ould be instituted, and the use ,of parenteral fluids guided by ,observati,on ,of the state ,of hydrati,on ,of the patient, the am,ounts ,of sucti,on drainage and urinary ,output, and the electr,olyte pattern. Neoplasms
Uterine myomas are c,omm,on tum,ors in the female. The vagaries ,of their bl,o,od supply predisp,ose t,o degenerative changes within the tum,or. Occasi,onally, a pedunculated tum,or may underg,o t,orsi,on. The pain that results fr,om tissue changes sec,ondary t,o these accidents may be acute in ,onset, and severe, but remains l,ocalized t,o the area ,of the tum,or. The patient d,oes n,ot appear "hard hit," and d,oes n,ot exhibit fever ,or leuk,ocyt,osis at the ,onset, alth,ough mild degrees ,of either fever ,or leuk,ocyt,osis may devel,op within eight t,o twenty-f,our h,ours. The findings on abd,ominal examinati,on will vary with the size and p,ositi,on ,of the tum,or, but usually there are signs ,of l,ocalized perit,oneal irritati,on. Pelvic examinati,on sh,ows a firm, exquisitely tender tum,or, attached t,o the uterus. In the absence ,of signs ,of intraperit,onealbl,o,od .l,oss, the patient may be ,observed with safety. The decisi,on as t,o definitive management is based up,on the c,ourse ,of the acute epis,ode, the size and p,ositi,on ,of the tum,or, and the presence ,of ,other sympt,oms ,of my,oma. The reader is referred t,o Payne! f,or a c,omprehensive survey ,of the management ,of these tum,ors, but it may be p,ointed Gut here that the ,occurrence ,of a single acute epis,ode ,of pain is n,ot in itself a s,ound indicati,on f,or surgical interventi,on. Acute l,ower abd,ominal pain may arise fr,om adnexal neoplasms which underg,o t,orsi,on, hem,orrhage int,o the tum,or, ,or rupture. In case ,of t,orsi,on,or hem,orrhage, the w,orking diagn,osis and management are clear. The acute pain, the l,ocalized perit,oneal irritati,on, the presence ,of an exquisitely tender adnexal mass, and the absence ,of evidence ,of pelvic infecti,on p,oint t,o the need f,or pr,ompt lapar,ot,omy. In c,ontrast, the rec,og~ niti,on ,of sp,ontane,ous rupture ,of an adnexal ne,oplasm may be difficult because ,of the absence ,of palpable tum,or. A w,orking diagn,osis ,of rupture ,of s,ome type ,of adnexal mass sh,ould be apparent fr,om the sudden ,onset ,of unilateral pain in a n,ormally menstruating w,oman, the signs ,of pr,ogressive perit,oneal irritati,on and the absence ,of substantial evidence ,of infecti,on, ,or bl,o,od l,oss. Only certain circumstantial p,oints may help the surge,on decide whether the adnexal mass that has ruptured may be ne,oplastic, ,or a simple retenti,on cyst. S,ometimes the c,ollapsed wall ,of a ruptured ne,oplasm may be felt as a definite adnexal thickening. The degree ,of perit,oneal irritati,on b,oth in intensity and in durati,on is m,ore marked with ruptured ne,oplasms than with simple cysts. In d,oubtful situati,ons, visualizati,on ,of the adnexa is indicated. Ruptured adnexal ne,oplasms .sh,ould be. rem,oved surgically. Endometriosis
End,ometri,osis rarely gives rise t,o acute abd,ominal pain. Occasi,onally, an end,ometri,oma may rupture sp,ontane,ously, pr,oducing sympt,oms
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similar to those described previously for ruptured neoplasm. The correct preoperative diagnosis may be suspected when there is a history of progressive premenstrual pain and dysmenorrhea, or when palpable, cul-de-sac endometriosis is present. The extent of the operative procedure will depend on the tissues involved in the disease, and the age and parity of the patient. ACUTE LOWER ABDOMINAL PAIN OF GENITAL ORIGIN IN THE PRESENCE OF PREGNANCY
Abortion
Abortion is the most common cause of acute lower abdominal pain in early pregnancy. The pain is the result of the active spontaneous contractions of the uterus attempting to empty itself, or of one of the complications of an induced abortion. The diagnosis of spontaneous abortion is rarely complicated. Occasionally, there may be relatively little vaginal bleeding, and such exquisite and diffuse lower abdominal pain as to suggest an intraperitoneal accident. In such patients, careful pelvic examination will show the signs of,a uterine pregnancy, at least some dilatation of the cervix, and an actively contracting uterus. It can be determined that the uterus is the site of origin of the pain. Management will depend on the amount of bleeding, and the condition of the cervix. Surgical evacuation of the uterus is indicated in the presence of excessive bleeding, and for the patient with acute pain when the cervix is partially dilated. Patients with induced abortions notoriously give false or incomplete histories. The possibility of the diagnosis of induced abortion should never be overlooked in any patient of reproductive age exhibiting acute lower abdominal pain or pelvic infection. The principal clues are the signs of pregnancy, the evidence of instrumentation, and the presence of infection. There may be a retained foreign body, or evidence of perforation of the uterus with hemorrhage or bowel injury. Cervical culture for both aerobic and anaerobic growths must be taken before antibiotics are administered. Search for a foreign body should be made by manual and x-ray examinations. The cellular and electrolyte elements of the blood need prompt determination and close observation. Urinary constituents and output require careful supervision because of the possibility of renal injury from sepsis or poisonous drugs. When there is no bowel injury, or"hemorrhage, control of infection is the major consideration. The infection is often severe, and of mixed type. Intramuscular aqueous penicillin, 100,000 to 200,000 units every third hour, and intravenous aureomycin or terramycin, 0.5 gm. every eighth hour, should be given. Hemorrhage or bowel injury is an indication for surgical intervention. Occasionally, evacuation of necrotic tissue from the uterus, or even removal of a grossly necrotic uterus with wide vaginal drainage, may be necessary if the patient does not respond to treatment. Extrauterine Pregnancy
