Gynecology for the general surgeon Gynecological causes of acute abdominal pain, ectopic pregnancy, pelvic inflammatory diseases, endometriosis)

1. Gynecology for the general surgeon
(Gynecological causes of acute abdominal pain,
ectopic pregnancy, pelvic inflammatory
diseases, endometriosis)
Dr. RUTAYISIRE François Xavier
PGY1
Common surgical conditions module
University of Rwanda
Lecturer: Dr. Justin BAYISENGA,
Senior Consultant General Surgeon, CHUB

2. Introduction
• The gynecological disorders most likely to be met by the general
surgeon are those that present with:
• Acute abdominal symptoms(ectopic pregnancy, PID, and
complications of ovarian cysts and abortion).
• Those unexpectedly encountered at laparotomy (endometriosis,
ovarian tumors, and myomatosis).

3. • Surgeons who began to specialize in the treatment of disorders of the
female genital tract were among the first to form a group separate from
surgeons in general.
• Special women's hospitals were founded at which techniques were
developed, notably by the school of Victor Bonney, which are still the
basis of gynecological surgery.
• However, the resultant isolation impeded the exchange of ideas; many
gynecologists were poorly trained in general surgery and general
surgeons ignored gynecology.

4. • A discussion of gynecology in relation to general surgery may be
considered under 5 headings, of which only the first and second will
be discussed in this presentation.
1) The acute abdomen.
2) Gynecological disorders unexpectedly discovered during laparotomy.
3) Abdominal pain in pregnancy.
4) Pregnancy and cancer.
5) Gynecological causes of urinary disorders.

5. THE ACUTE ABDOMEN
• Gynecological causes of abdominal pain may arise from conditions
associated with pregnancy and the non-pregnant state
• Ectopic pregnancy is the most common in pregnancy and present as
emergency
• In non pregnant women, the most common emergencies are acute
pelvic inflammatory disease and complications of ovarian cyst
• N.B. Always request pregnancy test for all childbearing women
presenting with abdominal symptoms

6. Ectopic pregnancy
• An ectopic pregnancy is one that
implants outside the uterine cavity
• Incidence: 1:100
• Implantation occurs in the fallopian
tube in 95% to 99%
• The most common site of
implantation in a tubal pregnancy
is the ampulla (70%), followed by
the isthmus (12%) and fimbriae
(11%).
• Other sites: the ovary, the cervix,
the outside of the fallopian tube,
the abdominal wall, or the bowel

7. Risk factors
• Previous ectopic pregnancy
• Previous pelvic inflammatory disease or STI
• Previous use of an IUD
• Previous tubal surgery
• Smoking
• Older age
• Previous spontaneous miscarriage
• Previous medical termination of pregnancy
• History of infertility and assisted reproduction
7

8. Presentation
• Amenorrhea (symptoms of early pregnancy) followed by
• Vaginal bleeding
• Abdominal pain( unilateral pelvic or low abdomen)
• Cervical excitation and tenderness
• Signs of hypovolemia and shock
• Signs of peritoneal irritation
Being a true surgical emergency when ruptured, all
female patients presenting with painful vaginal bleeding
should be evaluated for ectopic pregnancy
8

9. Diagnosis
• History and physical examination
• Pregnancy test
• β-hCG level: low for gestational age and does not increase at the
expected rate
• FBC
• Abdominal and/or transvaginal ultrasound
9

10. Treatment
• Stabilization: Large-bore IV line, start IVF, blood products and
vasopressors if needed
• Place foley catheter
• Analgesics
• Explorative laparotomy
• Explorative laparoscopy if the patient is stable
• Medical management with methotrexate is an option for unrupted
ectopic pregnancy

11. Indications
Indications for surgical treatment of ectopic pregnancy include the
following:
• The patient is not a suitable candidate for medical therapy.
• Medical therapy has failed.
• The patient has a heterotopic pregnancy with a viable intrauterine
pregnancy.
• The patient is hemodynamically unstable and needs immediate
treatment.

12. Laparotomy
• Through a small transverse suprapubic incision blood in the pelvis is cleared away
to allow inspection of the uterus, tubes, and ovaries.
• No organ is removed and no clamp is applied before such an inspection.
• The site of the tubal pregnancy is carefully identified and differentiated from a
possible hematosalpinx in the other tube.
• Subtotal salpingectomy is performed provided the other tube appears normal; the
ovary must not be removed unless it is disrupted by hematoma.
• If the other tube is diseased or has already been removed the affected tube may be
preserved.

