Topic: acute abdomen in gynecology topicality



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Topic: ACUTE ABDOMEN IN GYNECOLOGY

  1. Topicality: Urgent surgical aid is one most important problems of practical medicine. Quality of surgical aide in case acute diseases in obstetrics and gynecology depends on timely diagnostics, ability of a doctor to take and realize the best decision. That’s why the aim of the practical class is to bring up the sense of responsibility, patience and ability to determine the tactics of any gynecological pathology which became the cause of acute abdomen.

  2. Number of hours: 4

  3. Educational objectives: to study conditions resulting in acute abdomen in gynecology. To learn the tactics of management of women with interrupted extrauterine pregnancy, ovarian apoplexia, torsion of ovarian cyst, torsion of subserous myomatouse node, etc.

    1. To know: a=II.

  1. Connective apparatus of the uterine and ovaries.

  2. Blood supply of the internal reproductive organs.

  3. The range of surgical treatment depending on the cause of acute abdomen.

  4. The order of treatment of hemorrhagic shock.

  5. Pharmacological means for the treatment of bleedings.



    1. To be able to:

  1. Differentiate the causes of internal bleeding caused by interrupted tubular pregnancy and ovarian apoplexia.

  2. Differentiate the diagnosis of progressing tubular pregnancy and exarcebation of chronic adnexitis.

  3. Use intermediate methods of diagnostics to make the diagnosis.

  4. Make up a plan of rehabilitation of women operated on extrauterine pregnancy.

  5. Estimate the amount of blood loss.

  6. Make up a plan of recovery.

  7. Prepare a set of instruments to perform the operation of myomectomy in case of submucous myomatous node.

  8. Perform abdominal puncture through the posterior wall.




    1. To master practical skills: a=III

  1. Estimation of the uterine cervix.

  2. Bimanual gynecological examination.

  3. Abdominal puncture through the posterior wall.

  4. Estimation of the results of abdominal puncture.



Summary
ECTOPIC PREGNANCY

Pregnancy is called ectopic when it fertilized ovum implants outside the borders of uterine cavity.

Ectopic is one of the most serious gynecological diseases, because its interruption is followed by considerable intraperitoneal bleeding and needs emergency service.

Etiology. Anatomic changes in tissues of uterine tube that appear in the result of inflammatory processes are the main causes of the violation of ovum transport and ectopic pregnancy. Inflammation of mucous membrane, its edema and presence of inflammatory exudate in acute and chronic stages may cause dysfunction of uterine tubes. After this adhesions and closing of ampular end of the tube are formed. Damaging of muscular layer and changes in innervation of the tube lead to changes of its peristalsis and delay of fertilized ovum passing through it. Considerable anatomic changes in tubal layer or adjacent tissues cause abortions, operative interventions into the organs of true pelvis. Ectopic pregnancy frequently happens in women with genital infantilism, endometriosis, tumor of the uterus and uterine adnexa. Usage of intrauterine contraceptives increases the risk of ectopic pregnancy. There are scientific datas that toxic influence of exudate in tube at its chronic inflammation causes speed-up trophoblast maturing, that's why the proteolitic enzymes activize, and implantation comes before ferti­lized ovum enters the uterus. In case of the slow development of trophoblast an ovum is implanted in lower uterine (placenta praevia) segments or outside uterine cavity — in its cervix (cervical pregnancy).


Classification of ectopic pregnancy. Depending on that, where a fertilized ovum has implanted tubal pregnancy, ovarian pregnancy, abdominal pregnancy, pregnancy in rudimentary uterine horn, intraligamentaory (between folds of wide uterine ligament) and cervical pregnancy are distinguished.

In majority of cases (98,5 %) the tubal pregnancy occurs. Interstitial preg­nancy happens in interstitial portion of tube, isthmic — in isthmus and ampullar — in ampullar portion (fig. 76).

According to clinical duration unruptured and interrupting ectopic pregnancy are distinguished. Interrupting of ectopic pregnancy happens by type of tubal abortion or by type of uterine tube rupture (p. 77-80).

Fig. 76. Localozation of fertilized ovum in ectopic pregnancy: 1 — abdominal, 2 — tubal: 2a — interstitial; 26 — isthmic; 2b — ampular; 3 — ovarian; 3a — in a cavity of follicule; 3b — on ovarian surface; 4 — intraligamentory; 5 — cervical



Duration of ectopic pregnancy. After implantation of fertilized ovum in woman's organism there appear changes, typical for normal uterine pregnancy: yellow pregnancy body is developed in ovary, decidual membrane is generated in uterine, uterus becomes soft and enlarges under the influence of ovarian hormones. All these signs are typical for pregnancy. The chorionic gonadotropin is also produced. One can find gonadotropin by means of appropriate researches. Pregnancy test is positive. Women have presumptine pregnancy signs: nausea, appetite changes and so on.




A fertilized ovum, that has been implanted into endosalpinx, goes over the same development stages, as in case of uterine pregnancy. The chorion villi are generated. At first they grow into mucous layer of the tube, then, without finding sufficient conditions for development, they grow into its muscular layer. While the size of fertilized ovum increases, the walls of tube stretch. The chorion villi, invading deeper, bring on its destruction. A layer of fibrinoid necrosis is generated. For Werth's figure of speech, "a fertilized ovule digs in tube wall not only nest for oneself, but the grave". The wall of uterine tube can not create favourable conditions for fetal development, that's why within 4-7 weeks interrupting of ectopic pregnancy takes place.

Tubal pregnancy is interrupted for type of uterine tubal rupture or for type of tubal abortion, depending on the method the embryo is going out into abdominal cavity. In case of rupture of uterine tube destruction of its wall takes place in the result not of mechanical tension and rupture, but in the result of corrosion by chorion villi. At pregnancy interrupting for type of tubal abortion exfoliating of the embryo from tube walls and its passing into abdominal cavity through the ampular end takes place.