A patient with an ectopic pregnancy which has ruptured and produced intraperitoneal hemorrhage exhibits the symptoms described under
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Surgical Emergency and is so managed. A tubal gestation which has not ruptured, or one which has undergone minimal rupture, may be difficult to recognize. This diagnosis should be considered when a patient gives a history of acute unilateral abdominal pain after an abnormal or missed menses. The appearance of slight vaginal bleeding in close time relationship to the onset of the pain, and the presence of a tender adnexal mass establish ectopic pregnancy as a working diagnosis. In the early hours of observation, progressive signs of intraperitoneal bleeding call for prompt laparotomy with an adequate volume of matched blood available. Lack of progression or subsidence of symptoms does not exclude the diagnosis, and further investigation is indicated. A positive pregnancy test in the absence of uterine enlargement is confirmatory evidence. Endometrial scrapings which show decidual change without chorionic "villi are diagnostic. Negative reports should not unduly influence clinical 'judgment; if pain and adnexal tenderness persist, cul-de-sac puncture, culdoscopy, cul-de-sac exploration or even laparotomy may be needed to clarify the situation. The conditions which commonly simulate the clinical findings of ectopic pregnancy are early uterine pregnancy with a tender corpus luteum, especially if associated with threatened abortion, and the rupture of an ovarian retention follicle which has functionally delayed menstruation. This later entity is seen in patients with old salpingooophoritis, and may occur with .a persistent corpus luteum in an other~ wise normal pelvis. In an early uterine pregnancy with a tender corpus luteum, the certain exclusion of tubal pregnancy is most difficult. Both exhibit the signs of early pregnancy with a tender adnexal mass. In the absence of marked peritoneal irritation or other signs of intraperitoneal bleeding, a policy of continued close observation is indicated. However, if these signs are present and progressive, the cul-de-sac should be explored, directly; or by culdoscopy, depending on the experience of the surgeon. Unnecessary laparotomies have been done on the basis of a hasty and incompletely established diagnosis of ectopic pregnancy. The occurrence of acute unilateral adnexal pain and tenderness in a patient with delayed or scanty menses does not in itself warrant immediate operation. The demonstration of significant blood loss is the only indication for haste. The careful observation of patients with a ruptured retention follicle will disclose that the signs of pregnancy are absent. Usually, symptoms subside over twenty-four hours, and only rarely is it necessary to visualize the adnexa. Late Placental Accidents
The occurrence of acute lower abdominal pain in the later part of pregnancy should call to mind the possibility of premature separation of the placenta. The signs of massive placental separation, the hard painful uterus, maternal shock and fetal distress are distinctive. The less severe forms of this condition are harder to recognize. The pain of partial separation is more localized to a particular area of the uterus, and this same area is moderately tender. There may be generalized uterine irritability,
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but no sign of fetal distress. Vaginal bleeding of mild to moderate degree mayor may not occur. . Management is conservative, namely, bed rest and mild sedation. The use of estrogen, progesterone or combinations of the two has been advocated. Clear-cut evidence is lacking for their need or favorable effect. Generally, the symptoms subside over five to seven days and the pregnancy continues normally. Occasionally, vaginal bleeding becomes so severe as to demand emptying of the uterus. Placental infarction in late pregnancy may simulate partial placental separation. The pain and tenderness are referred to a local area of the uterus, but there is no vaginal bleeding. There is less tendency to uterine .irritability with infarction. Rest and sedation are indicated. Subsidence of symptoms may be expected over five to seven days. Rupture of the Uterus
