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A gynecological approach
Prinnisa A Jonardi | Supervisor: dr. Lidya F. Nembo SpOG
Brief
• Case
• Abdominal anatomy
• Approach to abdominal pain
• History taking
• Physical examination
• Laboratory
• Imaging
• Differential diagnosis
• Initial management
KASUS
Kasus
Obturator –
Psoas +
Rovsing +
Ekstremitas : akral hangat,
crt<2
Status Ginekologi
• Inspekulo:
Portio ukuran normal, licin, fluksus (-), oue tidak ada
pembukaan, fluor (-) perdarahan aktif (-), massa (-)
• RVT:
Vulva/vagina tenang, teraba fornices, portio licin,
pembukaan (-) nyeri goyang +, nyeri adnexa +
Mukosa rectum licin, TSA + baik
Laboratorium
Pemeriksaan USG
• Vesika urinaria penuh
• Uterus Antefleksi
ukuran 5 cm
• Massa kompleks di
andexa sinistra
• Fluid collection + di
cavum douglass
Anatomy of abdomen
Abdominal Quadrant: Anatomical
relevance
Cartwright, S. L. & Knudson, M. P. Evaluation of acute abdominal pain in adults. Am Fam Physician 77, 971–978 (2008).
Abdominal Quadrant: Anatomical
relevance
Adrenal
Small intestine, glands, Pancreas, left
spleen,
right kidney, pancreas, kidney, colon,
gallbladder, liver duodenum, spleen
liver, stomach
Duodenum,
Right colon, liver, Left kidney,
ileum,
gallbladder jejunum descending colon
Female
reproductive
organs, Sigmoid colon,
Cecum, appendix sigmoid descending colon
colon, urinary
bladder
Abdominal Quadrant and Clinical
relevance
https://meducation.net/resources/1717568-
Quadrants-of-the-Abdomen-
PAIN
“An unpleasant sensory and
emotional experience
associated with actual or
potential damage, or described
in terms such damage”
The International Association for the Study of Pain (IASP)
Type of Nociceptive Pain
Gynecologic
Pain
Above
65
(0.31%
)
General
Abdomen
• Inspection
• Palpation
• Percussion
• Auscultation
Rectal Examination
Physical Examination in non pregnant
women: Gynecological approach
1. Vulva • Adnexal mass
2. Speculum examination (if • Pouch of douglas
• Nodularity
available) • Tenderness
3. Bimanual examination 4. Rectovaginal examination
• Empty bladder
• Uterus
• Size
• Configuration
• Consistency
• Mobility
Lops, V. Essentials of obstetrics and gynecology, Second edition Edited by Neville F. Hacker and George J. Moore.
Philadelphia: WB Saunders, 1992. 634 pages, softcover. Journal of Nurse-Midwifery 39, 341–342 (1994).
Bimanual of left adnexa
Rectovaginal exam
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Cont..
• Pelvic examination
• Vaginal discharge, cervicitis: PID
• Vaginal bleeding: pregnancy complication, malignant
reproductive tract neoplasia, acute vaginal trauma
• Uterine enlargement: pregnancy, adenomyosis and leiomyomas
• Cervical motion tenderness: peritoneal irritation; PID,
appendicitis, diverticulitis and intraabdominal bleeding
• Adnexal mass: ectopic pregnancy, tuboovarian abcess, or ovarian
cyst
can be: non-gynecological organ: appendix
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Laboratorium Testing
• Complete blood count
• Hemorrhage
• Infection
• Beta-hCG
• IS A MUST: in every woman with reproductive age without prior
hysterectomy
• Urinalysis
• Possible urolithisis and cystitis
• Microscopic evaluation and culture of vaginal dicharge
• If possible
• Evaluate suspected case of PID
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Radiologic Imaging: Sonography
Transvaginal and transabdominal pelvic sonography
Non invasive
Obtained quickly
Operator dependent
Less common diagnosis able to be confirmed by sonography
• Uterine perforation by IUD device
• Hematometra cause by menstrual obstruction from
mullerian anomalies
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Radiologic Imaging: others
• Computed Tomography
• Superior performance
• Including GI tract and urinary tract
• Appendicitis false positive: decrease 24% to 3%
• Increase cancer risk: radiation
• Magnetic resonance
• Non-conclusive information
• Patient obesity and pelvic anatomy distortion; large leiomyomas,
mullerian anomalies, tumor growth.