Unruptured ectopic pregnancy

Difficulty of diagnosis is connected with absence of symptoms which differ ectopic pregnancy from the uterine one. Sometimes women can feel uterine pain in the 'ower part of abdomen. During bimanual research one can palpate the enlarged tube, but sometimes it is not possible to do that because only at the end of the second month the tube reaches the size of an ovum and soft elastic consistence gives no possibility to palpate it distinctly.

A differential diagnosis of unruptured ectopic pregnancy is made in case of uterine pregnancy of early terms, cyst, ovary cystoma and hydrosalpinx.

Elastic organ is palpated in case of either ovarian cystoma near the uterine or in case of unruptured tubal pregnancy, in which uterus is not enlarged, reaction to the chorionic gonadotropin (CG) is negative. There is no ischomenia.

In case of hydrosalpinx in adnexal region elastic organ is also found, but uterine is not enlarged, women do not complain on ischomenia, reaction on CG is negative.

Diagnosis difficulties appear owing that uterus continues to enlarge because of the development of decidual envelope and hypertrophy of mucose fibres, but uterus falls behind in dimensions typical for the certain pregnancy term.

Tests for chorionical gonadotropin determination in such cases give a possibility to establish the pregnancy presence, but they don't give answer to the question about its localization. In some cases one can make diagnosis of


unruptured ectopic pregnancy with ultrasonic research. In this case embryo is absent in uterine cavity. The diagnosis can be confirmed by means of laparoscopy (fig. 1). Urgent hospitalization for complex examination and supervision is necessary in case when there is suspicion for unruptured ectopic pregnancy. The patient has to stay under the careful supervision of medical personnel. One should inform a doctor in case when there appear some changes in woman's state, especially when there are the symptoms typical for internal bleeding.



Fig. 1. Unruptured ectopic pregnancy in ampular portion of tube

After entering stationary it is necessary to define blood type, and also rhesus-factor of the patient immediately.



Tubal abortion

Clinic. In case of tubal abortion exfoliating of an embryo from tube wall and its passing into abdominal cavity take place (fig. 2). The clinic of tubal abortion is displayed by colicky pain, that is localized in one of iliac parts and irradiates into thigh, rectum and sacrum. Sometimes pain appears in supracla­vicular part — frenicus-symptom. If embryo drives out from the tube at once, sometimes it is followed by considerable bleeding, giddiness and loosing of consciousness. Sometimes exfoliating of embryo ceases for a while, pain stops disturbing, however the pain is soon renewed. This can repeat once or twice, then the tubal abortion lasts for a long time. Blood, that outflow from the tube, accumulates in cul-de-sac and causes the feeling of pressure on rectum.

Discharge from external genitals have spotting character, and is brown in colour. Sometimes the scraps of decidual membrane can go out and sometimes decidual membrane goes out wholly.



Diagnosis. The diagnosis of tubal abortion is not very simple. Carefully studied past history is of a great importence. Doubtful and probable signs of pregnancy are present. Anaemia is common due to intensive blood loss, arterial pressure decreases abruptly and pulse accelerates. Abdomen is flatulent, its par­ticipation in breathing act is limited. In lateral abdominal parts blunting percusion

sound is determined, during palpation there are the symptoms of peritoneal irritation.

During speculum examination is revealed cyanosis of vaginal mucosa and uterine cervix, typical are the secretions, described previously. At bimanual examination one can find that uterus is enlarged, but it does not correspond to menstruation delay term, isthmus allotment is soft, cervix motions are painful. In adnexa region from one side one can palpate an organ of elastic consistence with unclear contours. Back vault is smoothened or even prominent.




Fig. 2. Tubal abortion

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Differential diagnosis of tubal abortion. In the cases, when there is no considerable intraperitoneal bleeding, tubal abortion should be differentiated with uterine abortion in early term, exacerbation of salpingo-oophoritis, dysfunctional uterine bleeding and cystoma cms torsion.

At uterine abortion there is a permanent colicky pain, that irradiates into lumbar part. Discharge is bright or dark red coloured.

At tubal abortion pain is periodic, colicky, ordinarily it is followed by diz­ziness, and irradiates into rectum.

When percussion blunting of sound in lateral part of the abdomen is found in ectopic pregnancy and tympan is in case of uterine abortion.

Secretions from vagina in tubal abortion appear after pain attact, they are dark, of poor amount, in case of uterine abortion they are bright red and consi­derable.

General woman's state in tubal abortion does not correspond to external hemorrhage, but in uterine abortion it does. Bimanual examination in case of tubal abortion gives a possibility to find a formation nearby the uterus, uterus does not correspond to pregnancy term, whereas in case of uterine abortion uterine size correspond to pregnancy term and ovaries are not altered.

There are some differences between the inflammatory process of uterine adnexa and tubal abortion. In case of inflammatory process there are no menses delays, reaction on CG is negative.

Unlike tubal abortion pain during this disease appears gradually, there is no dizziness. Pain is not colicky, but permanent.



In case of tubal abortion with a long abortion duration one can observe subfebryle temperature, whereas in case of acute uterine adnexa inflammation temperature is high in most cases.

Some blood loss at tubal abortion gives rise to BP lowering, in inflammatory process BP is normal. In case of abortion pulse is higher, temperature rises rarely.

In case of tubal abortion abdomen is slightly flatulent, but soft and painful during palpation on one side, during percussion blunting sound is observed in lateral departments. In case of inflammatory process examination of abdomen gives the identical symptoms, however there is no blunting of percussion sound.

Bloody secretions in inflammatory processes of ovaries can be rarely found. Unlike the secretions of tubal abortion, they are bright, sometimes with purulent admixtures.

During bimanual examination enlargement of uterus with unclear adnexa contours from one side testifies about tubal abortion rather than about inflam­mation of ovaries, in which uterus is not enlarged and ovaries are palpated as enlarged from both sides. Often in tubal abortion sagging of back vault is found.

In spite of great amount of differences, which give a possibility to make a differential diagnosis between tubal abortion and inflammatory process of ovaries, sometimes it is very hard to distinguish them. US and specially culdocentesis are importent in such case. In case of tubal abortion during puncture blood is received and in inflammatory processes one can get serous or a purulent liquid.