Rupture of the uterus in pregnancy may occur prior to or during labor. Only the former type is pertinent to this discussion. Rupture of the uterus prior to labor almost never occurs except after previous uterine surgery, particularly cesarean section. The rupture may be frank or occult, depending largely on the type of cesarean section done. Frank rupture is seen in patients who have had a previous corporeal section. The unmistakable signs of this castatrophe are sudden severe pain, exquisite diffuse peritoneal irritation, extreme shock, and the presence of the fetus free in the abdominal cavity. The initial management is that of a surgical emergency as described earlier. At the time of the operative procedure, a decision must be made as to how to handle the site of rupture. In most patients, hysterectomy is the treatment of choice. However, when future childbearing is desired, revision of the site of rupture by excision and careful suture may be warranted. Occult rupture may occur when there has been a previous low segment cesarean section. It is difficult to discern because the separation is in the lower uterine segment in a relatively avascular area behind the uterovesical fold of peritoneum. The patient may have no symptoms other than mild suprapubic discomfort, and some vesical irritability. Examination shows only minimal suprapubic tenderness. The observer might be inclined to a~cribe the symptom complex to pressure of the presenting _part. Any patient, however, who has had a previous low segment operation, and who exhibits the symptoms described, should be explored without undue delay. Neoplasms
Uterine myomas are prone to undergo acutely painful bouts of degeneration in pregnancy. The localization of the pain and tenderness to the tumor, and the attachment of the tumor to the pregnant uterus, establish the diagnosis. Rarely, the tumor may seem to be adnexal in origin, and the true diagnosis is apparent only after the abdomen is opened. Such tumors are usually pedunculated and readily excised
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without disturbing the pregnant uterus. In general, extensive myomectomies in pregnancy are not warranted. The basic management is rest, sedation and continued observation. Adnexal tumors in pregnancy deserve the same consideration as in the nonpregnant patient. An acutely painful adnexal mass should be removed surgically at whatever stage of pregnancy it is found. When operation is carried out in early pregnancy, the corpus luteum must be identified, because its removal may lead to abortion. Either extirpation or major disturbance of the corpus luteum is a logical indication for the administration of hormonal substitutes in the postoperative period. Both estrin and progesterone should be given. The amounts of the hormones substituted are the same as those naturally produced at the given stage of pregnancy. REFERENCE 1. Payne, F. L.: The Treatment of Uterine Fibroids. S. CLIN. NORTH AMERICA,
28: 1445, 1948.
THE female genital tract is a common site of origin of acute lower abdominal pain. These structures present an avenue to the peritoneal cavity for the entrance of infection. They are subject to neoplasms which may undergo acute changes. Not only are the complications of pregnancy numerous, but variants in otherwise physiologic cyclic phenomena may give rise to pain. Indeed, the wide variety of pattern offers a diagnostic challenge to the surgeon. The purpose of this clinic is to point out the basic methods of diagnosis and management which may serve as safeguards against error. THE APPROACH TO THE PATIENT: THE INTERVIEW
The circumstances surrounding the examination of the patient with acute abdominal pain often lead to confusion. The surgeon should take time to calm the patient and to seek an atmosphere conducive to sound observations. He will do well to keep an open mind, and not drive his questioning along preconceived lines. An adequate history is the foundation in the building of diagnosis. Methods of history taking are well known, but certain points bear repetition. Past medical events, especially previous operations and previous attacks of pain, should be noted, and documented if possible. The gynecologic and obstetric history should be reviewed. Recent therapy and instrumentation must not be overlooked. It is well to recall that women who want not to be pregnant may give false information. The menstrual history is of special significance. The most important points to note are the date of occurrence and character of the last menses, the presence of vaginal bleeding since the last normal period, and the sequence of appearance of vaginal bleeding in relation to abdominal pain. The amount of any abnormal external bleeding should be estimated as accurately as possible. The history of the site and character of onset of abdominal pain re-
* Assistant Profe8sor of Obstetrics and Gynecology, University of Pennsylvania School of Medicine; Assistant Obstetrician and Gynecologist, Hospital of University of Pennsylvania, Philadelphia. 1717
1718
PaulO. Klingensmith
quires special attention. The duration of the pain and its progression both in spread and intensity should be noted. The presence and sequence of gastrointestinal and urinary tract symptoms may be of significance. General phenomena such as fainting, chills and malaise should not be overlooked. Important points require checking from any available source, because the information obtained from acutely ill patients is often not reliable. THE PHYSICAL EXAMINATION
