Gynecologic Causes of the Acute Abdomen

The Acute Abdomen

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Gynecologic Causes of the Acute Abdomen

Lonnie S. Burnett, M.D.*

Acute surgical emergencies of gynecologic origin occur for the most part in women of reproductive age but occasionally in newborn and adolescent patients and rarely in the postmenopausal patient. The most common and most important conditions to be considered include pelvic inflammatory disease (PID) with abscess, ectopic pregnancy, hemorrhage from a functional ovarian cyst, and adnexal or ovarian torsion.

PELVIC INFLAMMATORY DISEASE WITH ABSCESS Pelvic inflammatory disease must be considered in virtually every woman of reproductive age with low abdominal pain. The surgeon must feel comfortable in distinguishing those patients requiring immediate operative intervention from those best managed medically.

TUB0-0VARIAN ABSCESS WITHOUT RUPTURE

Tubo-ovarian abscess is a frequent complication among patients with acute salpingitis and is especially likely when treatment is delayed, when there are repeat episodes of acute salpingitis, and when an intrauterine device .(IUD) is in situ. This complication occurs most commonly in the 30to 40-year-old patient but may be seen at any time during the reproductive years and occasionally even later. Twenty-five to fifty per cent of patients will be nulliparous, and subsequent childbearing is unlikely, being possible in only lO per cent to 20 per cent. H, 12• 19 The abscess may be largely confined to the uterine tube (pyosalpinx) but more commonly involves a tubo-ovarian complex. In some instances, purulent material will extend into the posterior pelvis and become walled off by multiple structures *Professor and Chairman, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Tennessee

Surgical Clinics of North America-Val. 68, No. 2, April 1988

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Table 1. Presenting Symptoms and Findings Among 232 Patients with Tuba-Ovarian Abscess Acute pain

NO. OF PATIENTS

PERCENT

206

89

Chronic pain

43

19

Fever/Chills

117

50

Vaginal discharge

64

28

Abnormal uterine bleeding

48

21

Nausea

61

26

Vomiting

36

16

Temperature > 100° F

139

60

WBC > 10,000/mm3

158

68

Modified from Landers DV, Sweet RL: Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis 5:876, 1983.

including the tubes, ovaries, broad ligaments, small bowel, and omentum. Whereas PID is almost invariably a bilateral process resulting in infection of both adnexa, the abscess may be unilateral. Landers and Sweet reported a unilateral abscess in 71 per cent of 232 patients. 11 An intraovarian abscess, contained within the parenchyma of the ovary, may occur through inoculation of an open wound such as that produced by ovulation or by surgery.

Bacteriology Tubo-ovarian abscess is virtually always a polymicrobial infection, and frequently three or more organisms can be recovered. Most often, the responsible bacteria are those normally found in the lower genital tract and include aerobes such as Streptococcus, Escherichia coli, and Haemophilus influenzae as well as anaerobes such as Peptococcus, Peptostreptococcus, and Bacteroides. 4 • 11 • 12 The sexually transmitted organisms such as the gonococcus and Chlamydia are usually not present within the abscess but may be recovered from the cervix in about one third of cases. In a review of 232 patients by Landers and Sweet, of those patients with positive cultures from the abscess, an average of two organisms were recovered per abscess. The most common were E. coli (37 per cent), aerobic streptococci (18 per cent), Bacteroides fragilis (22 per cent), Bacteroides species (26 per cent), Peptococcus (11 per cent), and Peptostreptococcus (18 per cent). 11 Diagnosis The most common presenting signs and symptoms are summarized in Table 1. Especially noteworthy is that patients with tubo-ovarian abscesses may be afebrile, and the white blood count may be normal. For example, among 57 patients with abscesses confirmed surgically, 35 per cent were afebrile, and 23 per cent had a normal white blood count (Table 1). Pelvic examination usually reveals extreme pelvic tenderness with increased pain on cervical motion. Adnexal induration and fixation are common, but identification of a pelvic mass is highly variable since pain and tenderness will preclude an optimal examination.

