Document 6427383

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