If one couldn't manage to specify diagnosis and the general woman's state is satisfactory, they hold on resolvent and hemostatic therapy during 5-7 days with careful clinical supervision. In tubal abortion all phenomena (colicky cha­racter of pain, bloody secretions) progress and at inflammatory process improve­ment of general state is observed.

Tubal abortion differs from cystoma cms torsion. In case of cystoma torsion there is no menses delay, reaction on chorionic gonadotropic is negative, bloody discharge and signs of internal bleeding are absent. Cystoma torsion is found by abdomen palpation. US and sometimes endoscopy is used as individual method.



Differential diagnosis between tubal abortion and appendicitis. In appendicitis a patient does not complain of menses delay, there are no signs of pregnancy. At tubal abortion pain is periodic, colicky, with one side localization. In appendicitis it apears at first in epigastria, and lateral then it localizes in right iliac region and it is accompanied by nausea and vomiting, that are rare in case of tubal abortion. Bloody excretions and signs of internal bleeding are absent. Palpation of the abdomen in acute appendicitis expresses tensity of the front abdomen, whereas in case of tubal abortion it is insignificant and sometimes it is absent. The Schotkin-Blumberg's and Rovzing signs testifies acute appendicitis while frenicus-symptom is absent. During bimanual examination in case of acute

appendicitis uterus and ovaries are not enlarged. If much time has passed since the beginning of the disease, one can not always palpate them because of irritation of pelvic peritoneum. An infiltrate is palpated above and it is not possible to reach it through vagina.

A blood analysis in case of appendicitis gives leucocytosis with shift to the left, there is no anemia, whereas at tubal abortion blood picture is typical for anemia. After all, a culdocentesis can be a diagnostic criterion.

When clear differentiation is impossible, it is necessary to make laparotomy.
Tubal rupture

Clinic. Tube rupture develops more frequently in that case, when pregnancy is localized in isthmus or interstitial department (fig. 3,4). Clinics displays by severe internal bleeding, shock and acute anaemia.

Disease begins after menses delay with acute pain in lower abdomen, which appears suddenly. It is localized in iliac areas and irradiates into rectum and sacrum. This pain is followed by momentary loosing consciousness. After this patient remains adynamic. During the attempt to get up she can lose her cons­ciousness again.

Patient has all signs typical for internal bleeding: acute pallor, cold sweat, coldness of lower limbs, feeling of weakness, sometimes there is a threadlike pulse. The abdomen is flatulent, its participation in breathing act is limited. There is blurting of percussion sound in lateral abdominal region. Palpation of the abdomen is very painful. There are signs of peritoneal irritation.



Fig. 3. Pregnancy in interstitial p of fallopian tube (section)

decidua

fetus

fundus of uterus

Fig. 4. Tubal rapture



Diagnosis. During .speculum examination cyanosis of mucous membrane of vagina is found. Bloody excretions are present, though not always. They are dark-coloured and look like coffee-grounds.

At bimanual examination cervical motion is always painful, there appears bulging and acute pain of the posterior pouch. Uterus body is enlarged insignifi­cantly and along its side painful organ with unclear contours can be palpated, sometimes it is pulsatory. One should remember, that it is not always possible to palpate uterus and ovaries because of acute pain during gynecological exami­nation.



Following signs can help in diagnosis of ectopic pregnancy:

  • Laffon's sign — consecutive shift of pain feelings: at first in suprabrachial part, then shoulder, then pain spreads into back part, scapulars, under sternum

  • Elecker s sign — abdominal-ache presence, that is followed by its irradiation into shoulder and scapulars on tubal rupture side

  • Gertsfield 's sign — urging to urination appears during tubal rupture moment

  • Kulenkampf's sign — intensive pain during percussion of anterior abdomenal wall

At vaginal research such signs are determined:

  • Landau s sign — intensive pain during speculum or fingers inserting into vagina

  • Golden s sign — uterine cervix pallor

  • Bolt's symptom — acute pain during an attempt to displace uterine cervix

  • Gudell s sign — soft consistence of cervix

  • Promptov s sign — woman feels acute pain during an attempt to displace uterus up by inserted into vagina and rectum fingers. At appendicitis examina­tion per rectum causes pain in rectouterine pouch

  • Goffman s sign — uterus displacement into contrary from altered tubal side. During examination uterus easily comes into normal position, and when examination is over it returns into its previous position

At long blood presence in abdominal cavity its partial resorbtion takes place and transformed bilirubin deposits in skin cells. That's why there appear such signs:

  • Gofshteter s sign — presence of blue-green or blue-black colouring of skin in navel region

  • Kuschtalov's sign — yellow skin colouring of palms and soles, specially in fingers area

At tubal rupture clinic of internal bleeding progresses, that's why, after careful taking of anamnesis, doctor can make a diagnosis at once. However intensity of internal bleeding depends on the individual placing of vessel which feed a tube and some patients after its rupture, in spite of abdominal-ache, giddiness, do not apply to a doctor at once. At the same time, lack of expressed symptoms can bring doctor into mistake, illness progresses. That's why for confirmation of diagnosis of interrupted ectopic pregnancy culdocentesis, during which blood is received should be made obligatorily. However it is necessary to remember, that in 10-15% of all cases a culdocentesis does not confirm the diagnosis. In the case, if general patient state is not satisfactory, endoscopic examination should be done.

Diagnosis:

  • history taking

  • physical examination with typical symptoms

  • pe'vic examination

  • test on pregnancy

  • ultrasonic diagnostics

  • culdocentesis

  • in complicated cases culdoscopy or laparoscopy are performed

Management. Each woman with suspicion on ectopic pregnancy should be hospitalized and must stay in stationary until clinical confirmation or refuse of suspicion on ectopic pregnancy.

Rare forms of ectopic pregnancy

Ovarian pregnancy, intraligamentous pregnancy, abdominal pregnancy, cervical pregnancy and pregnancy in rudimentary uterine horn belong to the rare forms of ectopic pregnancy.