• Pregnant patient, limited radiation
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Differential Diagnosis:
Right Lower Quadrant
Pain in Woman
Warning Sign
Previous Known
Age > 60 yrs History of IBS
surgery malignancy
Women of
Active Immunocompromised, Systemic
childbearing
chemotherapy steroid intake symptoms
age
Right Lower Quadrant Differential
diagnosis (Turkey 2009, 2013)
Hatipoglu, Sinan. “Acute Right Lower Abdominal Pain in Women of Reproductive Age: Clinical Clues.” World
Journal of Gastroenterology 20, no. 14 (2014): 4043. https://doi.org/10.3748/wjg.v20.i14.4043.
Abdominal Quadrant
Adrenal
Small intestine, glands, Pancreas, left
spleen,
right kidney, pancreas, kidney, colon,
gallbladder, liver duodenum, spleen
liver, stomach
Duodenum,
Right colon, liver, Left kidney,
ileum,
gallbladder jejunum descending colon
Female
reproductive
organs, Sigmoid colon,
Cecum, appendix sigmoid descending colon
colon, urinary
bladder
Differential diagnosis
Gynecological
Bowel
Pathologic
Pelvic
Inflammatory Miscellaneous
Disease
BOWEL
Acute and Perforated Appendicitis
Appendicitis is only one of a large number of gastrointestinal,
genitourinary, and gynecological disorders
Ferris, Mollie, Samuel Quan, Belle S. Kaplan, Natalie Molodecky, Chad G. Ball,
Greg W. Chernoff, Nij Bhala, et al. “The Global Incidence of Appendicitis: A
Systematic Review of Population-Based Studies.” Annals of Surgery 266, no.
2 (August 2017): 237–41. https://doi.org/10.1097/SLA.0000000000002188.
BOWEL
Scoring System:
Specificity and Sensitivity
Sensitivity Specificity
Alvarado Score 99% 43%
Cut-off < 7
AIR Score 33% 97%
Di Saverio, Salomone, Arianna Birindelli, Micheal D. Kelly, Fausto Catena, Dieter G. Weber, Massimo Sartelli, Michael Sugrue, et al. “WSES Jerusalem Guidelines for Diagnosis and
Treatment of Acute Appendicitis.” World Journal of Emergency Surgery 11, no. 1 (December 2016): 34. https://doi.org/10.1186/s13017-016-0090-5.
BOWEL
Alvarado Score
vs.
AIR Score
Di Saverio, Salomone, Arianna Birindelli, Micheal D. Kelly, Fausto Catena, Dieter G. Weber, Massimo
Sartelli, Michael Sugrue, et al. “WSES Jerusalem Guidelines for Diagnosis and Treatment of Acute
Appendicitis.” World Journal of Emergency Surgery 11, no. 1 (December 2016): 34.
https://doi.org/10.1186/s13017-016-0090-5.
BOWEL
Scoring System: Algorithm
(WSES, 2016)
• Hyperechoic appendicolith
• With posterior acoustic
shadow
• Periappendiceal fluid
collection
• Target appearance
• Wall thickening (>3 mm)
Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158 (2): 355-60.
Radiographic Approach
Longitudinal graded compression ultrasound image
demonstrates a mildly dilated appendix (black
• Hyperechoic appendicolith
• With posterior acoustic
shadow
• Periappendiceal fluid
collection
• Target appearance
• Wall thickening (>3 mm)
Puylaert JB. Acute appendicitis: US evaluation using graded compression. Radiology. 1986;158 (2): 355-60.
Gynecological
Pathology
Pelvic Pain
Acute pain
• Discomfort present less than 7 days
Chronic pain
• Non cyclic pain: persists for 6 or more months
• Localize to the anatomic pelvis to the anterior abdominal wall or
below umbilicus/to lumbosacral
• Pain sufficiently severe to cause functional disability or lead to
medical intervention
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton.
Williams Gynecology, 2016.
Gynecologic etiology
Incomplete
Dysmenorrhea
abortion
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton.
