CASE OF DD

INTERN PEPINO
INTERN PASTRANA
D.D.
• 51 year old G5P3 (4024) Chief complaint:
• Hypertensive Hypogastric pain
HYPOGASTRIC
HYPOGASTRIC PAIN
PAIN HYPOGASTRIC PAIN HYPOGASTRIC PAIN

● NO BLOATEDNESS
ASSOCIATED
INTERMITTENT
CONSULT DONE ● VAS BLOATEDNESS
8/10 BLOATEDNESS
● TOOK
FEVERDULCOLAX WITH NO RELIEF
CRAMPING
● VAS
VOMITING
3/10
EARLY SATIETY EARLY SATIETY EARLY SATIETY
● NON
BM CHANGES
RADIATING
● SPONTANEOUSLY
URINARY CHANGES RESOLVING
INCREASING ABDOMINAL GIRTH ● CONSULT DONE INCREASING ABDOMINAL GIRTH
● VAGINAL DISCHARGE OR
BLEEDING ● COLONOSCOPY - INTERNAL
● REPEAT TVS DONE HEMORRHOIDS ● MANAGED AS
FOLLOWED UPA CASE OF PELVIC
● DYSPAREUNIA ● WAB UTZ DONE DISEASE
INFLAMMATORY
● ADVISED SURGERY
ADMISSION
● WEIGHT CHANGES ● PRESCRIBED LAXATIVES AND
ADVISED DIET MODIFICATIONS ● GIVEN UNRECALLED
ANTIBIOTICS

1 1month
year 2 months interim
 PAST MEDICAL
HISTORY
HTN on Losartan 50mg OD
s/p PCS w/ BTL (1996).
s/p D&C x 2 (1995)

FAMILY HISTORY
PERSONAL/SOCIAL (+) Hypertension, diabetes mellitus, heart disease,
stroke.
HISTORY (-) thyroid disease, malignancies, asthma

24 pack year smoker, quit 10 yrs ago

Occasional alcoholic beverage drinker.

 MENSTRUAL
HISTORY
9 y/o | regular | 3-7 days | 3ppd, mod to fully
soaked |
(-) dysmenorrhea
Last menstrual period: 2016
OBSTETRIC
GYNECOLOGIC G5P3 (4024)
HISTORY
HISTORY G1 1986 FT NSD

G2 1991 FT NSD
Coitarche: 19 years old
G3 1995 SAB @ 12wks D&C

6 sexual partners G4 1995 SAB @ 12wks D&C

G5 1996 FT (twin pregnancy) CS d/t malpresentation

No dyspareunia, post-coital bleeding, STDs, (breech/vertex)

vaginal discharge

(-) OCP use

• Gastrointestinal: No diarrhea, nausea, vomiting.
• General: Denies fever, weight changes or malaise. Reports easy fatigability
• Genitourinary:  No dysuria, hematuria. vaginal bleeding or spotting, vaginal discharge,
• Skin, Hair, and Nails: No rashes or discoloration. No other skin changes
or genital lesions.
• HEENT: Head: No headaches. Eyes: No blurring of vision, pain, or redness. Ears: No
• Peripheral/Vascular: No claudication or edema.
hearing loss or aural discharge. Nose: No nasal discharge. Mouth/Throat: No mouth
• Musculoskeletal: No muscle or joint pains.
sores.
• Psychiatric: No history of depression or any psychiatric condition.
• Neck: No palpable lymph nodes.
• Neurologic: No report of dizziness or seizures.
•• Endocrine:
Respiratory:
NoNo cough
cold or dyspnea
or heat or difficulty in breathing
intolerance.
•• Hematologic: No No
Cardiovascular: reports
chestofpain
easyorbruising or gum bleeding.
palpitations.

• Breast and Axillae: No mass, discoloration, or discharge.

Review of Systems
 • Breasts and Axillae. Symmetric with no gross lesions. No palpable mass. No enlarged
lymph nodes.
• • General:
Abdomen.Conscious, coherent,normoactive
Flabby, distended, not in cardiorespiratory
bowel sounds,distress
(+) direct tenderness on
• Anthropometrics Height
hypogastric area, right> 147(+)
left, cmfluid
Weight 56Nokgmasses,
wave. BMI 25.9
spider angioma, no caput
medusa.
• Vital Signs. BP 120/80 mmHg. HR 83 bpm. RR 17 cpm. T (axillary) 36.9 ˚C.
• Internal/Bi-manual exam:   Vagina admits 2 fingers with ease. Cervix long, firm,
smooth.
• Skin. No No cervical
active motion tenderness. Uterus small, mobile, non tender. (+) 4 x 3 cm
dermatoses.
smooth, cystic left adnexal mass with no tenderness. (+) 6 x 6 cm right adnexal mass
• HEENT.
with tenderness at the posteriorEyes:
Head: Normocephalic. cul-de-sac.
Pink palpebral conjunctivae, anicteric sclera. Ears:
• No external abnormalities.
Rectovaginal examination:Nose: No bleeding
Smooth, or lesions.
nontender, Septum
cystic mass midline.
at the Mouth: Moist
superior
rectovaginal
lips area base
and oral mucosa. of which
Neck: measures
Thyroid 7cm
not enlarged; no cervical lymphadenopathies.
• Speculum Exam: Cervix pink, smooth, no lesions, no discharge.
• Thorax and Lungs. Symmetrical lung expansion. Clear breath sounds.
• Extremities. No edema; full and equal pulses.
• Cardiovascular. Adynamic precordium. Cardiac tones with normal rate and regular
• Neurologic. Coherent and oriented to person, place and time. No motor or sensory
rhythm.
deficits.No murmurs.
Normoreflexive.