Ovarian pregnancy. At such localization pregnancy develops either in fc .acle (follicular pregnancy), or upon the ovarian surface. Progressing of pregnancy is followed by pain, peritoneum tension, that covers an ovary. Interrupting comes in early terms. In rare cases pregnancy can reach late terms.





Abdominal pregnancy is primary and secondary. At primary one fertilized ovum is implanted immediately in abdominal cavity — on peritoneum, omentum, bowels, liver. Secondary abdominal pregnancy develops as a result of reimplan­tation of fertilized egg in cavity of small pelvis after proceeding from uterine tube by reason of tubal abortion. Abdominal pregnancy can be interrupted in early terms, bringing the picture of acute abdomen, but sometimes it can reach the late terms. A fetus is palpated right under the abdominal wall, its heart beat is clearly auscultated, enlarged uterus is determined separately from the fetus. In-term birth of living child is possible. Operation is in fetus and placenta removal but there appear considerable technical difficulties with compartment of placenta from internal organs.

Intraligamentoruspregnancy. If tubal pregnancy, chorion villi don't grow into the abdominal cavity, but into side of broad ligament of the uterus, separating it, embryo comes into space between leaves of lig. latum uteri and continues to develop between them. Embryo, protected by leaves of the broad ligament, can develop to late terms (fig. 5) or even to full-term, however more frequently interruption of such pregnancy in 2-3 months term takes place. At its interrupting a big haematoma accumulates, and if the leaves of the broad ligament are ruined in the result of chorion villi penetrating, bleeding into abdominal cavity can appear.

Fig. 5. Intraligamentary pregnancy



Pregnancy in rudimentary uterine horn. The rudimentary uterine horn can have junction with the cavity. In that case impregnated ovum is able to come there (fig. 6). Progressing pregnancy doesn't give special symptomatics. During palpation a tumor-like organ, adjacent to uterus is determined, sometimes on a

eras. It is mobile and painless. Muscular layer of rudimentary horn is developed insufficiently as compared with miometrium, but it is developed much better in comparison with the uterine tube, that's why pregnancy in rudimentary horn is interrupted in later terms. Bleeding at such localization of ectopic pregnancy is considerable, that's why quick transportation of a woman into medical establish­ment is necessary. Diagnosis and operation are of particular importance.

Fig 6.

Treatment. Just after confirming the diagnosis decision about operative treatment is taken. During hospitalization into stationary patients blood type and rhesus-factor is immediately determined, so that one can stop blood loss and shock. Amount of transfused blood is determined according blood loss and general state of a patient.

The altered uterine tube is removed during the operation. Conservative-plastic operations are made recently for saving of reproductive function of women. In absence of expressed anatomic changes in tube and at satisfactory woman's state embryo is removed from the tube, the tube is sutured. If pregnancy inter­rupting took place not long ago, blood is not hemolized, and there is a necessity for immediate blood transfusion. The blood, taken from abdominal cavity may be reinfused.

Patient rehabilitation in postoperation period (physiotherapy, usage of biostimulators) is of a great importance. After making organo-saving operations it is necessary to care about tubal passability by means of hydrotubation. It is desirable to hold 2-3 courses of rehabilitation therapy during 6 months with following sanatorium-health-resort cure.




OVARIAN APOPLEXY

Ovarian apoplexy is blood effusion into ovary parenchyma, which is followed by bleeding into abdominal cavity.

Apoplexy causes are not clearly determined. It can develop in any day of ovarian-menstrual cycle or after menses delay, but more frequently it can happen in the middle of the cycle. The provoking factors are sexual act, trauma of the abdomen, operative intervention, mechanical pressing of the vessels by pelvis tumor.

Clinic. Disease begins suddenly, with pain frequently in one of the iliac region, which often spreads through the abdomen and irradiates into rectum, inguinal areas, sacrum and legs. The symptoms of internal bleeding appear, shock with loss of consciousness is common. The body temperature is normal. During abdominal palpation it is flatulent, patient can feel pain in lower abdomen in one or both sides.

Diagnosis. Previous diagnosis is made on the basis of carefully taken anam­nesis and complaints. Disease onset data of physical and also vaginal examination are taken into consideration.

Bimanual research gives a possibility to set gynecological nature of the disease. Bulding (in case of severe bleeding) and pain of vaginal fornixes is present. Displacement of cervix causes strong pain. Uterus is of normal size, and pain is determined in ovaries region from one side. There is enlarged, cystically changed ovary.

Frequently at apoplexy a diagnosis of ectopic pregnancy is made, because there are no symptoms, typical for apoplexy.

Differential diagnostics is made with ectopic pregnancy and appendicitis. It is necessary because at ectopic pregnancy operative intervention is obligatory, while a apoplexy — not always.

During differential diagnostics of ovary apoplexy with ectopic pregnancy one must pay attention to the fact that at apoplexy there are not signs of pregnancy. More frequently ectopic pregnancy appears after menses delay (not always!). Pain in both cases appears abruptly, irradiates into the same areas. In ectopic pregnancy frenicus-symptom is expressed, while apoplexy it happens rarely.

In apoplexy the peritoneal irritation phenomena and symptoms of internal bleeding are not so clearly expressed. However there are no clear criterions, for which one can distinguish ovarian apoplexy from interrupted ectopic pregnancy, especially if it interrupts by tubal rupture type. That's why management has to be determined by patient's general state.

As for differential diagnostics with acute appendicitis, one must remember, that in appendicitis more frequently pain initiate at the epigastric region, there






are nausea and vomiting and no signs of internal bleeding. At abdominal examination muscular defancel and positive Schotkin-Blumberg's symptom are observed.

Treatment. At absence of expressed signs of internal bleeding a conservative cure can be applied. We put a cold thind on abdomen, hold haemostatics. After fading of acute phenomena physiotherapy is prescribed.

In case of expressed internal bleeding an operative intervention is indicated. Its volume depends upon the changes which take place in ovaries. If there is a big haematoma, and ovarian tissue is completely blasted by effusions of blood, it should be removed. In case of small haematoma an ovary resection is made.