Williams Gynecology, 2016.
Complication of Ovarian Cyst
Ovarian
Cyst rupture
torsion
Hemorrhagic
Ovarian cyst
Ovarian cyst: Epidemiology Ovarian cyst
classification
• Benign
• Borderline
• Malignant
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson,
Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Ovarian cyst: Diagnosis
Simple cyst features clear fluid, thin smooth walls, no loculations or Figure 5: Ovarian malignancy features solid areas that are not hyperechoic (especially if blood flow
to them); thick septations ( >2 - 3 mm wide, especially if blood flow within them); excrescences on
septae, and enhanced through-transmission of echo waves. inner/outer aspect of a cystic area; ascites; other pelvic/omental masses.
Timmerman, Dirk, Ben Van Calster, Antonia Testa, Luca Savelli, Daniela Fischerova, Wouter Froyman, Laure Wynants, et al. “Predicting the Risk of Malignancy in Adnexal Masses Based on the
Simple Rules from the International Ovarian Tumor Analysis Group.” American Journal of Obstetrics and Gynecology 214, no. 4 (April 2016): 424–37. https://doi.org/10.1016/j.ajog.2016.01.007.
Ovarian cyst: Diagnosis
Simple cyst features clear fluid, thin smooth walls, no loculations or Figure 5: Ovarian malignancy features solid areas that are not hyperechoic (especially if blood flow
to them); thick septations ( >2 - 3 mm wide, especially if blood flow within them); excrescences on
septae, and enhanced through-transmission of echo waves. inner/outer aspect of a cystic area; ascites; other pelvic/omental masses.
Timmerman, Dirk, Ben Van Calster, Antonia Testa, Luca Savelli, Daniela Fischerova, Wouter Froyman, Laure Wynants, et al. “Predicting the Risk of Malignancy in Adnexal Masses Based on the
Simple Rules from the International Ovarian Tumor Analysis Group.” American Journal of Obstetrics and Gynecology 214, no. 4 (April 2016): 424–37. https://doi.org/10.1016/j.ajog.2016.01.007.
Ovarian Cyst: Management
Mature Releasing
Rupture
follicle ovum
Accumulate in
Bleeding of cyst Abdominal pain
peritoneal cavity
Shiota, Mitsuru, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, and Hiroshi Hoshiai. “Preoperative Differentiation between Tumor-Related Ovarian Torsion and Rupture of Ovarian Cyst Preoperatively Diagnosed as Benign: A
Retrospective Study.” The Journal of Obstetrics and Gynaecology Research 39, no. 1 (January 2013): 326–29. https://doi.org/10.1111/j.1447-0756.2012.01926.x.
Gynae
Ovarian cyst rupture:
Diagnosis - History
• Acute abdominal pain
• Typically during physical activity (e.g
exercise or sexual intercourse)
• Onset tends to be in midcycle (the most
common: follicular cyst rupture)
• Vaginal bleeding
• Nausea and/or vomitting
• Weakness
• Syncope
• Shoulder tenderness
• Circulatory collapse
Shiota, Mitsuru, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, and Hiroshi Hoshiai. “Preoperative Differentiation between
Tumor-Related Ovarian Torsion and Rupture of Ovarian Cyst Preoperatively Diagnosed as Benign: A Retrospective Study.” The
Journal of Obstetrics and Gynaecology Research 39, no. 1 (January 2013): 326–29. https://doi.org/10.1111/j.1447-
0756.2012.01926.x.
Gynae
Ovarian cyst rupture: Diagnosis –
Physical Exam
• Abdominal pain
• Wide range: Mild unilateral ~ Acute abdomen (severe
tenderness, guarding, rebound and peritoneal signs)
• Elevated temperature
• Adnexal mass
• Probable
• Absence: no diagnostic value ~ cyst decompress after
rupture
Shiota, Mitsuru, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, and Hiroshi Hoshiai. “Preoperative Differentiation between Tumor-Related Ovarian Torsion and Rupture of Ovarian Cyst Preoperatively Diagnosed as Benign: A
Retrospective Study.” The Journal of Obstetrics and Gynaecology Research 39, no. 1 (January 2013): 326–29. https://doi.org/10.1111/j.1447-0756.2012.01926.x.