A good general survey of the patient must take precedence over local examinations. Accurate observation of the vital signs and general state of the patient is important. Special attention should be given to the presence or absence of constitutional signs of blood loss, or an inflammatory process. It is essential that the patient be catheterized prior to local examinations. Pelvic palpation should be deferred until the abdomen has been investigated. The abdominal examination will furnish the Surgeon with information concerning peristalsis, the presence of gaseous or fluid distention, the signs of peritoneal irritation, the localization of tenderness, and the occurrence of masses. Abdominal masses should be studied for the presence of a fetus. The accuracy of pelvic examination is enhanced by an unhurried and gentle technic. The lower genital tract is inspected for evidence of infection, instrumentation, and signs of pregnancy. Bimanual examination should be deferred until the vaginal fingers have tested the referral of pain from gentle motion of the cervix and explored the cul-de-sac and posterior pelvis. Rectovaginal palpation may permit more accurate definition and localization of masses and tenderness than the more customary vaginal examination. In any case, rectal palpation should not be omitted. LABORATORY EXAMINATIONS
Simple laboratory procedures meet the initial need, but there is a premium on the accuracy with which they are performed. The urine obtained by the original catheterization should be examined carefully. An accurate blood count is essential. In patients with suspected blood loss, or infection, serial counts are indicated. The basic electrolyte pattern should be determined in the seriously ill patient. Pregnancy tests may be required. The type of pregnancy test depends on. the available laboratory, but it is apparent that the shorter tests have advantages. Roentgen examination of the abdomen and pelvis is indicated when the surgeon suspects bowel involvement, foreign body, or pregnancy over four months' duration. DIAGNOSTIC POSSIBILITIES
When the historical and physical data have been collected, the diagnostic possibilities should be reviewed. The following list includes only
Acute AbMminal Pain of Female Genital Origin
1719
those conditions germane to this discussion of acute abdominal pain of female genital tract origin. A. No_evidence of pregnancy r. Variants in 'physiologic mechanisms a. Ruptured follicle h. Ruptured corpus luteum c. Primary dysmenorrhea 2. Inflammatory disease a. Acute salpingo-oophoritis b. Acute pelvic cellulitis c. Ruptured tubo-ovarian abscess 3. Neoplasms a. Uterine myoma b. Adnexal tumors and cysts 4. Endometriosis B. Evidence of pregnancy 1. Abortion a. Spontaneous b. Induced 2. Extrauterine pregnancy 3. Late placental accidents 4. Rupture of the uterus 5. Neoplasms a. Uterine myoma b. Adnexal tumors and cysts.
RECOGNITION AND MANAGEMENT OF A SURGICAL EMERGENCY OF GENITAL ORIGIN
True surgical emergencies are limited to conditions which are asso~ ciated with progressive, severe hemorrhage. Hemorrhage from abortion and placental separation has self-evident characteristics which will be discussed later. However, the etiology of intraperitoneal hemorrhage may be difficult to discern. It is more important to be able to recognize the signs of this catastrophe than to make an exact diagnosis of its cause. Prompt action is indicated for a patient who gives a history of lower abdominal pain of sudden onset and rapid progression, and who exhibits diffuse peritoneal irritation, abdominal distention of nongaseous character, and signs of restlessness, pallor, pulse hurry, and hypotension. Occasionally, a similar clinical picture may be produced by a ruptured tubo-ovarian abscess. Fortunately, the initial treatment for ruptured tubo-ovarian abscess is essentially similar to that of hemorrhage. The essence of treatment in massive intraperitoneal hemorrhage is the control of shock and hemostasis. The patientshou,ld be prepared rapidly, and the administration of narcotics omitted. She can be moved tp the operating room while a large volume of suitably matched blood is being secured. The operating team devotes its attention to the establishment of at least two ample avenues of blood administration. The anesthetist begins the administration of oxygen and prepares to give an agent which will permit continued high oxygen intake and minimum hypotensive effect. No other procedure is begun until the patient exhibits signs of recovery from shock. The actual operation will depend on the findings,
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but the object is to carry out the minimum procedure that will secure adequate hemostasis. . . Postoperative care should include careful observation of vital signs, and urinary output. The patient must not be overloaded with fluids. Gastric or intestinal suction is used if abdominal distention develops. Prophylactic antibiotics are indicated. ACUTE LOWER ABDOMINAL PAIN OF GENITAL ORIGIN IN THE ABSENCE OF PREGNANCY
Physiologic Variants
The principal clue to the diagnosis of ruptured follicle is the coincidence of unilateral lower abdominal pain with the midcycle time of a normally menstruating woman. The pain is sudden in onset and may be severe. It tends to diminish in severity over a space of several hours unless the rupture has been complicated by continuing hemorrhage. Signs of local peritoneal irritation are present with unilateral pelvic tenderness. There may be slight vaginal bleeding. Pelvic mass or signs of pregnancy are absent. There is no general evidence of an inflammatory process. The immediate management is rest, mild sedation, and observation for signs of blood loss. Rarely, there may be evidence of progressive blood loss, but usually the symptoms and signs progressively diminish over twentyfour hours. Should blood loss require laparotomy for control, simple local hemostasis of the bleeding site, not