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Abnormal findings on abdominal examination should be largely confined to the lower abdomen and include signs of peritonitis and sometimes a tender, fluctuant mass; most often, the abnormalities are bilateral but may be accentuated on one side. Careful examination usually demonstrates that any signs of peritonitis become more intense as one approaches the pelvic brim and are maximally intense deep in the pelvis, as demonstrated by rectal examination. When the intensity of peritonitis increases as the examiner progresses away from the pelvic brim, especially on the right side, it is circumstantial evidence that the inflammatory process is coming from an intra-abdominal rather than a pelvic source. Pelvic ultrasound is a highly important noninvasive diagnostic tool and provides information extremely useful in the patient's management. When an abscess is present, ultrasonography will usually show a complex adnexal mass, although in some cases a purely cystic lesion will be seen. 11 · 18 In the surgically confirmed group of patients with abscesses reported by Landers and Sweet, ultrasonography demonstrated a complex adnexal mass in 94 per cent and a cystic mass in 6 per cent; in no instance did ultrasound fail to demonstrate a mass of some type. 11 When a tubo-ovarian abscess is suspected or diagnosed, the surgeon must determine if it is confined to the pelvis and lower abdomen or if there is evidence ofleakage or rupture; the latter is a surgical emergency. In the absence of leakage or rupture, evidence of peritoneal irritation should be limited to the pelvis or lower abdomen; peritoneal signs in the upper abdomen or above the umbilicus suggest leakage or rupture, and surgical intervention is usually indicated. Treatment For the patient with an unruptured abscess, the initial treatment should usually be medical, with antibiotics appropriate for a polymicrobial infection including both aerobes and anaerobes. There is widespread agreement that the antibiotic regimen should include a drug effective against frequently drug-resistant gram-negative anaerobic rods such as Bacteroides fragilis and Bacteroides bivius; the regimen should also be effective against other anaerobes such as Peptococcus and Peptostreptococcus and aerobes including E. coli. 1• 4 • 11 · 12 A commonly used and highly effective regimen consists of an aminoglycoside such as gentamicin and clindamycin or metronidazole. Dodson and associates have reported success with the monocyclic betalactam aztreonam in combination with clindamycin. This regimen has as an advantage the avoidance of the potential nephrotoxicity of the aminoglycosides. 10 The optimal management of a patient with an unruptured tubo-ovarian abscess presents a special challenge for the surgeon and should take into account the following facts and circumstances. First, the diagnosis of a pelvic or tubo-ovarian abscess is not sufficient to define a surgical emergency. In the absence of rupture or leakage, nonoperative management with appropriate antibiotics may be successful in 33 per cent to 74 per cent of cases. 11 · 19 With leakage or rupture, on the other hand, surgical intervention should be carried out promptly. 11- 13 The challenge, therefore, is to distinguish a ruptured from an unruptured abscess.