Gynae
Ovarian cyst rupture:
Diagnosis – Laboratorium
• Urinalysis
• Rule out:
• Urinary tract Infection
• Renal bladder stone
• Serum or urine pregnancy testing
• Rule out:
• Ectopic pregnancy
• Hematocrit
• Evaluate hemorrhage
• Serially, if necessary
• C-Reactive Protein (Shiota et al, 2013)
• Higher in ovarian cyst rupture
• Rule out ovarian torsio
Shiota, Mitsuru, Yasushi Kotani, Masahiko Umemoto, Takako Tobiume, and Hiroshi Hoshiai. “Preoperative Differentiation between Tumor-Related Ovarian Torsion and Rupture of Ovarian Cyst
Preoperatively Diagnosed as Benign: A Retrospective Study.” The Journal of Obstetrics and Gynaecology Research 39, no. 1 (January 2013): 326–29. https://doi.org/10.1111/j.1447-0756.2012.01926.x.
A d n e x a l To r s i o n
Gynae
Adnexal Torsion: Brief
• Epidemiology
• Pathophysiology
Ashwal, Eran, Liran Hiersch, Haim Krissi, Ram Eitan, Saharon Less, Arnon Wiznitzer, and Yoav Peled. “Characteristics and Management of Ovarian Torsion in Premenarchal
Compared With Postmenarchal Patients.” Obstetrics and Gynecology 126, no. 3 (September 2015): 514–20. https://doi.org/10.1097/AOG.0000000000000995.
Gynae
Adnexal Torsion: History
• Onset
• Sudden
• Median duration
• Pre menarchal: 24 hours
• Post menarchal: 8 hours
• Commonly during exercise
• Unilateral lower abdominal
• Worsen over many hours
• Sharp, stabbing
• Third semester of pregnancy
• Non specific symptoms
Raziel, A., R. Ron-El, M. Pansky, S. Arieli, I. Bukovsky, and E. Caspi. “Current Management of Ruptured Corpus Luteum.”
European Journal of Obstetrics, Gynecology, and Reproductive Biology 50, no. 1 (June 1993): 77–81.
Gynae
Adnexal Torsion: Physical exam
• Palpable abdominal mass
• Found in 50-90%
• Cannot exclude the diagnosis
• Mass tenderness
• Mild (30%) to absent (30%)
Raziel, A., R. Ron-El, M. Pansky, S. Arieli, I. Bukovsky, and E. Caspi. “Current Management of Ruptured Corpus Luteum.”
European Journal of Obstetrics, Gynecology, and Reproductive Biology 50, no. 1 (June 1993): 77–81.
Ectopic pregnancy
Gynae
Ectopic Pregnancy: Brief
• Life threatening situation
• Epidemiology
• Pathophysiology
Fallopian tube
Anatomy defect
Ovary
Functional defect
Uterus
Mol, F., E. van den Boogaard, N. M. van Mello, F. van der Veen, B. W. Mol, W. M. Ankum, P. van Zonneveld, et al. “Guideline Adherence in Ectopic Pregnancy Management.” Human
Reproduction (Oxford, England) 26, no. 2 (February 2011): 307–15. https://doi.org/10.1093/humrep/deq329.
Gynae
Ectopic Pregnancy: History
• Classic triad
Pain 75%
Amenorrhea Only 50%
Vaginal bleeding 40-50%
Mol, F., E. van den Boogaard, N. M. van Mello, F. van der Veen, B. W. Mol, W. M. Ankum, P. van Zonneveld, et al. “Guideline Adherence in Ectopic Pregnancy Management.” Human
Reproduction (Oxford, England) 26, no. 2 (February 2011): 307–15. https://doi.org/10.1093/humrep/deq329.
Gynae
Ectopic Pregnancy: Site of implantation
Cervical motion
Peritoneal sign
tenderness
Unilateral or
bilateral
abdominal or
pelvic tenderness
Mol, F., E. van den Boogaard, N. M. van Mello, F. van der Veen, B. W. Mol, W. M. Ankum, P. van Zonneveld, et al. “Guideline Adherence in Ectopic Pregnancy Management.” Human
Reproduction (Oxford, England) 26, no. 2 (February 2011): 307–15. https://doi.org/10.1093/humrep/deq329.