oophorectomy, is the treatment of choice. Rupture of a corpus luteum may present a clinical picture essentially similar to that of ruptured follicle except that the time of onset in relation to menstruation is different, and there is almost always some menstruallike uterine bleeding due to the hormonal withdrawal from the endometrium. When rupture occurs just prior to or coincident with menstruation, the pain is usually mild and short in duration. However, the corpus luteum may persist and delay the expected menses, and subsequent rupture produce signs which closely simulate those of early tubal pregnancy. A positive pregnancy test will exclude simple corpus luteum rupture, but a negative test does not exclude ectopic gestation. In patients suspected of corpus luteum rupture, direct visualization of the adnexa must be considered when the signs do not subside progressively after the first twenty-four hours. The method of visualization is a choice conditioned by experience, but culdoscopy or cul-de-sac exploration will often avert the need for laparotomy. The basic management of corpus luteum rupture is the same as that described for ruptured follicle. Primary dysmenorrhea should rarely present a problem in diagnosis, but occasionally in young girls the pain may be so acute as to suggest an intra-abdominal accident. The patient lies doubled over with pain and exhibits apprehension, pallor, and pulse hurry. Nausea and vomiting and urinary urgency may be present. Determination of the fact that menstruation is in process, and normal as to time and character, furnishes the major clue to the correct diagnosis. Demonstration of the uterine origin of pain with otherwise normal pelvic structures, the absence of
Acute Abdominal Pain of Female Genital Origin
1721
general or local signs of inflammation, and negative urine will make the diagnosis clear. Treatment is reassurance, adequate sedation and continued observation. Inflammatory Disease
The typical picture of acute salpingo-oophoritis is well described in standard textbooks. Numerous difficulties arise, however, in the differential diagnosis of this condition and appendicitis, and also between inflammatory disease and noninflammatory conditions which give acute bilateral abdominopelvic pain and tenderness. The differential diagnosis of appendicitis and acute salpingo-oophoritis in the typical early acute stage is easily recognized. Difficulties may arise in atypical forms, however, in appendicitis with perforation, or when the course of salpingo-oophoritis has been altered by inadequate antibiotic therapy. Even in such instances, the history of onset may give the major clue to proper differentiation. The onset of pain in patients with acute salpingo-oophoritis is bilateral and low in the pelvis, subsequently spreading up over the entire lower abdomen. In contrast, appendiceal pain is unilateral and higher at the onset, and tends to come down to localize in the low right abdomen or right pelvic area. Anorexia and nausea often appear before significant pain in the course of ,appendicitis, whereas patients with acute salpingo-oophoritis usually do not exhibit upper gastrointestinal symptoms until they have been ill at least six to twelve hours. An estimate of the relative severity of the illness may also prove helpful in the differential diagnosis. Given the same duration of symptoms without treatment, most patients with acute salpingo-oophoritis look more ill, have higher temperatures, exhibit more diffuse peritoneal irritation, and run higher leukocyte counts than those with appendicitis. Two points on pelvic examination should be given particular attention, namely, the evidence of infection of the lower genital tract, and the referral of pain on gentle motion of the cervix. This later maneuver is especially helpful in distinguishing the unilateral character of appendicitis from the bilateral one of inflammatory disease. Many women with acute bilateral pelvic pain do not have "P.I.D.," at least not 'in an active inflammatory stage. Those with ovaries altered by endometriosis, cystic change, old burned-out inflammation or previous operative procedures may exhibit acute bilateral pelvic pain in the mid cycle or premenstrual time as a result of cyclic stimulation or follicle rupture. They do not show significant malaise, fever or leukocytosis; careful examination demonstrates lack of true peritoneal irritation, but, instead, localized ovarian tenderness. The management is quite different from that of patients with acute inflammatory disease. The treatment of acute salpingo-oophoritis should not be instituted until cultures from the urethral meatus and cervix are taken for bacteriologic control. Cultures for gonococcus must be planted immediately on a suitable medium, and not allowed to stand around. Blood should be drawn for a base line serology before antibiotics are given. The patient is put to bed with head and trunk elevated, and begun on parenteral
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PaulO. Klingensmith
