.abdominal pain.

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

•Perempuan, 40 tahun datang dengan nyeri

perut bagian bawah sejak satu minggu
sebelum masuk rumah sakit. Keluhan
dirasakan memberat selama 2 hari tanpa ada
keluhan buang air besar dan buang air kecil.
Tidak ada demam.
Riwayat Ginekologi
• Pasien menstruasi teratur 28-30 hari, setiap siklus 7-10
hari, satu kali menstruasi ganti pembalut 2-3 hari.
Terakhir menstruasi satu minggu lalu, hanya tiga hari.
Keputihan (+) Perdarahan saat ini (-)

• Pasien memiliki memiliki 2 anak, sekarang terpasang

IUD sejak 8 tahun lalu, sempat kontrol setahun
sebelumnya dikatakan normal
Alvarado score
Migrating pain 0
Anorexia 0
Nausea 0
Tenderness in RLQ 2
Rebound pain 2
Elevated temperature 0
Leucocytosis 2
Shift to left 1 Total score: 7
Tanda Vital
Status Generalis
Kesadaran :Compos mentis
Keadaan umum : Tampak sakit sedang
Tekanan darah : 110/70 mmHg
Nadi 88x/menit
Laju napas 22x/menit
Suhu : 370C
Pemeriksaan Fisik
Status Generalis
Mata : Konjunctiva anemis -, sklera ikterik -

Paru : Vesikuler, rhonki -/-, Wheezing

Jantung : S1,S2, murmur -, gallop -

Abdomen Nyeri +, massa -

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

Visceral Deep somatic Superficial pain

• Sensitive to stretch, • Stimulation in •Nociceptors in the

ischemia and ligaments, tendons, skin and superficial
inflammation bones, blood vessels, tissue
• Insensitive to other fasciae and muscle •Sharp, well-defined
stimuli • Characteristic: Dull, and clearly located
• Characteristic: difficult aching, poorly
to locate, distant, localized
sickening, deep,
squeezing, and dull
EPIDEMIOLOGY
Cervellin, G. et al. Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department:
retrospective analysis of 5,340 cases. Ann Transl Med 4, 362 (2016).
 Under
65
(2.86%
)

Gynecologic
Pain

Above
65
(0.31%
)

Cervellin, G. et al. Epidemiology and outcomes of acute abdominal pain in a

large urban Emergency Department: retrospective analysis of 5,340 cases.
Ann Transl Med 4, 362 (2016).
DIAGNOSIS
 History Taking
• Onset (acute/chronic or acute • Cardinal symptoms (OPQRST)
exacerbation)
• Alarm symptoms Onset Provocation
• Primary location
• 9 Quadrants of abdominal anatomy
• Diffuse abdominal pain
• Gastrointestinal symptoms Quality Radiation
• Constipation: Absolute constipation,
abdominal pain, distension
• Diarrhea: frequency, concistency, blood, Timing/
mucus, pus Severity
treatment
Raftery, A. T., Lim, E. K. S. & Östör, A. J. K. Churchill’s pocketbook of
differential diagnosis. (Elsevier, 2014).
 History taking in non pregnant
women: Gynecological approach
Menstrual pattern Contraception
• Cycle length Cervical and vaginal cytology
• Duration of flow
• Amount of flow Infection
• Associated pain
• Intermenstrual bleeding Fertility/infertility
Peri/menopause
Sexual history
• Bleeding pattern
• Vasomotor symptoms Obstetric history
• Hormone replacement therapy
Past medical/surgical history
Bowdler, N. C. & Elson, M. The Gynecologic History and Examination. The Global
Library of Women’s Medicine (2009). doi:10.3843/GLOWM.10003
 History taking: Clinical relevance
• Verbal description of the pain
• Onset
• Abrupt: organ torsion, rupture or ischemia
• Nature of the pain
• Visceral (e.g early appendicitis) : midline, diffuse, dull, and cramping
• Colicky pain: obstruction
• Associated symptoms
• Urinary pathology: dysuria, hematuria, frequency or urgency
• Gynecological pathology: vaginal bleeding, vaginal discharge,
dyspareunia, or amenorrhea
• GI tract: diarrhea, constipation or GI bleeding
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
“In general, well-localized pain
or tenderness, persisting for
longer than 6 hours and
unrelieved by analgesic, has an
increased likelihood of acute
peritoneal pathology”
Hoffman, Barbara L, John O Schorge, Karen D Bradshaw, Lisa M Halvorson, Joseph I Schaffer, and Marlene M Corton. Williams Gynecology, 2016.
Physical Examination: General

