Surgery chapters
Pelvic conditions in surgery: PID and ectopic pregnancy
How a surgeon approaches lower abdominal and pelvic pain in a woman: ectopic pregnancy (risk factors, hCG and ultrasound, methotrexate or salpingectomy), pelvic inflammatory disease and tubo-ovarian abscess, Fitz-Hugh–Curtis syndrome, ovarian cyst accidents and how they differ from appendicitis.
- In any woman of reproductive age with abdominal pain, do a pregnancy test: a positive test with an empty uterus on transvaginal ultrasound is an ectopic pregnancy until proved otherwise. Shock in early pregnancy = ruptured ectopic → resuscitate and operate (salpingectomy).
- Stable ectopic: expectant, methotrexate (small mass, low hCG, no heartbeat) or laparoscopic salpingectomy.
- PID (Chlamydia commonest): bilateral lower pain, discharge, cervical excitation, fever; treat empirically with a cephalosporin plus doxycycline and metronidazole; complications include tubo-ovarian abscess, infertility, ectopic and Fitz-Hugh–Curtis perihepatitis.
On this page
Overview
Many young women sent to the surgical team with "right iliac fossa pain" have a gynaecological cause. The two that matter most are:
- Ectopic pregnancy: a leading cause of death in early pregnancy. A ruptured ectopic is a surgical emergency with internal bleeding.
- Pelvic inflammatory disease (PID): common, often mistaken for appendicitis, and a major cause of infertility and later ectopic pregnancy.
A surgeon must recognise them, start resuscitation and involve the gynaecology team early.
Every woman of reproductive age with abdominal pain needs a pregnancy test. A negative sensitive urine or serum test essentially excludes ectopic pregnancy.
Approach to acute pelvic pain in a woman
| Clue | Points towards |
|---|---|
| Missed period, positive pregnancy test, shoulder-tip pain, fainting | Ectopic pregnancy |
| Bilateral lower pain, vaginal discharge, dyspareunia, fever, recent new partner or IUCD insertion | PID |
| Sudden one-sided pain with vomiting, tender adnexal mass | Ovarian torsion (often a dermoid or other cyst) |
| Pain mid-cycle, mild, settles in hours | Mittelschmerz (ovulation) |
| Pain in the second half of the cycle with fluid in the pelvis | Ruptured or bleeding corpus luteum cyst |
| Central pain shifting to RIF, anorexia, vomiting, one-sided tenderness | Appendicitis |
| Dysuria, frequency, loin pain | UTI or pyelonephritis |
| Feature | Appendicitis | PID | Ectopic pregnancy |
|---|---|---|---|
| Onset | Central, then RIF | Lower abdomen, often both sides | One-sided, may be sudden |
| Anorexia, vomiting | Common | Less common | Variable |
| Discharge | No | Yes | Bleeding (often dark, scanty) |
| Fever | Low-grade | Often over 38°C | Usually none |
| Pregnancy test | Negative | Negative | Positive |
| Pelvic examination | Right-sided tenderness on PR | Cervical excitation, bilateral adnexal tenderness | Cervical excitation, adnexal tenderness or mass |
| Shock | Late (peritonitis) | Rare | Early if ruptured |
Cervical excitation (pain on moving the cervix) occurs in both PID and ectopic pregnancy; it does not separate them. The pregnancy test does.
Ectopic pregnancy
Definition and sites
An ectopic pregnancy implants outside the uterine cavity.
- Over 95% are tubal: ampulla commonest, then isthmus, fimbria, interstitial (cornual) part.
- Rare sites: ovary, cervix, abdominal cavity, caesarean section scar.
- Heterotopic pregnancy: one pregnancy inside and one outside the uterus at the same time; rare naturally, commoner after IVF.
- Incidence: roughly 1 in 80–90 pregnancies.
Interstitial and isthmic pregnancies rupture earlier and bleed more (thicker muscle, rich blood supply).
Risk factors
- Tubal damage: previous PID (Chlamydia, gonorrhoea), previous ectopic, tubal surgery (including sterilisation and reversal).
- Previous abdominal or pelvic surgery (appendicectomy, caesarean section), endometriosis.
- Subfertility and IVF.
- Smoking, older maternal age.
- Pregnancy with an IUCD in place, or after progestogen-only or emergency contraception failure.
An IUCD lowers the overall chance of any pregnancy, but if a woman conceives with one in place, the pregnancy is more likely to be ectopic.
Clinical features
- Typical picture: amenorrhoea of about 6–8 weeks, lower abdominal pain (often one-sided) and vaginal bleeding (usually scanty, dark).