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Second, most patients with tuba-ovarian abscesses will be in their reproductive years, and many will have an iritense desire to preserve reproductive function. The surgeon must therefore be knowledgeable regarding new technology such as in vitro fertilization and embryo transfer, which may permit childbearing even though the uterine tubes may be functionally destroyed by infection or surgcally removed. Third, when the patient with a tuba-ovarian abscess does require surgical intervention because of rupture or failure to respond to medical treatment, removal of the uterus and both adnexa may provide the least risk of postoperative morbidity and the least risk of reoperation for an unresolved infection but results in surgical castration at a young age and no chance for subsequent reproduction; On the other hand, an operation that preserves the uterus and some ovarian tissue carries with it at least a possibility of childbearing but a greater likelihood of persistent or recurrent infection and a possible need for reopetation and, sometimes, prolonged hospitalization. Choosing the best operation for any particular patient requires a careful assessment of the options, the risks, and the benefits for each one. When feasible, it is imperative that the patient and the patient's family participate to an appropriate extent in the decision. Among patients with unruptured tubo-ovarian abscess who undergo medical treatment initially, surgical intervention will be required in 5 per cent to 25 per cent during the same hospitalization. 1(}...12 On a short-term basis, the indications for surgical intervention are suspicion of leakage or rupture of the abscess and failure to respond to conservative management. On a long-term basis, surgical intervention shouid be considered when the pelvic mass persists, when the abscess recurs, or when long-standing chronic pelvic pain is thought to be a sequela of the damaged adnexa. Successful medical therapy should be associated with clinical improvement within 3 to 5 days, evidenced by progressive resolution of pain, fever, leukocytosis, and peritoneal irritation. Failure to improve within this span or an increase in the size of the abscess are reaSons to proceed with operative management. When tuba-ovarian abscess is bilateral or greater than 8 em in diameter, there is an increased likelihood that resolution will require surgical intervention. Even when surgicai treatment is planned, initial medical treatment with antibiotics for at least 3 to 5 days is desirable. Vaginal drainage of a pelvic abscess by posterior colpotomy may be considered in selected cases but should be restricted to those patients in whom there is a midline fluctuant mass dissecting into the upper third of the rectovaginal septum. The incision is made posterior to the cervix over the site of fluctuance and is followed by gentle finger exploration of the abscess cavity in order to drain loculated purulent material maximally. The effectiveness of drainage by this route is variable. Among 59 patients reported by Rivlan, 22 per cent required laparotomy during the same hospital admission and another 19 per cent required reoperation at a later time. 17 On the other hand, 12.5 per cent of the potentially fertile patients subsequently had a successful pregnancy. 17 When surgical intervention is indicated, laparotomy is usually required. Traditionally, there has been enthusiasm for removal of the uterus and both adnexa on the basis that more conservative surgery was frequently

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associated with a need for reoperation and was only rarely followed by childbearing. With the antimicrobial therapy available today, however, the surgical treatment selected should take account of the patient's age and desire for childbearing and whether the abscess is unilateral or bilateral. For the young patient desirous of future reproductive function, preservation of the uterus and some ovarian tissue is frequently possible. Under these circumstances, new technology such as in vitro fertilization and embryo transfer may permit successful pregnancy even when the uterine tubes are damaged beyond repair or are surgically removed. When the abscess is unilateral, a circumstance seen in as many as 70 per cent of patients, preservation of one adnexa may be indicated even when the remaining tube is seriously damaged. With preservation of the uterus and one adnexa, about 10 per cent of patients will need reoperation at a later date. 11 • 12 In the absence of a specific contraindication, the appendix should be removed. In some instances, it will be involved in the infectious process. Furthermore, reinfection is not uncommon, and there is comfort in being able to exclude appendicitis as a cause of the problem. Other measures to be considered include using a semi-Fowler's position to minimize the spread of infection into the upper abdomen and the use of low-dose subcutaneous heparin to reduce the risk of lower-extremity and pelvic thrombophlebitis.

TUB0-0VARIAN ABSCESS WITH RUPTURE

A ruptured pelvic abscess is an acute surgical emergency; prompt laparotomy and appropriate surgical therapy will reduce both morbidity and mortality rates and in some instances can preserve reproductive function. Although most ruptured abscesses occur in the 30- to 40-year-old age group, the condition can be seen at any time during the reproductive years and, rarely, in the postmenopausal patient. For the young patient, appropriate management must take into account that surgical castration is highly undesirable and that future childbearing may be a high priority. The bacteriology of the infection and antimicrobial therapy are similar to those of unruptured tubo-ovarian abscess. 11 Diagnosis The clinical picture of a patient with a ruptured pelvic abscess is highly variable. In some instances, the patient undergoing therapy for an unruptured abscess or the patient who is untreated will experience a sudden, sharp, diffuse abdominal pain. Examination may demonstrate signs of generalized peritonitis, no longer confined to the pelvis or lower abdomen. Pelvic examination will invariably be abnormal, and a pelvic mass is usually palpable. Fever is usually present but may be low grade. In some instances, the patient will demonstrate a full picture of shock. When the patient is under therapy for a known tubo-ovarian abscess, the early diagnosis of intraperitoneal leakage or frank rupture may be challenging. In general, if the signs of peritoneal irritation progress upward or extend into the upper abdomen, leakage or rupture is likely, and early