antibiotics. Penicillin, aureomycin and terramycin have each proved to be effective if dosage is adequate. Inadequate dosage is uneconomic in the long run, and increases the chance for residual damage. In severely ill patients, aqueous penicillin, 100,000 to 200,000 units, every three hours intramuscularly, or 0.5 gm. of aureomycin, or terramycin intravenously in 5 per cent glucose in water every eight hours is a good beginning. Full dosage should be maintained until the clinical improvement is evident and continued until the temperature has been normal for at least twenty-four hours. Fluid and electrolyte balance requires close supervision, especially if gastrointestinal suction is needed to help control ileus from pelvic peritonitis. If improvement is not evident in forty-eight hours, several possibilities must be reviewed, namely, incorrect diagnosis, ineffective therapy or the appearance of a pelvic abscess. Should the diagnosis seem to be correct, the antibiotic in use is checked against the cervical culture, and a change considered. The possibility of a pelvic abscess is investigated. This complication is rare, but a progressively enlarging abscess is one of the few indications for surgical drainage. In those patients in whom the correct diagnosis is recognized only at the time of laparotomy, cultures should be taken, the abdomen closed without drainage or other manipulation, and treatment begun as outlined earlier. Pelvic cellulitis is seen most frequently in puerperal patients. It may, however, occur in nonpregnant patients after uterine or cervical instrumentation, either because of faulty technic, or because the procedure was done in the presence of unrecognized cervical infection. The prophylactic management is self-evident, whereas the care of active pelvic cellulitis is essentially similar to that described for acute salpingo-oophoritis. Intraperitoneal rupture of a tuba-ovarian abscess is a major catastrophe. The patient mayor may not have been known to have had salpingooophoritis. The onset of lower abdominal pain is sudden, and rapidly progressive both in intensity and in diffusion to the entire abdomen. Constitutional signs of an inflammatory process are obscured by a shocklike state exhibited by pallor, restlessness, pulse hurry and hypotension. The abdomen is tense, rigid and exquisitely tender. Peristalsis is absent. Pelvic examination contributes little except for confirmation of the diffuse tenderness. The initial management is similar to that described previously under Surgical Emergency. After treatment of shock, laparotomy is begun with the principal aim of establishing intraperitoneal drainage. The temptation to carry out extensive pelvic surgery should be resisted, but if the abscess can be excised easily, the patient's recovery may be hastened. The type of intraperitoneal drainage may vary with the preference of the surgeon, but a sump type of drain is most useful. The value of the introduction of antibiotics intraperitoneally is questionable, but adequate doses should be given parenterally in the postoperative period. In view of the mixed infection in these abscesses, both penicillin and either aureomycin or terramycin should be administered. A suggested dosage schedule is aqueous pencillin, 200,000 units intramuscularly every three hours, and aureomycin or terramycin, 0.5 gm. intravenously every
Acute Abdominal Pain of Female Genital Origin
1723
eight t,o twelve h,ours. C,ontinu,ous intestinal sucti,on sh,ould be instituted, and the use ,of parenteral fluids guided by ,observati,on ,of the state ,of hydrati,on ,of the patient, the am,ounts ,of sucti,on drainage and urinary ,output, and the electr,olyte pattern. Neoplasms
Uterine myomas are c,omm,on tum,ors in the female. The vagaries ,of their bl,o,od supply predisp,ose t,o degenerative changes within the tum,or. Occasi,onally, a pedunculated tum,or may underg,o t,orsi,on. The pain that results fr,om tissue changes sec,ondary t,o these accidents may be acute in ,onset, and severe, but remains l,ocalized t,o the area ,of the tum,or. The patient d,oes n,ot appear "hard hit," and d,oes n,ot exhibit fever ,or leuk,ocyt,osis at the ,onset, alth,ough mild degrees ,of either fever ,or leuk,ocyt,osis may devel,op within eight t,o twenty-f,our h,ours. The findings on abd,ominal examinati,on will vary with the size and p,ositi,on ,of the tum,or, but usually there are signs ,of l,ocalized perit,oneal irritati,on. Pelvic examinati,on sh,ows a firm, exquisitely tender tum,or, attached t,o the uterus. In the absence ,of signs ,of intraperit,onealbl,o,od .l,oss, the patient may be ,observed with safety. The decisi,on as t,o definitive management is based up,on the c,ourse ,of the acute epis,ode, the size and p,ositi,on ,of the tum,or, and the presence ,of ,other sympt,oms ,of my,oma. The reader is referred t,o Payne! f,or a c,omprehensive survey ,of the management ,of these tum,ors, but it may be p,ointed Gut here that the ,occurrence ,of a single acute epis,ode ,of pain is n,ot in itself a s,ound indicati,on f,or surgical interventi,on. Acute l,ower abd,ominal pain may arise fr,om adnexal neoplasms which underg,o t,orsi,on, hem,orrhage int,o the tum,or, ,or rupture. In case ,of t,orsi,on,or hem,orrhage, the w,orking diagn,osis and management are clear. The acute pain, the l,ocalized perit,oneal irritati,on, the presence ,of an exquisitely tender adnexal mass, and the absence ,of evidence ,of pelvic infecti,on p,oint t,o the need f,or pr,ompt lapar,ot,omy. In c,ontrast, the rec,og~ niti,on ,of sp,ontane,ous rupture ,of an adnexal ne,oplasm may be difficult because ,of the absence ,of palpable tum,or. A w,orking diagn,osis ,of rupture ,of s,ome type ,of adnexal mass sh,ould be apparent fr,om the sudden ,onset ,of unilateral pain in a n,ormally menstruating w,oman, the signs ,of pr,ogressive perit,oneal irritati,on and the absence ,of substantial evidence ,of infecti,on, ,or bl,o,od l,oss. Only certain circumstantial p,oints may help the surge,on decide whether the adnexal mass that has ruptured may be ne,oplastic, ,or a simple retenti,on cyst. S,ometimes the c,ollapsed wall ,of a ruptured ne,oplasm may be felt as a definite adnexal thickening. The degree ,of perit,oneal irritati,on b,oth in intensity and in durati,on is m,ore marked with ruptured ne,oplasms than with simple cysts. In d,oubtful situati,ons, visualizati,on ,of the adnexa is indicated. Ruptured adnexal ne,oplasms .sh,ould be. rem,oved surgically. Endometriosis