General

Pulse, temperature, respiration

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

Bimanual of right adnexa

Physical Examination: Clinical
Relevance
• “First look” : Urgency
• General appearance: facial expression, diaphoresis, pallor,
and degree of agitation
• Elevated temperature, tachycardia, hypotension
• Constant, low-grade fever: Inflammatory condition:
diverticulitis and appendicitis
• Higher temperature: PID, peritonitis, pyelonephritis

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

High sensitivity for detection of structural pelvic pathology

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)

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.
Ruling out:
appendicitis
 BOWEL
Appendicitis Vs. OB-GYNc SCORE
Indicator Appendicitis OB-GYNc Score
Score
Guarding/rebound 1.9 0
tenderness
Pregnancy -1.7 2.4
Leucocytosis 1.5 0
Neutrophil > 75% 1.3 1.6
RLQ tenderness 1.5 0
LLQ Tenderness 0 1.9
Diarrhea -1.4 -2.3
Constant -1.5 0
Jearwattanakanok, Kijja, Sirikan Yamada, Watcharin Suntornlimsiri, Waratsuda Smuthtai, and Jayanton
Patumanond. “Clinical Scoring for Diagnosis of Acute Lower Abdominal Pain in Female of Reproductive Age.”
Emergency Medicine International 2013 (2013): 1–6. https://doi.org/10.1155/2013/730167.
 BOWEL
Appendicitis Vs. OB-GYNc SCORE:
Interpretation
Diagnostic preference Criteria

Appendicitis Appendicitis Score > OB-GYN score

AND
appendicitis score > 0

Common OB-GYN conditions OB-GYN score > appendicitis score

AND
OB-GYN score > 0

Non-specific abdominal pain Appendicitis score < 0

AND
OB-GYN Score < 0
 Radiographic Approach
Longitudinal graded compression ultrasound image
demonstrates a mildly dilated appendix (black

• Dilated appendix (> 6 mm) arrows) with preservation of the expected

multilayered appearance of bowel. Note blind end of
the appendix (white arrow). There is no evidence of
an appendicolith or adjacent flui

• 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

• Dilated appendix (> 6 mm) arrows) with preservation of the expected

multilayered appearance of bowel. Note blind end of
the appendix (white arrow). There is no evidence of
an appendicolith or adjacent flui

• 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

Tuboovarian Ovarian Ectopic

abcess torsion pregnancy

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

Approximately 15 cases per

100,000 women per year • Physiologic
Found in nearly all premenopausal women • Neoplastic

• 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

Leung, P. C. K, and E. Y Adashi. The Ovary, 2019.

http://search.ebscohost.com/login.aspx?direct=true
&scope=site&db=nlebk&db=nlabk&AN=1724820.
Ovarian cyst r upture
 Gynae
Ovarian Cyst Rupture: brief
• Epidemiology
• Pathophysiology

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

Torsion of ovarian • Reduce venous return

tissue • Stromal edema
• Internal hemorrhage

Risk factor: Ovarian cyst 50-60%

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

Sites and frequencies of ectopic pregnancy.

By Donna M. Peretin, RN. (A) Ampullary, 80%;
(B) Isthmic, 12%; (C) Fimbrial, 5%; (D)
Cornual/Interstitial, 2%; (E) Abdominal, 1.4%;
(F) Ovarian, 0.2%; and (G) Cervical, 0.2%
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: Physical
Exam

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

Multiple sex partners

History of previous PID

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:
Diagnosis (cont.)