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operative intervention is usually imperative. In some instances, serial ultrasound examinations may demonstrate the progressive accumulation of free fluid in the upper abdomen. Surgical Treatment Operative intervention is imperative as soon as the patient has been stabilized with intravenous fluids, blood, and antibiotics. Low-dose heparin prophylaxis for deep vein thrombosis is usually desirable, although its efficacy has not been proven. Large fluid shifts into the peritoneal space are common both intraoperatively and postoperatively, and the presence of a central line or Swan-Ganz catheter may be highly beneficial. A liberal midline incision provides the best opportunity to deal with both the pelvic pathology and the pockets of purulent material in the upper abdomen. 13 Prior to 1950, the initial management of a ruptured tubo-ovarian abscess was generally conservative and nonoperative and associated with a mortality rate approaching 80 per cent. With the landmark publications by Vermeeren and Telinde in 195421 and Collins and Jansen in 1959, 8 aggressive surgical management became the standard and included total abdominal hysterectomy, bilateral salpingo-oophorectomy, and careful evacuation of all pockets of purulent material elsewhere in the abdomen. The mortality rate promptly dropped to about 20 per cent. With the introduction of improved antimicrobial agents, experience has demonstrated that more conservative surgery may be indicated under selected circumstances when preservation of reproductive function is a high priority and there is willingness to accept the possibility of reoperation. It is generally recognized, however, that in most instances the patient with a ruptured tubo-ovarian abscess will be best served by complete hysterectomy and bilateral salpingo-oophorectomy. If there is preservation of the uterus, at least one uterine tube, and some ovarian tissue, a subsequent pregnancy is at least possible. However, tubal damage is usually profound, making infertility likely and increasing the risk of ectopic implantation should pregnancy occur. If the abscess is unilateral, an adnexectomy of the involved side may be sufficient. The opposite adnexa will almost always be abnormal, and tubal occlusion with hydrosalpinx or pyosalpinx is likely. Under these circumstances, if the less-involved adnexa is preserved, the tube may be opened and drained by a longitudinal or transverse incision, which is left unclosed. Under these circumstances, some have advocated postoperative continuous peritoneal irrigation at the site of residual infection carried out through two or more intraperitoneal tubes appropriately placed during the operation. 18 When the patient is young and when future childbearing is a high priority, it may be reasonable and prudent to try to preserve reproductive function. The presence of the uterus and some ovarian tissue will introduce the possibility of childbearing through the use of in vitro fertilization and embryo transfer. Careful exploration of the entire abdomen and examination of all bowel is in order to identifY and drain the multiple collections of pus that are frequently present. Copious irrigation of the peritoneal cavity with 5 to 10 L of fluid is appropriate, as is the liberal use of suction drains at sites of residual infection, especially within the pelvis. Pelvic drains may be brought out through the vaginal cuff, which is generally left open.

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Closure of the abdominal incision deserves special attention. There is abundant evidence that mass closure with heavy, nonabsorbable suture material such as Prolene or stainless steel wire including peritoneum, muscle, and fascia is highly effective and associated with a negligible risk of dehiscence. Delayed closure of the skin and subcutaneous tissue is advisable. 12 Postoperative ileus is to be expected, and nasogastric drainage may be required for an extended period. When recovery is expected to be prolonged, total parenteral nutrition is appropriate. ECTOPIC PREGNANCY When the fertilized ovum implants at any site other than the endometrial mucosa lining the uterine fundus, the pregnancy is referred to as ectopic. Although most of these (95 per cent) occur within the uterine tube, about 1 per cent to 3 per cent begin in the ovary. Even fewer begin in the uterine cervix or on the abdominal peritoneum. 9 Interstitial pregnancy refers to implantation in the portion of the uterine tube that traverses the wall of the uterus. A tubal implantation may erode into the broad ligament, becoming a ligamentous pregnancy. Abdominal pregnancy refers to implantation anywhere on a peritoneal surface. Although an abdominal pregnancy may result from primary implantation, most probably occur secondarily following tubal abortion. In the United States, about one of every 200 diagnosed pregnancies is ectopic, and about 50,000 such cases are reported each year. There is thought to be an increase in both the absolute numbers reported each year and the rate of ectopic pregnancies per 1000 diagnosed gestations. Ectopic pregnancy continues to be a leading cause of maternal death. 22 Risk Factors Early diagnosis and surgical intervention requires an awareness of those conditions and circumstances that increase the risk that a given pregnancy will be in an ectopic location. Whereas the overall risk is about one in 200 pregnancies, in selected groups of women, this risk may be increased 20- to 100-fold. Prior Salpingitis. As many as 50 per cent of uterine tubes removed because of an ectopic gestation will show evidence of a prior inflammatory condition. The increasing incidence of PID, in many cases asymptomatic and therefore unrecognized, is thought to be a major factor in the increased numbers of ectopic gestations. 9 Prior Tubal Ligation. Tubal ligation is the most frequently performed gynecologic surgical procedure in this country and is the most common method of birth control in women over 30 years of age. Failure rates (subsequent pregnancy) are low and vary with the technique; overall, about one in 350 to 500 women having a tubal ligation will subsequently experience an unplanned pregnancy. Of those pregnancies occurring after tubal ligation, 10 to 50 per cent will be ectopic, representing a 20- to 100fold increase in risk. 3• 22