During hospitalization of the woman into statinary with suspicion on ovary apoplexy one should define blood type, rhesus-factor, measure arterial blood pressure, make a clinical blood test immediately. During conservative cure, woman is to be held under permanent careful surveillance of medical personnel and a nurse or midwife must report about the changes in woman's health to the doctor.

PYOSALPINX RUPTURE

An abscess rupture takes place spontaneously or in the result of physical trauma.



Clinic. Before abscess perforation there is always patient's health change to the worse — pain reinforces, temperature rises, peritoneum irritation symptoms are intensifying. Just after rupture there appears an acute pain which has a cutting character through the abdomen, collapse, nausea, vomiting, stomach is strained and strongly painful. General patient's state becomes worse, the face features sharpen, breathing becomes frequent and superficial. In the result of bowels pa­resis abdomen becomes flatulent, peristalsis disappears and meteorism develops.

Diagnosis. During stomach percussion one can find blunting of sound in lateral departments because of exudate presence in abdominal cavity.

During bimanual examination uterus and ovaries palpation is impossible because of acute pain and tension of front abdominal wall and vaginal fornixes bulgeng. Pelvic peritonitis may develop in the result of pyosalpinx rupture. Specification of the diagnosis can be made by means of ultrasonic research and culdocentesis.



Treatment. Cure of patients with purulent process in abdominal cavity is a complicated problem, successful solving of which needs fast and decisive actions. Operative cure with ablating of altered ovaries and following drainage of abdo­minal cavity is necessary. Laparotomy should be made by lower-middle incision, because this access gives a possibility to make a revision of abdominal cavity

organs and its wide drainage, and if it is necessary — peritoneal dialysis. During the operation it is necessary examine appendix because its frequent involving in pathological process. If pathological changes are found appendectomy is done. Removal of purulent mass is technically difficult and needs caution and care­fulness, but ablating of purulent formation is obligatory, because drainage, withoul ablating causes formation of purulent fistulas, those do not heal for a long time A conservative care of such patients (antibiotics, vitamin therapy, cold on umbi­licus) can give a temporary state improvement, but not a convalescence. Disease acquires chronic recidivate character with frequent acutenings. Operative interven­tion is inevitable anyways, however before operation it is necessary to make ou suitable patient's preparation with stimulation of immune system and detoxicaton



Torsion of tumor crus

Cystoma crus torsion can happen more often, but sometimes the crus о subserous fibrous myoma can also happen. Quick motions, pregnancy, labor stormy bowel peristalsis can cause torsion. In the result of torsion trophies о tumor tissue disturb, degenerative changes and necrosis with wall rupture appea in it (fig. 7).



Fig. 7. Torsion of ovarian rumor eras

Clinic. Complete and incomplete crus torsion may occur. Clinically at cru torsion the symptoms of "acute abdomen" appear. Muscles of anterior abdc minal wall tension is expressed on the part of process localization. In case of big tumor its contours are available for palpation through abdominal wall, an during bimanual examination one can reach a lower tumor pole. Examination i very painful. In incomplete torsion the clinical picture is poor less and all phenc mena can temporally vanish if blood supply of the tumor will be renewed.

Treatment Torsion of tumor crus needs immediate operation. Protractio with laparotomy gives rise to tumor necrosis, infection, beginning of adhesion process and accretion of tumor to adjacent organs, that will create addition:

complications during the operation. An operation volume depends on ovarian tumor type: at benign tumor it is removed; in suspicion of malignization total hysterectomy with omentum resection is indicated.

There is a peculiarity in the operation: clench is laid more proximally from the place of torsion and the tumor is cut off without twisting its crus. It is forbidden to twist the crus because the thrombs those are in eras and also substances of necrotic destruction of the tumor can get into woman's blood.

UTERINE BLEEDING

Causes of uterine bleeding are extraordinarily various, they can be mani­festations of general changes in organism, endocrine violations in ovaries (dys­functional uterine bleeding), changes in the part of uterus (submucous fibromatous nodes, polyps), interrupting of pregnancy.



Dysfunctional uterine bleeding

The dysfunctional uterine bleeding appears in the result of various violations of neurohumoral and hormonal regulation of menstrual cycle. Structural changes in women's genital organs are absent. Inflammatory processes or pregnancy are also absent. These bleedings can be both cyclic and acyclic. They happen in different phases of menstrual cycle.



Juvenile bleeding, bleeding of reproductive and menopause period are distinguished, that's why the approach to taking of diagnostic manipulations, treatment and emergency help in each case must be different. Emergency help includes hemostasis and prevention of bleeding relapse, and also anemia or hemorrhagic shock treatment which can appear when the bleeding is massive.

The juvenile bleedings appear in the period of puberty, usually on the back­ground of general and gynecological diseases (angina, glomerulonephritis, anemia, hypovitaminosis, diseases of blood and so on).

The girls with hypoplastic constitution and vegetodystonia suffer from this pathology more frequently. Sometimes a hyperplasia of thyroid gland is found in them. In winter-spring period bleeding appears more frequently, than in summer-autumn one. As a rule, such girls have menarche at the age of 12 or 13 years, but then menses last with long interruption and following bleeding.

The long acyclic bleedings cause anemia of the patient, lead to her exhaustion that into its turn causes states which contribute to beginnings of these bleeding. Ordinarily the bleeding becomes severe at once causes state of the patient.

Treatment of juvenile bleeding begins with using remedies for uterine contraction (Oxytocin, Methylergometrine), hemostatic preparations (Vicasol,





EACA, Nettle, watery pepper tincture, Dicinon). A bottle with ice can be put down on the lower abdomen. These methods give a possibility to decrease bleeding. For further treatment patient has to be directed to gynecologist, in case of severe bleeding she must be transported by sanitary carriage into stationary. In majority of cases treatment is conservative. Only on condition of absence of effect from treatment defloration is held and uterine curretage with parents' consent. Hormonal therapy with the aim of hemostasis can be used only after detailed examination.