End,ometri,osis rarely gives rise t,o acute abd,ominal pain. Occasi,onally, an end,ometri,oma may rupture sp,ontane,ously, pr,oducing sympt,oms
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PaulO. Klingensmith
similar to those described previously for ruptured neoplasm. The correct preoperative diagnosis may be suspected when there is a history of progressive premenstrual pain and dysmenorrhea, or when palpable, cul-de-sac endometriosis is present. The extent of the operative procedure will depend on the tissues involved in the disease, and the age and parity of the patient. ACUTE LOWER ABDOMINAL PAIN OF GENITAL ORIGIN IN THE PRESENCE OF PREGNANCY
Abortion
Abortion is the most common cause of acute lower abdominal pain in early pregnancy. The pain is the result of the active spontaneous contractions of the uterus attempting to empty itself, or of one of the complications of an induced abortion. The diagnosis of spontaneous abortion is rarely complicated. Occasionally, there may be relatively little vaginal bleeding, and such exquisite and diffuse lower abdominal pain as to suggest an intraperitoneal accident. In such patients, careful pelvic examination will show the signs of,a uterine pregnancy, at least some dilatation of the cervix, and an actively contracting uterus. It can be determined that the uterus is the site of origin of the pain. Management will depend on the amount of bleeding, and the condition of the cervix. Surgical evacuation of the uterus is indicated in the presence of excessive bleeding, and for the patient with acute pain when the cervix is partially dilated. Patients with induced abortions notoriously give false or incomplete histories. The possibility of the diagnosis of induced abortion should never be overlooked in any patient of reproductive age exhibiting acute lower abdominal pain or pelvic infection. The principal clues are the signs of pregnancy, the evidence of instrumentation, and the presence of infection. There may be a retained foreign body, or evidence of perforation of the uterus with hemorrhage or bowel injury. Cervical culture for both aerobic and anaerobic growths must be taken before antibiotics are administered. Search for a foreign body should be made by manual and x-ray examinations. The cellular and electrolyte elements of the blood need prompt determination and close observation. Urinary constituents and output require careful supervision because of the possibility of renal injury from sepsis or poisonous drugs. When there is no bowel injury, or"hemorrhage, control of infection is the major consideration. The infection is often severe, and of mixed type. Intramuscular aqueous penicillin, 100,000 to 200,000 units every third hour, and intravenous aureomycin or terramycin, 0.5 gm. every eighth hour, should be given. Hemorrhage or bowel injury is an indication for surgical intervention. Occasionally, evacuation of necrotic tissue from the uterus, or even removal of a grossly necrotic uterus with wide vaginal drainage, may be necessary if the patient does not respond to treatment. Extrauterine Pregnancy
A patient with an ectopic pregnancy which has ruptured and produced intraperitoneal hemorrhage exhibits the symptoms described under
Acute Abdominal Pain of Female Genital Origin
1725
Surgical Emergency and is so managed. A tubal gestation which has not ruptured, or one which has undergone minimal rupture, may be difficult to recognize. This diagnosis should be considered when a patient gives a history of acute unilateral abdominal pain after an abnormal or missed menses. The appearance of slight vaginal bleeding in close time relationship to the onset of the pain, and the presence of a tender adnexal mass establish ectopic pregnancy as a working diagnosis. In the early hours of observation, progressive signs of intraperitoneal bleeding call for prompt laparotomy with an adequate volume of matched blood available. Lack of progression or subsidence of symptoms does not exclude the diagnosis, and further investigation is indicated. A positive pregnancy test in the absence of uterine enlargement is confirmatory evidence. Endometrial scrapings which show decidual change without chorionic "villi are diagnostic. Negative reports should not unduly influence clinical 'judgment; if pain and adnexal tenderness persist, cul-de-sac puncture, culdoscopy, cul-de-sac exploration or even laparotomy may be needed to clarify the situation. The conditions which commonly simulate the clinical findings of ectopic pregnancy are early uterine pregnancy with a tender corpus luteum, especially if associated with threatened abortion, and the rupture of an ovarian retention follicle which has functionally delayed menstruation. This later entity is seen in patients with old salpingooophoritis, and may occur with .a persistent corpus luteum in an other~ wise normal pelvis. In an early