Physical Examination
Approach
to Pelvic
Pain
Approach to
Pelvic Pain
10/19/17
Approach
to Pelvic
Pain
Approach to Pelvic Pain

11/17/17
12/11/17
 Other work up
12/14/17
CBC 12.8/38.8/4.35/ 12370 (N73 L19 E2 M5 B1 / 339K
UA yellow/ clear/ 6.0/ 1.025/ Alb Tr/ WBC 1/ RBC 2/
GBKNL (-)
CEA 7.5 HE4 33.4
FBS 107 Crea 0.69 BUN 13
Na 140 K 3.3
PT 11.1 PTT 32.1 INR 0.97
 ● TUBO-OVARIAN ABSCESS/COMPLEX
Usually a complication of pelvic inflammatory disease
RISK FACTORS

● Age 15-25 years old

● Multiple sexual partners
● STI in partner
● Previous PID
● Intrauterine devices
● Uncontrolled inflammatory
disease of the bowels,
appendicitis

Granberg S, Gjelland K, Ekerhovd E. The management of pelvic abscess. Best Pract Res Clin Obstet Gynaecol. 2009;23(5):667. Epub 2009 Feb 20.
 PATHOGENESIS
Pathogen Bacterial proliferation
Inflammation Pyosalpinx and adhesions
ascends to the
and edema
fallopian tubes
Endogenous flora Consequent tubal Necrotic tissues produce purulent Anaerobic environment promotes
blockage due to exudate. Tubal structures adhere growth of numerous anaeobic
Sexually transmitted clubbing, ischemia, and coalesce with adjacent bacteria
pathogen and necrosis tissues to form a complex mass.
 MICROBIOLOGY

POLYMICROBIAL

● Similar to pathogens found in patients with uncomplicated PID

● Common organisms include Escherichia coli, aerobic streptococci, Bacteroides
fragilis, Prevotella, and other anaerobes, such as Peptostreptococcus
● N. gonorrhoeae and C. trachomatis are rarely isolated from the abscess cavity of
a TOA.

Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983;5(5):876.
 PRESENTATION
Typical presentation of..

a sizable percentage of women with TOAs do not report specific antecedent

acute symptoms directly attributable to PID

40% of patients were afebrile, 25% complained of chronic pain, 23% had
normal white blood cell counts

Ruptured TOA: signs of sepsis + acute abdomen

Wiesenfeld HC, Sweet RL. Progress in the management of tuboovarian abscesses. Clin Obstet Gynecol. 1993;36(2):433
Landers DV, Sweet RL. Tubo-ovarian abscess: contemporary approach to management. Rev Infect Dis. 1983;5(5):876.
 DIAGNOSIS
A clinical diagnosis of tubo-ovarian abscess (TOA) is most often made based upon the
finding of an inflammatory adnexal mass on pelvic imaging in a woman who meets
diagnostic criteria for pelvic inflammatory disease (PID)

Beigi R, Sharp H, Sexton D. Epidemiology, clinical manifestations, and diagnosis of tubo-ovarian abscess. Retrieved from: https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-diagnosis-of-tubo-
ovarian-abscess?sectionName=CLINICAL%20PRESENTATION&anchor=H2672637&source=see_link#H2457481
 ESTABLISHING THE DIAGNOSIS
Minimum criteria Additional criteria to enhance the specificity
● Cervical motion tenderness OR
● Fever (>38.3C)
● Uterine tenderness OR ● Mucopurulent vaginal discharge
● Adnexal tenderness ● Abundant WBC on saline microscopy of vaginal
secretions
● Elevated ESR
● Elevated CRP
Specific criteria ● Laboratory documentation of cervical infection of N.
● Histopathologic criteria of endometritis on gonorrhea and C. trachomatis
endometrial biopsy
● TVS or MRI: thickened fluid-filled tubes with or
without free pelvic fluid or tubo-ovarian complex, or
Doppler studies suggestive of infection (hyperemia)
● Laparoscopic abnormality - most definitive diagnosis
of PID

CDC Guidelines for STD, 2006

 ANTIBIOTIC THERAPY ALONE
● hemodynamically stable with no signs of a
MANAGEMENT ruptured TOA
1. Intensive antibiotic therapy ● Abscess < 9 cm diameter
2. Minimally-invasive drainage procedures ● Adequate response to antibiotic therapy
3. Invasive surgery ● Premenopausal
4. Combination

Women with tubo-ovarian abscess should have at IMMEDIATE SURGERY

● Rupture of TOA
least 24h of inpatient observation.
● Overt signs of sepsis and/or a large abscess

What is the role of TAHBSO?