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)

Bio-social factors Laboratory and Radiology

• WBC (16.3+6.5 vs. 11.2+5.1)

• Age (44.9+5.4 vs. 39.1+7.4) • CRP (59.5+39.3 vs. 48.6±38.9)
• IUD • Maximum dimension of
TOA (>5.2 cm)
Farid, Huma, Trevin C. Lau, Anatte E. Karmon, and Aaron K. Styer. “Clinical Characteristics Associated with Antibiotic Treatment Failure for Tuboovarian Abscesses.” Infectious Diseases in Obstetrics and Gynecology 2016
(2016): 5120293. https://doi.org/10.1155/2016/5120293.
Akkurt, Mehmet Ozgur, Serenat Eris Yalcin, Iltac Akkurt, Burak Tatar, And Yavuz, Yakup Yalcin, Mehmet Akif Akgul, and Fulya Kayikcioglu. “The Evaluation of Risk Factors for Failed Response to Conservative Treatment in
Tubo-Ovarian Abscesses.” Journal of the Turkish German Gynecological Association 16, no. 4 (November 26, 2015): 226–30. https://doi.org/10.5152/jtgga.2015.15123.
 PID
Pelvic Inflammatory Disease:
Parenteral treatment (CDC STD, 2015)

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

Adjacent organ Wall of mass

(e.g appendix)
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: Diagnosis
• No guideline for diagnosis of TOA
• Extended disease of PID
• Ultrasound
• Complex solid/cystic mass
• Pyosalpinx (elongated, fluid-filled mass with partial septae
and thick wall)
• Inflammation of tubal (incomplete septae)
• Cogwheel sign (thickened endosapingeal)
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:
Ultrasound

Cogwheel sign resulting from thickened Tubo‐ovarian complex, mostly in posterior

endosalpingeal folds.

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

•Perempuan, 40 tahun datang dengan nyeri

perut bagian kanan sejak satu minggu sebelum
masuk rumah sakit. Keluhan dirasakan
memberat selama 2 hari tanpa ada keluhan
buang air besar dan buang air kecil. Tidak ada
demam.
Riwayat Obstetri dan Ginekologi
• Pasien menstruasi teratur 28-30 hari, setiap siklus 7-10
hari, satu kali menstruasi ganti pembalut 2-3 hari.
Terakhir menstruasi satu minggu lalu, hanya tiga hari.
Keputihan (+) Perdarahan saat ini (-)

• Pasien memiliki memiliki 2 anak, sekarang terpasang

IUD sejak 8 tahun lalu, sempat kontrol setahun
sebelumnya dikatakan normal
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
Pemeriksaan Fisik
Status Generalis
Mata : Konjunctiva anemis -, sklera ikterik -

Paru : Vesikuler, rhonki -/-, Wheezing

Jantung : S1,S2, murmur -, gallop -

Abdomen Nyeri +, massa -

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

• Circulation Blood transfusion

C • Conciousness • Hb <7 g/dL

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

1. Rapid initial evaluation of pain intensity

2. Administration of the appropriate

analgesic by appropriate route

3. Adjuvant measure and repetition for

continuous pain and re-assesment
Pain assessment
VAS
• Visual analogue scale

NRS
• Numerical rating scale

VRS
• Verbal rating scale

SAS
• Smiley analogue scale
 metamizole

Pain
management
algorithm for
abdominal pain
 WHO Ladder

WHO step ladder, 1986

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

WHO step ladder, 1986

Cancer control, 2000

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.
 Analgesic options
Simple Analgesics
• Parasetamol
• Non Steroidal Anti Inflammation

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
As. Tranexamat 3x500 mg
Meropenem 3x1 gr
Metronidazole 3x500 mg
Analgesik
Drip petidin 20 tpm
Ketorolac 3x30 mg
PCT 4x500 mg
Omeprazole 2x1
As. Tranexamat 3x500 mg
Meropenem 3x1 gr
Metronidazole 3x500 mg
Analgesik
Drip petidin 20 tpm
Ketorolac 3x30 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