uterine pregnancy with a tender corpus luteum, the certain exclusion of tubal pregnancy is most difficult. Both exhibit the signs of early pregnancy with a tender adnexal mass. In the absence of marked peritoneal irritation or other signs of intraperitoneal bleeding, a policy of continued close observation is indicated. However, if these signs are present and progressive, the cul-de-sac should be explored, directly; or by culdoscopy, depending on the experience of the surgeon. Unnecessary laparotomies have been done on the basis of a hasty and incompletely established diagnosis of ectopic pregnancy. The occurrence of acute unilateral adnexal pain and tenderness in a patient with delayed or scanty menses does not in itself warrant immediate operation. The demonstration of significant blood loss is the only indication for haste. The careful observation of patients with a ruptured retention follicle will disclose that the signs of pregnancy are absent. Usually, symptoms subside over twenty-four hours, and only rarely is it necessary to visualize the adnexa. Late Placental Accidents
The occurrence of acute lower abdominal pain in the later part of pregnancy should call to mind the possibility of premature separation of the placenta. The signs of massive placental separation, the hard painful uterus, maternal shock and fetal distress are distinctive. The less severe forms of this condition are harder to recognize. The pain of partial separation is more localized to a particular area of the uterus, and this same area is moderately tender. There may be generalized uterine irritability,
1726
PaulO. Klingensmith
but no sign of fetal distress. Vaginal bleeding of mild to moderate degree mayor may not occur. . Management is conservative, namely, bed rest and mild sedation. The use of estrogen, progesterone or combinations of the two has been advocated. Clear-cut evidence is lacking for their need or favorable effect. Generally, the symptoms subside over five to seven days and the pregnancy continues normally. Occasionally, vaginal bleeding becomes so severe as to demand emptying of the uterus. Placental infarction in late pregnancy may simulate partial placental separation. The pain and tenderness are referred to a local area of the uterus, but there is no vaginal bleeding. There is less tendency to uterine .irritability with infarction. Rest and sedation are indicated. Subsidence of symptoms may be expected over five to seven days. Rupture of the Uterus
Rupture of the uterus in pregnancy may occur prior to or during labor. Only the former type is pertinent to this discussion. Rupture of the uterus prior to labor almost never occurs except after previous uterine surgery, particularly cesarean section. The rupture may be frank or occult, depending largely on the type of cesarean section done. Frank rupture is seen in patients who have had a previous corporeal section. The unmistakable signs of this castatrophe are sudden severe pain, exquisite diffuse peritoneal irritation, extreme shock, and the presence of the fetus free in the abdominal cavity. The initial management is that of a surgical emergency as described earlier. At the time of the operative procedure, a decision must be made as to how to handle the site of rupture. In most patients, hysterectomy is the treatment of choice. However, when future childbearing is desired, revision of the site of rupture by excision and careful suture may be warranted. Occult rupture may occur when there has been a previous low segment cesarean section. It is difficult to discern because the separation is in the lower uterine segment in a relatively avascular area behind the uterovesical fold of peritoneum. The patient may have no symptoms other than mild suprapubic discomfort, and some vesical irritability. Examination shows only minimal suprapubic tenderness. The observer might be inclined to a~cribe the symptom complex to pressure of the presenting _part. Any patient, however, who has had a previous low segment operation, and who exhibits the symptoms described, should be explored without undue delay. Neoplasms
Uterine myomas are prone to undergo acutely painful bouts of degeneration in pregnancy. The localization of the pain and tenderness to the tumor, and the attachment of the tumor to the pregnant uterus, establish the diagnosis. Rarely, the tumor may seem to be adnexal in origin, and the true diagnosis is apparent only after the abdomen is opened. Such tumors are usually pedunculated and readily excised
Acute Abdominal Pain of Female Genital Origin
1727
without disturbing the pregnant uterus. In general, extensive myomectomies in pregnancy are not warranted. The basic management is rest, sedation and continued observation. Adnexal tumors in pregnancy deserve the same consideration as in the nonpregnant patient. An acutely painful adnexal mass should be removed surgically at whatever stage of pregnancy it is found. When operation is carried out in early pregnancy, the corpus luteum must be identified, because its removal may lead to abortion. Either extirpation or major disturbance of the corpus luteum is a logical indication for the administration of hormonal substitutes in the postoperative period. Both estrin and progesterone should be given. The amounts of the hormones substituted are the same as those naturally produced at the given stage of pregnancy. REFERENCE 1. Payne, F. L.: The Treatment of Uterine Fibroids. S. CLIN. NORTH AMERICA,
28: 1445, 1948.