Treatment of dysfunctional uterine bleeding in women in reproductive and climacteric age begins from uterine curretage with the following hormonal correction (combination of estrogens with gestagens, progestins). Symptomatic therapy at this pathology includes application of haemostatics (Vicasol 1% 1 ml, Dycinon, Calcium chloride 10% 10 ml, EACA 0,1 three times a day), retractive preparations (Oxytocin, Methylergometrin), a bottle with ice may be put down on abdomen. If bleeding causes considerable anaemia, that is followed by lowering of circulatory blood volume, lowering of arterial pressure, pulse acceleration, one should make a transfusion of the blood substitutes immediately. One should define a patient's blood type, rhesus-factor and transfuse the same group blood according to the volume of hemorrhage.

Interrupting of pregnancy

Initial abortion. Bloody excretions from vagina on this stage of pregnancy violation are nonsignificant, because embryo exfoliates on small area. Cervical canal is closed or slightly opened.

On this stage of pregnancy violation one should employ arrangements, directed to save of pregnancy (spasmolitics, analgetics, vitamin E, Progesterone). It is necessary to note that abortion may go into the following stage — inevitable abortion. Strong bleeding appears. During bimanual examination cervical canal is opened, normally we can palpate the embryo in it.

There appears considerable bleeding in case of incomplete abortion. When part of an embryo is localized in uterine cavity. In this case cervical canal and internal os lets a finger in.

In such cases (inevitable abortion and incomplete abortion) patient has to be transported into the hospital. In case of severe bleeding the transfusion of blood substitutes can be adjusted on stage of unspecialized help. Taking into account the possibility of hemotransfusion need, a blood type and rhesus-factor should be defined. Treatment is a removal of the embryo or its remainders with instrumental methods. Antibacterial therapy, haemostatics retractives are pre­scribed after curretage. If it is necessary anemia treatment should be continued.




Bleeding because of uterine fibromyoma

Bleeding can happen in presence of the submucous fibrous myoma. Some­times a patient knows about the presence of fibromyoma, however in some cases diagnosis is made only after bleeding.

Its intensity can be different, but long repeating bleeding causes anemia in women, exhaustion of their protective forces.

Bimanual examination reveals enlarged uterus and rather frequently, ovaries are enlarged (cystic changed) too. US diagnosis is helpful.

The patient should be given hemostatics (Vikasol, EACA, Calcium chloride). Blood substitutes and hemotransfusion, according to blood loss are used. The contractile remedies are not used in that case. The woman must be hospitalized. Submucous fibromyoma of the uterus must be operated.

Bleeding appearing due to uterine cervix cancer, cervical pregnancy must be treated by tight tamponade of the vagina. The tampon can include EACA. It is possible to use intravenous introduction of blood substitutes, inhalation of Oxygen. Giving emergency help, a patient should be transported into hospital.

TRADMAS 0¥ FEMALE GENITALS

Damages of external genitals can be as contusion, haematoma, hypodermic effusions of blood, that ordinary are accompained by damage of skin. More often these damages appear as a result of trauma such as falls and blows. In the village hornblows of domestic animals are observed. These traumas can be followed by lacerated wounds which ordinary penetrating deeply into tissues, sometimes vagina and even rectum can be damaged. In case of heavy traumas of urethra, urinary bladder, and also pelvis bone can be damaged. In case of damage of vagina trauma can penetrate into abdominal cavity. Ruptures of lateral walls of vagina are very dangerous because vaginal branches of uterine arteries pass in this area.



Clinically trauma is characterised by pain and haematoma of blue to purple colour in damaged place. In case of severe internal bleeding a picture of hemor­rhagic shock develops. Bleeding can be followed by anaemia. In case of clitoris rupture bleeding can be especially massive. Sometimes inserting of foreign objects into genital organs can happen. Especially frequently it happens in girls before 10 years. Adult women can introduce catheters, sounds and other objects into uterus with aim of pregnancy interruption. In such cases frequently uterus perfo­ration, bleeding can appear, that's why the woman applies for medical care. If there is no damage of genital organs, presence of foreign body causes inflam­matory process. Purulent excretions from vagina, sometimes with blood admix-




tures appear. Foreign body in adults can be found due to speculum examination. For children one should use cautious rectal research and vaginoscopy.

Diagnosis is based on examination. If there is suspicion on trauma of adjacent organs catheterization of urinary bladder, cystoscopy is made. US can be useful for diagnostics of foreign bodies in vagina.

Treatment. Traumatized tissues are sutured. In case of haematoma it is incised, bleeding vessels are knitted and drained. If it is necessary hemotransfusion is performed. Uterine cervix, vaginal, uterine ruptures, associated with labor act, are described in obstetrics course.



HEMORRHAGIC SHOCK

State, associated with acute blood loss, which is in abrupt lowering of cir­culatory blood volume (CBV), cardiac outflow and tissual perfusion in the result of adaptation mechanisms decompensation is the so-called "hemorrhagic shock". In gynecology hemorrhagic shock often appears as a result of internal bleeding in case of ectopic pregnancy, ovarian rupture or external bleeding in case of artificial and spontaneous abortion, stand still pregnancy, hydatiform mole, dysfunctional uterine bleeding, traumas.

Shock appears at hemorrhage, which exceeds more than 20% of CBV or 15 ml per kg of body mass. Practically blood loss over 1000 ml causes shock development, blood loss over 1500 ml is considered to be massive and it is very dangerous for woman's life.

The main part in pathogenesis of hemorrhagic shock is a disproportion between diminished CBV and volume of vascular system.