Gynae
Ectopic Pregnancy: Warning Sign
Hypovolemic Shock
•Orthostatic blood
In 20% cases
pressure
•Tachycardia
Mol, F., E. van den Boogaard, N. M. van Mello, F. van der Veen, B. W. Mol, W. M. Ankum, P. van Zonneveld, et al. “Guideline Adherence in Ectopic Pregnancy Management.” Human
Reproduction (Oxford, England) 26, no. 2 (February 2011): 307–15. https://doi.org/10.1093/humrep/deq329.
Gynae
Ectopic Pregnancy:
Laboratory and imaging
Complete blood
bhCG
count
Ultrasonography
Mol, F., E. van den Boogaard, N. M. van Mello, F. van der Veen, B. W. Mol, W. M. Ankum, P. van Zonneveld, et al. “Guideline Adherence in Ectopic Pregnancy Management.” Human
Reproduction (Oxford, England) 26, no. 2 (February 2011): 307–15. https://doi.org/10.1093/humrep/deq329.
Ectopic pregnancy seen as a hematoma.
In this 21-year-old woman with positive serum pregnancy test and vaginal
bleeding, a complex echogenic mass (arrow) is seen in the right adnexa, which
separates from the right ovary (open arrow) with applied pressure during Tubal ring sign.
transvaginal ultrasound. The echogenic adnexal mass is representative of a A. In this 20-year-old woman with a positive pregnancy test presenting to the emergency
hematoma at the site of ectopic implantation. The patient was treated surgically. department with pelvic pain and vaginal spotting, there is an adnexal mass with echogenic
ring (arrow). B. A color Doppler image of the right adnexa shows increased vascularity in the
echogenic ring. The patient was diagnosed with ectopic pregnancy based on a clinical and
Lee, Robert, Carolyn Dupuis, Byron Chen, Andrew Smith, and Young H. Kim. “Diagnosing Ectopic Pregnancy in the sonographic assessment and was treated successfully with methotrexate.
Emergency Setting.” Ultrasonography 37, no. 1 (January 1, 2018): 78–87. https://doi.org/10.14366/usg.17044.
Pelvic Inf lammator y
Disease
PID
Pelvic Inflammatory Disease
• Pelvic inflammatory disease is an infectious and
inflammatory disorder of the upper female genital tract
• INCLUDING;
• Uterus
• Fallopian tubes
• Adjacent pelvic structures
• Sexually Transmitted Disease
Most common: Neisseria gonorrhea and Chlamydia trachomantis + IUD (4-6 wks post insertion)
PID
Pelvic Inflammatory Disease:
Risk Factors
Infection with STI, mostly gonorrhea
and chlamydia
Data from the National Survey of Family Growth (NSFG) from 2006 to 2010
showed that 5.0% of women reported being treated for PID in their lifetime
Das, Breanne B., Jocelyn Ronda, and Maria Trent. “Pelvic Inflammatory Disease: Improving Awareness, Prevention, and Treatment.” Infection and Drug Resistance 9 (2016): 191–97.
https://doi.org/10.2147/IDR.S91260.
PID
Pelvic Inflammatory Disease:
Pathophysiology
Tubo- Fitz-Hugh-
PID ovarian Peritonitis Curtis
abcess Syndrome
Symptoms: Perihepatitis
• Right upper quadrant tenderness
• Rebound tenderness Inflammation of liver capsule
• Pelvic exam: without inflammation of liver
• Cervical motion tenderness parenchym
• Adnexal tenderness
• Uterine compression tenderness on Workowski, Kimberly A., Gail A. Bolan, and Centers for Disease Control and Prevention.
“Sexually Transmitted Diseases Treatment Guidelines, 2015.” MMWR. Recommendations
and Reports: Morbidity and Mortality Weekly Report. Recommendations and Reports 64, no.
bimanual RR-03 (June 5, 2015): 1–137.
PID
Pelvic Inflammatory Disease:
Diagnosis
Workowski, Kimberly A., Gail A. Bolan, and Centers for Disease Control and Prevention. “Sexually Transmitted Diseases Treatment Guidelines, 2015.” MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report.