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Table 2. Presenting Symptoms and Findings Among 154 Patients with Ectopic Pregnancy

Pain Abnormal uterine bleeding Missed menstrual period Pelvic mass Positive culdocentesis* Positive sonogramt

NUMBER

PERCENT

150 132

97 86 61 40

94 62

82 84

*Culdocentesis performed in 120 patients. tSonogram performed in 50 patients. Positive defined as absence of gestational sac and! or free fluid in cul de sac. From Weinstein L, Morris MB, Dotters D, et al: Ectopic pregnancy-a new surgical epidemic. Obstet Gynecol 61:698, 1983.

Prior Tubal Repair. Increasing numbers of women are undergoing tubal surgery for the correction of infertility. In some, the operation is a reversal of a prior tubal ligation and in others the primary repair of a tube damaged by PID or other conditions. Among women who undergo tubal repair for the correction of infertility, about one third to one half will achieve pregnancy; of those pregnancies, 10 per cent to 20 per cent will be implanted in the uterine tube. 9 Presence of an Intrauterine Device. Among women with an IUD in place, about 2 to 4 per cent will experience an unplanned pregnancy. In those unplanned pregnancies, the risk of an ectopic implantation is increased. The presence of an IUD greatly reduces the risk of an intrauterine pregnancy, reduces the risk of tubal pregnancy but with somewhat less efficiency, and has no effect on the incidence of ovarian pregnancy. Therefore, although the risk of an ectopic pregnancy among IUD users is reduced overall compared with women using no contraception, among women who experience a pregnancy with an IUD in situ, the chance that the pregnancy will be ectopic is significantly increased. 15 Prior Ectopic Pregnancy. Among women with a history of prior ectopic pregnancy, infertility is common, and the chance for subsequent successful childbearing is reduced. Among the 30 to 50 per cent who subsequently achieve pregnancy, the risk of another ectopic one is about 10 per cent, a 20-fold increase in risk compared with women without a history of a prior ectopic pregnancy. Signs and Symptoms The frequency of various signs and symptoms is summarized in Table 2. 22 Pain is the most common symptom and is present to some degree in virtually all patients. The nature of the pain is extremely variable; it may be constant or intermittent, dull or sharp, and localized to the pelvis and lower abdomen or diffuse. Shoulder pain representing diaphragmatic irritation is infrequent but when present is often a clue that rupture has already occurred. A history of menstrual abnormality is almost invariably present, but its detection may require careful and detailed questioning. Amenorrhea, a delayed menstrual period, an abnormal period, and noncyclic bleeding are