At blood loss, that does not exceed 10% of circulatory blood volume (com­pensated hemorrhage), compensation for rise of venous vessels tone, receptors of which are most sensible to hypovolemia takes place. Due to this tissual per­fusion does not change, frequency of cardiac beats and BP remain normal. Due to blood loss, which exceeds these indexes, expressed hypovolemia can appear. As a reaction on stress situation, the tone of sympato-adrenal system rises, release of catecholamines, aldosterone, glucocorticoids, activates renin-angiotensive system activation. Due to these factors increasing of cardiac contractions intensity, liquid excretion delay, spasm of peripheral vessels, opening of arteriovenosus shunts take place. This causes centralization of blood circulation, owing to which minute heart volume and BP are supported for a while. However blood circulation centralization can't support organism's vital functions for a long time, that is why during this violation of peripheral blood flow and oxygenation in tissues is available. Hypoxia and metabolic acidosis can appear. In this case microelements redistribution takes place - Sodium and Hydrogen ions go inside the cells, and


ignesium and Potassium go into intercellular space. This causes hydrataion i their damage. Poor perfusion in tissues is followed by stasis, formation of ombs, blood secvestration, in the result of which CBV continues to fall down, an effect of CBV deficiency there is violation of vitally important organs >od perfusion, cardiac blood flow falls down, coronal insufficiency develops, не factor plays a very important role in the expression of pathophysiologycal morrhage effects. The faster hemorrhage is, the more severe are hemodynamic Nations. Whereas slow blood loss, even more massive, can cause less expressed alations, but there exists the danger of inconvertible changes initiation.

Clinic of hemorrhage shock

Three stages of hemorrhage shock are distinguished:



  • 1st stage — compensated shock

  • 2nd stage — decompensated reverse shock

  • 3rd stage — inconvertible shock

1st stage shock (compensated shock). It is developed in case of CBV lowering ) 20 % (loss of blood, that composes 1% of body mass). Systolic BP during this tage decreases to 100 mm. Hg., tachycardia is moderate, pulse is not more than 00 bt/min. The shock index (correlation of cardiac contractions frequency and ystolic BP) is equal to 1. Pallor skin body temperature decreasing, closing ypodermic veins on hands, moderate oliguria, venous hypotonia are observed, 'atient is adequate.

2nd stage shock (decompensated reversible shock). It develops when the )lood loss is 25-30% of CBV (1,5% of body mass). Such signs are observed as )allor skin, coldness of extremities, acrocyanosis. Tachicardia is up to 120 bt/min, iullness of cardiac tones, dyspnoea are also present. Systolic arterial pressure iecreases to 100-80 mm.Hg. Blood supply of vitally important organs such as heart, lungs, brain, organs of abdominal cavity alteres, but these changes are still reversible. Oliguria develops. Shock index is equal to 1,5.

3rd stage shock appears at blood loss, that is over 35% of CBV (more then 2% of body mass). Clinically it is displayed by acute pallor and coldness of skin, frequent breathing, stupor, dilatation of pupils. Systolic pressure is lower than 70 mm.Hg. (diastolic one could not be determined). Pulse is speed-up to 140 bt./min. The shock index composes 2.

If blood loss reaches more than 50% of the circulatory blood volume, a deep coma can develop. Pulse becomes threadlike, and is accelerated more than 140 bt./min, BP is impossible to determine. Uncomtrolled hypotensia and anuria testify about process inreversibility.






Diagnosis of hemorrhage shock in most cases is not complicated, however frequently a shock degree is underestimate, that is in need for timely adequate treatment. For estimation of hemodynamics violation degree it is necessary to use listed symptoms (colour and temperature of skin, BP, pulse rate, shock index, collapse of hypodermic veins on extremities and neck, diuresis per hour). Hemoglobin indexes, hematocrit number are also of a great importance. If there is a possibility, it is desirable to determine coagulogram, acid-alkaline blood state, and also electrolyte balance.

Color and temperature of skin — this is the index of peripheral blood flow. Warm, pink skin even at low BP testifies about normal blood supply of peripheral tissues and on the contrary — cold, pale skin, at normal or even raised ВТ indexes confirm centralization and violation of peripheral blood circulation. A "marble" skin coloring, acrocyanosis confirm threat of inconvertible changes.

Pulse rate can be a criterion only in connection with other indexes: BP and central venous pressure (CVP).

The shock index is very informative. In healthy people it composes 0,5. At shock index more than 1,0 the patient is in a serious danger, and a rise over 1,5 testifies about threat to woman's life.

Diuresis per hour. Lowering of urine excretion to 30 ml/hr testifies about insufficiency of peripheral blood circulation, to 15 ml/hour — about approach of inconvertible shock phase.

Big sense in complex estimation of patient's state has CVP measuring. In healthy peoples CVP is 50-120 mm. lift. CVP lowering below 50 mm. lift, testifies hypovolemia, which needs immediate VBC renewal.

The test for determination of hemorrhage degree and violation of blood circulation is hematocrit. Its normal index in women is 43%. Lowering of hematocrit number below 30% is an impending symptom, if it is below 25% — testifies about severe degree of hemorrhage. The sign of terminal shock stage is the rise of hematocrit number.

Treatment of hemorrhage shock should be made by gynecologist together with anesthesiologist-reanimatologist. It must be complex, intime and include such arrangements:


  • operations with hemostatic aim

  • adequate anestesiologic help

  • immediate arrangements, directed to guiding the patient out of shock state

Not only woman's health, but also her life depends on the quickness and accuracy of doctor's actions. If it is necessary to remove the uterus for hemostatic, we must make it, without thinking about preserving menstrual or reproductive woman's function. However in case of difficult woman's state one should re­member about the sequence of actions, namely:

hemorrhagic shock


It is important to remember, that after completion of operation it is necessary to perform anestesiologic arrangements and artificial ventilation of lungs which are important component in complex shock therapy.