Recommendations and Reports 64, no. RR-03 (June 5, 2015): 1–137.
PID
Pelvic Inflammatory Disease:
Oral treatment (CDC STD, 2015)
• Antibiotic
• Azithromycin (500 mg IV daily 1-2 doses,followed by 250
mg orally daily 12-14 days)
• Or in combination with metronidazole 1g once a week, for 2
weeks
• Ceftriaxon 250 mg IM single dose
• Fluoroquinonlone (if individual and community prevalence
of gonorrhea are low)
• Levofloxacin 500 mg once daily
• Metronidazole 500 mg twice daily 14 days
Sweet, Richard L. “Treatment of Acute Pelvic Inflammatory Disease.” Infectious Diseases in Obstetrics and Gynecology 2015 (2011): 1–13. https://doi.org/10.1155/2011/561909.
PID
Pelvic Inflammatory Disease:
Follow up(CDC STD, 2015)
Clinical
improvement in Hospitalization
72 hours
Reduction of
Assessment of
uterine, adnexal
antimicrobial
and cervical motion
regimen
tenderness
Additional
diagnostic
Sweet, Richard L. “Treatment of Acute Pelvic Inflammatory Disease.” Infectious Diseases in Obstetrics and Gynecology 2015 (2011): 1–13. https://doi.org/10.1155/2011/561909.
PID
Pelvic Inflammatory Disease:
Factors affecting therapy response
Study in Turkey (2015), including 76 women with PID
Massachutes (2001-2012, including 113 patients with PID)
Sweet, Richard L. “Treatment of Acute Pelvic Inflammatory Disease.” Infectious Diseases in Obstetrics and Gynecology 2015 (2011): 1–13. https://doi.org/10.1155/2011/561909.
TOA
Pelvic Inflammatory Disease:
Admission Criteria (UK, 2018)
• Admission for parenteral therapy, observation and
further investigation and/or possible surgical
intervention should be considered in the following
situation
Lack of Presence of a
Clinically Intolerance to
response of tubo-ovarian
severe disease oral therapy
oral therapy abcess
Workowski, Kimberly A., Gail A. Bolan, and Centers for Disease Control and Prevention. “Sexually Transmitted Diseases Treatment Guidelines, 2015.” MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report.
Recommendations and Reports 64, no. RR-03 (June 5, 2015): 1–137.
Tubo Ovarian Abcess
TOA
Tubo Ovarian Abcess
• Etiology
Cervical or
Periotenal
vaginal Endometrium Fallopian tube
cavity
infection
Wall of mass
Munro, Kirsty, Asma Gharaibeh, Sangeetha Nagabushanam, and Cameron Martin. “Diagnosis and Management of Tubo-
Ovarian Abscesses.” The Obstetrician & Gynaecologist 20, no. 1 (January 2018): 11–19. https://doi.org/10.1111/tog.12447.
TOA
Tubo Ovarian Abcess
• Etiology
Cervical or
Periotenal
vaginal Endometrium Fallopian tube
cavity
infection
Munro, Kirsty, Asma Gharaibeh, Sangeetha Nagabushanam, and Cameron Martin. “Diagnosis and Management of Tubo-Ovarian Abscesses.” The Obstetrician & Gynaecologist 20, no. 1 (January 2018): 11–19. https://doi.org/10.1111/tog.12447.
TOA
Tubo Ovarian Abcess: Therapy
• Antimicrobial agents alone are effective in 70%
• Candidates for antibiotic therapy alone (Gr. 2C)
• No signs of rupture/sepsis
• Abcess <9cm in diameter
• Adequate response to antibiotic therapy
• Premenopausal
• No response after 48-72 hours
• Drainage or surgery
Munro, Kirsty, Asma Gharaibeh, Sangeetha Nagabushanam, and Cameron Martin. “Diagnosis and Management of Tubo-Ovarian Abscesses.” The Obstetrician & Gynaecologist 20, no. 1 (January 2018): 11–19. https://doi.org/10.1111/tog.12447.