13. Pelvic inflammatory disease
(PID)
13

14. Introduction
• PID is an infection of the upper female genital tract involving any or all
of the uterus, oviducts and ovaries, often associated with
involvement of neighboring pelvic organs.
• Any combination of endometritis, salpingitis, tubo-ovarian abscess,
and pelvic peritonitis.
• It is caused by ascending STI and rarely pelvic organ infection
• Predisposes to infertility and ectopic pregnancy
14

15. Risk factors
• Age and sex are primary risk factors
• Young age at first sexual activity
• High number of sexual partners
• Current use of an IUD
• Surgical procedure
• Prior history of PID
• Cigarettes smoking
15

16. Causative agents
• Polymicrobial
• The most causative organism is chlamydia trachomatis, followed by
Neisseria gonorrhoeae
• Others organisms: Bacteroides species, Gardnerella, Escherichia coli,
Haemophilus influenzae, and streptococci
16

17. Pathophysiology
• Infection of the upper female genital tract leads to inflammatory
damage, resulting in scarring, adhesions, and partial or total
obstruction of the Fallopian tubes.
• This can result in loss of the ciliated epithelial cells along the fallopian
tube lining, resulting in impaired ovum transport and increased risk
for infertility and ectopic pregnancy.
• Additionally, adhesions can lead to chronic pelvic pain.

18. Clinical presentation
• Pelvic /lower abdominal pain
• Vaginal or cervical discharge
• Deep dyspareunia
• Abnormal odor
• Abnormal bleeding
• Cervical motion tenderness, uterine tenderness, or adnexal tenderness
• Gastrointestinal disturbances
• Urinary tract symptoms
• Fever
18

19. Diagnosis
• History and physical examination
• Vaginal swab
• FBC
• ESR and CRP
• Pelvic ultrasound
• Laparoscopy
• Endometrial biopsy
19

20. Differential diagnosis
• Endometriosis
• Urinary tract infection
• Appendicitis
• Gastrointestinal dysfunction
• Ectopic pregnancy
20

21. Management
In patients:
• Cefoxitin 2 g IV every 6 hours or cefotetan 2 g IV every
12 hours until clinical improvement plus
• Doxycycline 100 mg IV or orally every 12hours for 14
days
• For patients allergic to cephalosporin, give IV
clindamycin and gentamicin
 OPD:
• Single dose of ceftriaxone 250 mg IM or cefoxitin 2 g
IM plus 1 g of probenecid orally along with oral
doxycycline 100 mg orally BID for 14 days
21

22. Rwanda PID Treatment Guidelines
• Acute PID
• Admit the patient
• First line treatment: Ampicillin, 500 – 1000 mg I.V. QID followed by 500
mg QID plus Gentamicin, 160 mg IM.
Injection plus Metronidazole, 500 mg IV TID followed by 500 mg P.O.TID
For 10-14 days
Alternative treatment
Cefixime 800 mg PO single dose plus Doxycycline PO 100 mg BD plus
metronidazole 500 mg PO TDS for 10-14 days
• Cefixime 800 mg PO single dose plus Azithromycine single plus
metronidazole 500 mg PO TDS for 10-14 days
• Ceftriaxone, 1 g/day, IV Plus Gentamicin, 160mg, OD IM plus
Metronidazole, 500mg
Surgical treatment
• Laparatomy/Laparoscopy and drainage of abscess, salpingo-
oopherectomy
• Colpotomy
• Hysterectomy with or without salpingo-oophorectomy

23. Complications
• Infertility (12% with 1 episode, 20% 2 episodes and 40% with 3 or
more episodes)
• Ectopic pregnancy ( increase of 7 to 10 folds)
• Fitz-Hugh Curtis syndrome (perihepatitis)
• TOA and intra-abdominal sepsis
• Chronic pelvic pain
• Dyspareunia
• Pelvic adhesions
23

24. UNEXPECTED GYNAECOLOGICAL DISORDERS
• These are gynecological conditions which the general surgeon may encounter
unexpectedly at laparotomy(endometriosis, ovarian tumors, and myomatosis)
• To avoid making serious mistakes in treatment, follow the following advice.
1) The opinion of an experienced gynecologist should be sought when the nature
of a lesion is doubtful or its surgical treatment is uncertain.
2) The uterus, both ovaries, and both tubes should be inspected before any
structure is removed.
3) Ovarian disease is frequently bilateral; each ovary should be regarded as one
half of a single structure.
4) Removal of an ovarian cyst preserving the rest of the ovary that is, ovarian
cystectomy-is usually a simple procedure.
5) When a surgeon operates on a young woman to remove the appendix and this is
found to be normal he must resist the temptation to remove the ovary even though
it appears cystic. The left ovary is fortunate in being out of reach of the surgeon
using a McBumey's incision.
6) The general surgeon should realize that the ovary is as important to a woman as
is the testis to a man.