Unilateral adnexectomy for
unilateral TOAs
Very acutely ill, completed child bearing or family size
Beigi
a RH. Management and complciations of Tubo-ovarian abscess. Retrieved from: https://www.uptodate.com/contents/management-and-complications-of-tubo-ovarian-abscess
Sweet RL. Soft tissue infection and pelvic abscess. In: Infectious diseases of the female genital tract, 5th ed, Sweet RL, Gibbs RS (Eds), Lippincott Williams and Wilkins, Philadelphia 2009.
Ginsburg DS, Stern JL, Hamod KA, Genadry R, Spence MR.Tubo-ovarian abscess: a retrospective review. Am J Obstet Gynecol. 1980;138(7 Pt 2):1055.
 ANTIBIOTIC THERAPY

FIRST LINE MANAGEMENT Ampicillin-Sulbactam

and
3 g IV every 6 hours

Cefoxitin and 2 g IV every 6 hours

Doxycyline 100 mg orally or IV every 12 hours
Doxycyxline 100 mg orally or IV every 12 hours

SECOND CHOICE
Cefotetan and 2 g IV every 12 hours
Levofloxacin and 500 mg IV once daily
Doxycyline 100 mg orally or IV every 12 hours
Metronidazole 500 mg IV every 8 hours

Imipenem-Cilastatin 500 mg IV every 6 hours

Clindamycin and 900 mg IV every 8 hours

Gentamicin 2 mg/kg loading dose then 1.5 mg/kg q 8 hours IV or IM

OUTPATIENT

Levofloxacin or 500 mg orally once daily

Ofloxacin and
Ampicillin and 2 g IV every 6 hours
Metronidazole 500 mg orally twice daily
Clindamycin and 900 mg IV every 8 hours
Amoxiclav XR 2000 mg XR orally 2x daily
Gentamicin 2 mg/kg loading dose then 1.5 mg/kg q 8 hours IV or IM
 TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-OOPHORECTOMY +
ENTEROLYSIS + APPENDECTOMY + COLORRHAPHY

MANAGEMENT
Intraoperative findings: upon entry into the abdomen, the uterus was small with smooth serosal surface. The rectosigmoid
colon was densely adherent to the posterior aspect of the uterus. The left ovary was thin walled, unilocular, and cystically
Internal
enlarged to 7 xexamination:
6 x 4 cm. The right ovaryvagina admits
and fallopian tube weretwo
denselyfingers
adherent towith ease, colon
the rectosigmoid smoothand the cul-
desac. Both of which were dilated exuding yellowish pus like exudate. On cut section of the uterus, it measured 6 x 5 x 3 cms
vaginal
Ciprofloxacin walls,
with thin endometrium.
400mg cervix
Thefor
IV q12 right long,
ovary
2 doses firm,
measured
then 7 x 6closed, uterus
x 5 cms, fallopian midline,
tube measured 5 x 4 xseems small,
3 cms The left ovary had a
smooth capsule, measuring 7 x76days.
x 5 cms.
slightly movable, there is a cystic mass at the posterior cul-de-sac
shifted to 500 mg PO for

base of which measures approximately 7 cms.

MANAGEMENT

Women should demonstrate clinical improvement (e.g., defervescence; reduction in direct or rebound
abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after
initiation of therapy

After 48 to 72 hours of treatment with antibiotics alone, patients with TOA who do not respond or worsen
require either minimally invasive abscess drainage or surgery (either open or laparoscopic)
MANAGEMENT

● For postmenopausal women with a presumed TOA, we suggest surgical diagnosis and/or treatment
rather than treatment solely with antibiotics or a minimally invasive drainage procedure (Grade 2C)
● Case series have reported that there is a high rate of malignancy among postmenopausal women with
TOA.
MANAGEMENT

After 7-10 days of completing therapy:

- Repeat endocervical and rectal cultures or NAAT

Sex partners within the preceding 4 weeks:

- Examination and urethral smear and culture and NAAT

- Empiric cefixime and doxycycline or azithromycin
51 yr old G5P3 (4024) Tubo-ovarian abscess,
Right; Simple ovarian cyst, Left;
Hypertension; s/p Primary Cesarean section
for malpresentation (twin
pregnancy, breech) with bilateral tubal
ligation (1996)
s/p TAHBSO, enterolysis, colorrhaphy,
appendectomy under general anesthesia
(12/19/17); Menopause x 1 year
FINAL DIAGNOSIS