Kasus
• RVT:
Vulva/vagina tenang, teraba fornices, portio licin, pembukaan
(-) nyeri goyang +, nyeri adnexa +
Mukosa rectum licin, TSA + baik
Pemeriksaan Fisik
Status Generalis
Mata : Konjunctiva anemis -, sklera ikterik -
Obturator –
Psoas +
Rovsing +
Ekstremitas : akral hangat,
crt<2
Laboratorium
Pemeriksaan USG
• Vesika urinaria penuh
• Uterus Antefleksi
ukuran 5 cm
• Fluid collection + di
cavum douglass
Working diagnosis
Tubo-ovarian abcess
Initial Therapy:
Right Lower Quadrant Pain
in Woman
Initial
Therapy Fluid
(Japan,2016)
Should initiated IMMEDIATELY
• Airway
A Crystalloid vs Colloid
• First choice: crystalloid
• Breathing • Colloid is not recommended
B • Adverse effect: renal failure and
bleeding
Mayumi, Toshihiko, Masahiro Yoshida, Susumu Tazuma, Akira Furukawa, Osamu Nishii, Kunihiro Shigematsu, Takeo Azuhata, et al. “The Practice Guidelines for Primary Care of Acute Abdomen 2015.” Japanese
Journal of Radiology 34, no. 1 (January 2016): 80–115. https://doi.org/10.1007/s11604-015-0489-z.
Pain Management
Masking reliability of physical
Analgesic examination???
Analgesic Masking reliability of
physical examination???
Manterola, Carlos, Manuel Vial, Javier Moraga, and Paula Astudillo. “Analgesia in Patients with Acute Abdominal Pain.” Edited by Cochrane Colorectal Cancer Group. Cochrane Database of
Systematic Reviews, January 19, 2011. https://doi.org/10.1002/14651858.CD005660.pub3.
Analgesic Masking reliability of
WHICH ONE TO CHOSE?? physical examination???
Manterola, Carlos, Manuel Vial, Javier Moraga, and Paula Astudillo. “Analgesia in Patients with Acute Abdominal Pain.” Edited by Cochrane Colorectal Cancer Group. Cochrane Database of
Systematic Reviews, January 19, 2011. https://doi.org/10.1002/14651858.CD005660.pub3.
Consideration
NRS
• Numerical rating scale
VRS
• Verbal rating scale
SAS
• Smiley analogue scale
metamizole
Pain
management
algorithm for
abdominal pain
WHO Ladder
Vargas-Schaffer, Grisell. “Is the WHO Analgesic Ladder Still Valid? Twenty-Four Years of Experience.” Canadian Family Physician Medecin De Famille Canadien 56, no. 6 (June 2010): 514–17,
e202-205.
WHO Ladder
Weak Opioid
• Tramadol
• Oxycodone
Strong opioid
• Morphine
• Fentanyl
Vargas-Schaffer, Grisell. “Is the WHO Analgesic Ladder Still Valid? Twenty-Four Years of Experience.” Canadian Family Physician Medecin De Famille Canadien 56, no. 6 (June 2010): 514–17,
e202-205.
Surgical Treatment
Transabdominal histerectomy salphingoovarectomy +
appendectomy + adhesiolysis + drainage
Follow up treatment post surgery
22/12 Omeprazole 2x1 26/12 Omeprazole 2x1
As. Tranexamat 3x500 mg As. Tranexamat 3x500 mg
Meropenem 3x1 gr Meropenem 3x1 gr
Metronidazole 3x500 mg Metronidazole 3x500 mg
Analgesik Analgesik
Drip petidin 20 tpm Drip petidin 20 tpm
Ketorolac 3x30 mg Ketorolac 3x30 mg
PCT 4x500 mg PCT 4x500 mg
Aff drain
Follow up treatment post surgery
27/12 Cefixime 2x200 mg p.o
Metronidazole 3x1p.o
As. Tranexamat 3x500 mg p.o
As. Mefenamat 3x1 po
Rawat luka
TAKE HOME MESSAGE
• Consider gynecological ddx
• Routine gynecological examination approach in every
women with abdominal pain
• Appendicitis vs. OBGYN-c Score
• USG ~ the most effective and cost-benefit imaging study
• Management
• Pain management: goal ~ pain free
• WHO step ladder
• Consider available weak opioid