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examples of typical menstrual abnormalities. Nevertheless, even a normal menstrual history cannot exclude the presence of ectopic pregnancy. Subjective symptoms of pregnancy are present in less than 50 per cent of patients and may include morning sickness, breast tenderness, or other subjective feelings interpreted by the patient as indicative of pregnancy. 22 The physical examination may be especially useful in making a diagnosis and in distinguishing this condition from others such as PID. Fever is rarely present, so a significant elevation of temperature usually points to other diagnoses. Signs of peritoneal irritation should not be expected in the unruptured ectopic pregnancy but may be pronounced when blood has accumulated over a period of days or weeks and the collection ruptures, spilling blood that has undergone proteolytic digestion. Findings on pelvic examination are also highly variable. An adnexal mass will be appreciated in about one third of patients and will usually be tender with any manipulation or pressure. Diffuse pelvic tenderness and pain on cervical motion may suggest free blood within the pelvis. 22 The sudden rupture of a blood-filled tube or walled-off collection of blood in the pelvis may produce a classic picture of severe pelvic and abdominal pain, shoulder pain, an urge to defecate, and syncope even in the absence of hypovolemia. Severe hypovolemic shock associated with massive intraperitoneal hemorrhage is uncommon (about 5 per cent of patients). Ectopic pregnancy is an important cause of maternal death. Diagnosis Diagnosis requires consideration of other pelvic pathology including acute PID, intrauterine pregnancy with a corpus luteum cyst that may have ruptured, incomplete spontaneous abortion, and torsion of the adnexa. Chorionic Gonadotropin Testing. Of special importance is the observation that when chorionic gonadotropin is absent by specific and sensitive testing, ectopic pregnancy can essentially be excluded from the differential diagnosis. Although the conventional radioimmunoassay for the beta subunit of human chorionic gonadotropin remains the most sensitive and specific test available, the results generally are not available for several hours and frequently longer; its usefulness in an emergency room setting is therefore limited. A currently popular test is the enzyme-linked immunoassay urine pregnancy test (ICON). The test regularly identifies chorionic gonadotropin concentrations of 50 miU per ml and will frequently identify much lower levels; test results are generally available in less than 1 hour. With some minor test modifications, Cartwright and associates have reported that the result was positive in 26 of 27 patients with ectopic pregnancy. 5 When the test is negative, the more sensitive radioimmunoassay may be indicated. Although a positive test by any technique will not distinguish between an intrauterine and ectopic implantation, a negative test may exclude ectopic pregnancy from consideration. Culdocentesis. Needle aspiration of the posterior cul de sac through the posterior vaginal fornix may provide information useful in the diagnosis of ectopic pregnancy. A positive result for intraperitoneal blood requires the aspiration of at least 0.5 ml of nonclotting blood, whereas the presence of serous fluid represents a negative result. Other results are usually

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considered inconclusive and frequently indicate that the needle was not introduced into the peritoneal cui de sac. Although the presence of free blood within the peritoneal cavity may come about from many conditions other than ectopic pregnancy, a positive tap in conjunction with a positive test for chorionic gonadotropin means that an ectopic pregnancy is highly likely and generally warrants an immediate operative approach. 6 Ultrasound. When a gestational sac can be identified within the intrauterine cavity with reasonable certainty by ultrasound, ectopic pregnancy can be excluded, since an intrauterine pregnancy and a concomitant ectopic one is exceptionally rare. In the absence of a clearly defined intrauterine sac, ultrasound may still be helpful in identifying a complex adnexal mass or even a clear gestational sac. Ultrasound imaging is especially sensitive and accurate in the identification of free fluid in the pelvis or elsewhere, a finding to be expected in the presence of a leaking or ruptured ectopic pregnancy19 Laparoscopy. When the diagnosis remains in question and in the absence of a clear-cut indication for laparotomy, diagnostic laparoscopy may permit a definitive diagnosis and allow the patient to be safely discharged home within a few hours. This procedure has been especially useful in diagnosing the unruptured or leaking corpus luteum associated with an early intrauterine pregnancy. Management Although spontaneous resolution of ectopic pregnancy is possible and may even be frequent, the risk of intraperitoneal hemorrhage warrants early operative intervention in every patient. Operation prior to rupture is ideal and is the reward for early diagnosis. Choosing the best operative procedure requires consideration of the operative findings in the pelvis, the patient's general condition, and her desire for subsequent childbearing. Choices include a partial salpingectomy with the aim of preserving tubal function, a complete salpingectomy, and salpingo-oophorectomy on the affected side. 13 Primary tubal repair is possible in selected cases but requires a surgeon experienced in microsurgical repair of the tube and a patient whose general condition is satisfactory for a long procedure. For the patient who desires future childbearing, preservation of the uterus and some ovarian tissue is almost always possible; even in the absence of a residual functional uterine tube, pregnancy continues to be a possibility through the use of in vitro fertilization and embryo transfer. Highly selected cases of tubal ectopic pregnancy can sometimes be managed through operative laparoscopy, which may result in brief hospitalization and a postoperative recovery of only a few days. Such an approach is generally limited to those instances in which the ectopic pregnancy is unruptured and is small, usually less than 4 em in diameter. The approach also requires that the surgeon be experienced in operative laparoscopy and the use of intraperitoneal laser technology. 7 · 9 • 20 Postoperative Outcome Most patients who experience an ectopic pregnancy will subsequently have impaired reproductive function. Among those desirous of future