25. ENDOMETRIOSIS

26. Introduction
• Endometriosis is defined as the presence of normal endometrial
mucosa (glands and stroma) abnormally implanted in locations other
than the uterine cavity
• Affects up to 10% of women in the reproductive years. from all ethnic
and social groups.
• The etiology and pathogenesis is not known with certainty

27. Cont’d
Sampson’s theory attributed endometriosis to:
• Reflux of menstrual endometrium through the fallopian tubes.
• Alternative theory to Sampson’s theory is the coelomic metaplastic theory
suggested by Meyer. This theory relies on the ability of parietal peritoneum
epithelium to differentiate into endometrial tissue
• The hypothesis of metaplasia could justify the occurrence of endometriosis
in women without a uterus or a lack of endometria, such as female
patients with Mayer-Rokitansky-Küster-Hauser syndrome or the rare cases
of males suffering from endometriosis.
• Embolization of menstrual fragments through vascular or lymphatic
channel, explain its occurrence at less accessible sites like umbilicus, pelvic
lymph nodes, ureter, rectovaginal septum , bowel wall and remote sites like
the lung, pluera, endocardium and the extremities

28. Sites of endometriosis
1. Ovary
2. Cul-de-sac
3. Uterosacral lgmnt
4. Broad lgmnt
5. Fallopian tubes
6. Uterovesical fold
7. Round ligaments
8. Appendix
9. Vagina
10. Rectovaginal septum
11. Rectosigmoid colon
12. Caecum
13. Ileum
14. Inguinal canal
15. Abdominal scars
16. Ureters
17. Ureters
18. Umbulicus
19. vulva

29. Diagnosis
On history
Common symptoms:
Chronic pelvic pain
Worsening dysmenorrhea
Acquired dyspareunia
Infertility
Dyschezia
Premenstrual spotting
Risk factors:
First degree relative affected, short menstrual cycles, long duration of
menstrual flow, low parity, infertility

30. Cont’d
• Hemoptysis at the time of menstruation
• Hemothorax
• However, the predictive value of any one symptom or set of
symptoms remains uncertain as each can have other causes and a
significant proportion of affected women are asymptomatic.

31. Cont’d
Examination
Bilateral pelvic tenderness, fixed or enlaged ovaries and painful
uterosacral nodularity.

32. Cont’d
Investigations
Laparoscopy: gold standard
Ultrasound. Has a limited role, however the
addition of color doppler claims to increase the
sensitivity to 91.85%. specificity of 91.3%
MRI
Ca-125 may be elevated in severe endometriosis

33. Treatment
• The dependence of endometriosis on the cyclic
production of menstrual cycle hormones provides the
basis for medical therapy
• Combination oral contraceptive pills(COCPs)
• Pregestin agents
• GnRH analogue

34. • Surgical care for endometriosis
The aim is to destroy visible endometriotic implants and lyse peritubal
and periovarian adhesions that are source of pain.
Laparoscopic approach is the method of choice.
Ablation can be performed with:
• Laser
• Electrodiathemy

35. • Radical surgery
Total hysterectomy with bilateral oophorectomy and cytoreduction of
visible endometriosis.
Adhesiolysis is performed to restore mobility and normal intrapelvic
organ relationship

36. References
• RWANDA GYNECOLOGY AND OBSTETRICS CLINICAL PROTOCOLS & TREATMENT
GUIDELINES(September 2012)
• Cameron M. (1975). Gynaecology and general surgery. Annals of the Royal
College of Surgeons of England, 56(3), UNKNOWN.
• Mummert T, Gnugnoli DM. Ectopic Pregnancy. [Updated 2021 Aug 11]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK539860/
• Jennings LK, Krywko DM. Pelvic Inflammatory Disease. [Updated 2021 May 13].
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
Available from: https://www.ncbi.nlm.nih.gov/books/NBK499959/
• Tsamantioti ES, Mahdy H. Endometriosis. [Updated 2021 Aug 25]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK567777/