One should remember, that for treatment results not only plenitude, but also hemorrhage renewing speed are important. Infusion-transfusion therapy is the main in treatment of shock, it provides:



  • CBV renewing and elimination of hypovolemia

  • removal of microcirculation violations

  • elimination of hypoproteinemia

  • electrolytes level and acid-alkaline blood state normalization

  • removal of hemocoagulation violations

For guaranteeing of the first condition it is necessary to transfuse blood and blood substitutes. As the speed of blood loss renewing is of great importance one should mobilize two large-calibres veins and make a jet transfusion in case of decompensated shock. If BP is 70/40 mm.Hg. and less, endarterial blood pum­ping is performed, and after rise of arterial pressure to 80/50 mm.Hg. intravenous introduction is indicated. At 1000 ml hemorrhage a volume of transfusion must be more than 1,5, at 1500 ml — more than 2 times, at 2000 ml and more — 2,5 times. The speed, which is necessary to restore CBV, is the following: 75% of lost blood must be renewed at the first 1,5-2 hours from the bleeding beginning. Correlation of transfusion components has to be such: donor blood — 60%, native albumen and colloid solutions — 20%, glucose solution and balanced electrolytes solutions — 20%). Conserved donor blood (with storage time up to 3 days), plasma (dry or frozen), polyglucin, reopolyglucin, glucose-novocaine mix­ture are used. Blood substitutes improve reological blood properties, decrease aggregation of blood cells, that improves peripheral bllod circulation. These properties are best in polyglucin and reopolyglucin. The excessive liquid is moved out by enforced diuresis (Mannit 2 g/Kg, Furosemid or basics 40 mg). It is made only after renewing of blood loss.

It is rationally to make catheterisation of subclavian vein enabling to make transfusion therapy for a long time.

Liquid inflowing speed, choice of blood, and its substitutes amount, moving out excessive liquid should be controlled by BP indexes, pulse, hour diuresis, by colour of skin covers. In case of general state stabilization cyanosis, acute pallor and skin sweating, dyspnoea disappearing, achievement of hourly diuresis is not less than 30-50 ml are observed. Transfusion of erythromass and liquid in correlation 2:1 is indicated.




In acute stage glucocorticoids (Hydrocortison 1000 mg, Dexason 12 mg, Prednisolone 120 mg) must be used. The complex of medical arrangements should include cardiac remedies (0,06% solution of Corglicon, 0,05% solution of Strofantin), antigistamins preparations (1% Dimedrol, 2,5%) Diprasin, 2% solution of Suprastin). The spasm of peripheral vessels are removed by using of No-spa (4 ml of 2%> solution), Euphilin (10 ml of 2,4% solution), Pentamin (1 ml of 0,5%) solution). Introduction of 200 ml 0,5% Novocain solution with 200 ml 20%) glucose solution and adequate amount of Insulin give a good effect.

Metabolic acidosis is managed by introduction of 200-250 ml 5% Sodium hydrocarbonate solution. Violations of electrolytic balance are restored by means of intravenous Potassium and Magnesium introduction.

At steady loss of vascular tone Noradrenalin (1 ml 0,1 % solution) or Dofamin (100 mg) in 150-200 ml of Sodium chloride isotonic solution is indicated. If it is necessary a patient is transferred on artificial lungs ventilation. Introduction of medical solutions doses and ALV are made to complete renewing of microcircu­lation, respiratory, cardiac-vascular systems function, stabilization of all hemo­dynamic indexes.

Violation of blood coagulation takes place at hemorrhage shock. On the 1 st and 2nd stages coagulative ability of blood increases, and on the 3rd stage consumptive coagulopathy appears. Proceeding from this, one should take renewing of blood coagulability properties by means of procoagulants introduction with «warm» donor blood, dry or native plasma, antihemophil plasma, cryo-precipitate or fibrinogen. For fibrinolisis decreasing antifibrinolitic remedies — Contrycal, Gordox are used.

Managing the patient out shock is only the first cure stage. Further the therapy, directed to elimination of massive hemorrhage effects is continued. Ii this period efforts should be directed on maintenance of heart functions, livei kidneys, normalization of water-saline and albumin metabolism, treatment о anaemia, infection prophylaxy.

]


    1. Theoretical questions to the class:

1. Connective apparatus of the uterine and ovaries.

2. Blood supply of the internal reproductive organs.

3. The range of surgical treatment depending on the cause of acute abdomen.

4. The order of treatment of hemorrhagic shock.

5. Pharmacological means for the treatment of bleedings.
5.3. Practical skills (trained during the class):

1. Estimation of the uterine cervix.

2. Bimanual gynecological examination.

3. Abdominal puncture through the posterior wall.

4. Estimation of the results of abdominal puncture.

5.4. Materials for Self-assessment:

A: Questions for Self-assessment:


  1. Etiology, pathogenesis and classification of extrauterine pregnancy.

  2. Clinical signs of progressing extrauterine pregnancy and the methods of its diagnostics.

  3. Clinical signs of interrupted extrauterine pregnancy and the methods of its diagnostics.

  4. Clinical differences of extrauterine pregnancy interrupted by the rupture of the uterine tube and tubular abortion.

  5. Differentiation diagnostics of extrauterine pregnancy and acute appendicitis.

  6. Methods of surgical treatment of extrauterine pregnancy.

  7. Indications for concervative treatment of tubular pregnancy.

  8. Methods of concervative treatment of tubular pregnancy.

  9. Cervical pregnancy. Diagnostics and treatment.



B. Tasks for self-assessment:

1. A 31- year- old patient is admitted in the gynecological department complaining of severe blood discharge from the genitals, weakness, and dizziness. She experienced measles, parotitis flu, frequent quinsy. Menstrual cycle is not regular, starting from the age of 12. She became sick 15 days ago, when blood discharge appeared from the genitals after 2 months of delay. The following days intensity of bleeding increased, weakness and dizziness developed. A general condition is of moderate severity. Pulse is 90. BP- 80/70, mercury. The tongue is moist and clean. The patient is of an average fatness, the mammary glands are poorly developed. Heart or lung pathology is not found. Blood analysis: haemolobin- 50g/l, erythrocytes- 2200000. Rectal-abdominal examination: smooth and conical cervix, uterine body is in the normal position, small, mobile, painless. The adnexa are not detected on the both sides. Blood discharge with clots.

Diagnosis. Plan of treatment. Measures concerning prevention of uterine bleeding.




References:

1. Obstetrics – edited by Professor I.B. Ventskivska, Kyiv “Medicine”, 2008.

2. Gynecology – Stephan Khmil - Ternopil, 2003.

3. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 201-225.

4. Basic Gynecology and Obstetrics. - Norman F. Gant, F. Gary Cunningham. -1993. -- P. 406-412.

5. Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher Carey. - Springer-Verlag New York, 1994. - P. 62-64.






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