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childbearing, 20 to 70 per cent will achieve an intrauterine pregnancy, but repeat ectopic pregnancy is common (10 to 50 per cent).

HEMORRHAGE FROM FUNCTIONAL OVARIAN CYSTS The vast majority of follicular and corpus luteum cysts should be managed expectantly, as most resolve spontaneously within 4 to 8 weeks without medical or surgical intervention. In most instances, their importance to the surgeon comes about because they may be confused with other conditions appropriately managed by laparotomy including ectopic pregnancy, neoplasm, or ovarian torsion. In some instances, bleeding occurs into the substance of the ovary, producing a large blood-filled cyst that may subsequently rupture. In other instances, bleeding may occur from the surface of an ovary that is minimally enlarged. Significant and sometimes severe intraperitoneal hemorrhage may occur. Signs and Symptoms In most instances, symptoms begin at or after ovulation. Pain is the usual presenting symptom; it is most often in the lower abdomen and is frequently bilateral and ill defined. With rupture of a blood-filled corpus luteum cyst, pain is more apt to be sudden and diffuse and may be indistinguishable from that associated with a ruptured ectopic pregnancy. On pelvic examination, there is usually diffuse pelvic tenderness, often accentuated on the side of the corpus luteum, and a mass may be palpable but frequently is not. If the corpus luteum is associated with an early gestation, there may be the usual symptoms of pregnancy, and examination may reveal a softened cervix and a slightly enlarged and boggy uterus. On occasion, hemorrhage is severe, producing abdominal distention and sometimes hypovolemic shock. Diagnosis Tests for human chorionic gonadotropin are highly important and should be both sensitive and rapid. When they are negative, the presence of free blood in the pelvis in an ovulating female is highly suggestive of corpus luteum rupture and hemorrhage. When pregnancy tests are positive, on the other hand, the surgeon will be faced primarily with distinguishing a ruptured ectopic pregnancy from a bleeding corpus luteum of pregnancy. The distinction is imperative, since surgical intervention is always appropriate for ectopic pregnancy but can sometimes be avoided when the bleeding is coming from a corpus luteum of pregnancy. When the patient is hemodynamically stable, pelvic and abdominal ultrasound may be valuable. Classic findings include free fluid in the cul de sac and sometimes in the upper abdomen and the presence of a complex or cystic adnexal mass. The identification of an intrauterine gestational sac essentially excludes the diagnosis of ectopic pregnancy and may permit expectant management even when intraperitoneal bleeding has occurred. 19

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Management The majority of functional cysts of the ovary are best managed expectantly, as they usually resolve spontaneously within 4 to 8 weeks. Therefore, in the absence of complications such as hemorrhage or torsion, the patient may be asked to return after an interval of 4 to 6 weeks to determine whether the cyst has regressed and thus whether intervention is necessary. When there is significant hemorrhage or torsion, laparotomy is indicated. Many patients will be young, and the cosmetic results of the incision will be important. A low transverse Pfannensteil-type incision usually permits adequate exposure for management and provides the best cosmetic results. After confirmation that the bleeding is secondary to an ovarian cyst, excision of the cyst can usually be achieved with preservation of the remaining affected ovary. The defect is closed in layers with very fine absorbable suture. The avoidance of unnecessary trauma to the adnexa in the young female is highly important in order to minimize adhesions that may subsequently become a factor in tubal infertility. When it is necessary to remove a corpus luteum of early pregnancy, progesterone replacement is advisable and may be given intramuscularly or by vaginal or rectal suppositories. Ovarian Hemorrhage and Anticoagulant Therapy All physicians who care for patients receiving anticoagulants should be aware that ovarian hemorrhage in association with a follicular cyst or corpus luteum may be associated with life-threatening intraperitoneal hemorrhage. Among women with a retained ovary who continued on anticoagulation, intraperitoneal hemorrhage recurred in almost one third. Therefore, for the patient requiring long-term anticoagulation, such as one with a cardiac valve prosthesis, serious consideration should be given to the removal of both ovaries if the patient requires surgery for ovarian hemorrhage. 16

ADNEXAL TORSION Although torsion of the normal ovary and adnexa is possible, in most instances, torsion is preceded by ovarian enlargement by a functional cyst or neoplasm. Torsion of an ovary or adnexa may occur at any age, even in the neonate; it is rare in the postmenopausal patient. 14 On occasion, torsion may be intermittent with periods of spontaneous resolution and remission of symptoms. Especially among young women, early diagnosis is important since surgical intervention prior to infarction may permit ovarian and adnexal preservation. Diagnosis Pain, usually low abdominal and frequently lateralized, is almost always the presenting complaint. The pain may be colicky or constant; most important, it is usually intense and frequently progressive. In many instances, it will appear to be out of proportion to the other findings. Lowgrade temperature elevations may occur, but significant fever is unlikely

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and usually points to other diagnoses. Pelvic examination usually demonstrates tenderness at least on the affected side. Especially when the patient is examined early, there may be no adnexal mass. With the passage of time, even a few hours, adnexal or ovarian swelling may occur, producing the typical findings of a large edematous ovary with infarction. When adnexal torsion is suspected but not confirmed, re-examination at frequent intervals may be important in establishing an early diagnosis. The use of pelvic ultrasound is especially appropriate when the diagnosis is in question. The enlarged ovary usually appears as a uniformly echogenic mass, sometimes partially cystic. Torsion of the entire adnexa is more apt to produce complex features. 2 Diagnostic laparoscopy is indicated when clear-cut indications for surgical intervention are lacking and ovarian torsion is considered a possible diagnosis. Especially important in the young patient, early laparoscopy may permit salvage of an ovary or adnexa that would otherwise be lost through infarction. Management

At laparotomy, the first step is the determination of ovarian or adnexal viability. In most instances, infarction will already be evident, and removal of the ovary or adnexa will be necessary. Late diagnosis may be associated with thrombosis of the ovarian vessels, and many surgeons advocate ligation of these vessels prior to correction of the torsion in order to minimize the risk of embolization. When torsion is associated only with an enlarged edematous ovary without infarction, correction of the torsion and preservation of the ovary may be possible. Reduction in ovarian size through aspiration of cystic structures or through wedge resection may reduce the risk of subsequent torsion. Shortening of the utero-ovarian ligament or suturing of the ovarian ligament to the posterior wall of the uterus will likely reduce the risk of recurrent torsion. It is always important to remember that in most instances, torsion involves a previously enlarged ovary. With this in mind, the ovary should be examined intraoperatively for the presence of a neoplasm; diagnosis or suspicion of a malignant tumor will influence appropriate intraoperative management. Among children, adolescents, or young adults, malignant neoplasms are usually germ cell in origin, and appropriate surgical management is usually limited to a unilateral adnexectomy. Among older women, epithelial malignancy is more common and is best managed by total abdominal hysterectomy and bilateral salpingo-oophorectomy. Among all patients in whom malignancy is diagnosed or suspected, appropriate surgical staging is important and includes careful inspection of all peritoneal surfaces, including the right hemidiaphragm, with liberal biopsies, an omental biopsy, and, frequently, pelvic and periaortic node sampling.

REFERENCES 1. American College of Obstetrics and Gynecology: Antimicrobial Therapy for Gynecologic Infections. Technical Bulletin No. 97, October 1986

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