- Shoulder-tip pain (blood irritating the diaphragm; phrenic nerve, C3–C5), dizziness or fainting, urge to defaecate (blood in the pouch of Douglas).
- Signs: adnexal tenderness or mass, cervical excitation, peritonism.
- Ruptured ectopic: sudden collapse, tachycardia, hypotension, distended tender abdomen, haemoperitoneum. Bluish periumbilical discoloration (Cullen sign) was first described in ruptured ectopic pregnancy.
- Many present subacutely with only mild pain and spotting, which is why ectopic is easily missed.
Investigations
- Pregnancy test (urine; serum β-hCG for quantification).
- Transvaginal ultrasound (TVUSS):
- An intrauterine gestation sac with a yolk sac effectively excludes ectopic (except rare heterotopic). - Empty uterus with an adnexal mass strongly suggests ectopic. - Fluid (blood) in the pouch of Douglas suggests bleeding or rupture.
- Serial serum β-hCG, 48 hours apart:
- Normal intrauterine pregnancy: rises by at least about 63% (roughly doubles). - Failing pregnancy (miscarriage): falls by half or more. - Static or suboptimal rise or fall: suggests ectopic. - Empty uterus on TVUSS with hCG above about 1500 IU/L ("discriminatory zone"): highly suggestive of ectopic.
- FBC, group and save / cross-match, rhesus status.
- Laparoscopy: diagnostic and therapeutic when doubt remains.
Pregnancy of unknown location (PUL): positive test, no pregnancy seen inside or outside the uterus. It is a working label, followed with serial hCG until the site is known.
Day 0 hCG = 1000 IU/L; 48 hours later = 1200 IU/L.
Rise = (1200 − 1000) ÷ 1000 × 100 = 20% → well below the expected rise of about 63% → suspicious of ectopic pregnancy (or failing pregnancy); scan and repeat.
If the second value had been 1450 IU/L: rise = 45%, still suboptimal.
Management
| Option | Who | Points |
|---|---|---|
| Expectant | Stable, minimal or no symptoms, low and falling hCG | Many tubal pregnancies resolve; serial hCG until undetectable |
| Medical: methotrexate (IM) | Stable, minimal pain, unruptured, adnexal mass under about 40 mm, no fetal heartbeat, hCG under about 3000 IU/L, can attend follow-up | Folic acid antagonist, kills trophoblast; dose 50 mg/m² body surface area; hCG checked on days 4 and 7 (should fall at least 15% between them), then weekly; avoid pregnancy for 3 months; avoid alcohol and sunlight |
| Surgical: laparoscopy | Pain, larger mass, high hCG, heartbeat, failed methotrexate, or patient choice | Salpingectomy if the other tube is healthy; salpingostomy if the other tube is damaged or absent |
| Laparotomy | Haemodynamically unstable (ruptured with shock) or no laparoscopic facility | Resuscitate, clamp and remove the bleeding tube |
- Salpingostomy keeps the tube but carries a risk of persistent trophoblast (follow hCG until negative) and of repeat ectopic in that tube.
- Methotrexate contraindications: liver, kidney or blood disorders, active infection, immunodeficiency, breastfeeding, ruptured ectopic, intrauterine pregnancy.
- Anti-D immunoglobulin for rhesus-negative women who have surgery for ectopic pregnancy.
Day 4 hCG = 2000 IU/L; day 7 hCG = 1600 IU/L.
Fall = (2000 − 1600) ÷ 2000 × 100 = 20% → more than 15% → adequate response; continue weekly hCG.
If day 7 were 1800 IU/L: fall = 10% → inadequate → second dose or surgery.
Shock + positive pregnancy test = ruptured ectopic. Do not wait for a scan: two large-bore cannulas, cross-match, call seniors, and take the patient straight to theatre.
"Positive test, empty womb, think tube."
Pelvic inflammatory disease
Definition and organisms
PID is infection ascending from the cervix to the uterus (endometritis), tubes (salpingitis), ovaries and pelvic peritoneum, sometimes forming a tubo-ovarian abscess.
- Chlamydia trachomatis is the commonest cause; Neisseria gonorrhoeae in some areas; Mycoplasma genitalium; anaerobes and vaginal organisms join in.
- Risk factors: age under 25, new or multiple partners, previous STI or PID, recent IUCD insertion, instrumentation (termination, hysteroscopy, HSG), postpartum or post-abortion infection.
- Secondary PID can follow pelvic spread from appendicitis or diverticulitis.
Clinical features
- Bilateral lower abdominal pain and tenderness.
- Deep dyspareunia.
- Abnormal vaginal or purulent cervical discharge.
- Intermenstrual or postcoital bleeding.
- Fever 38°C or more, raised white cells and CRP.
- Cervical motion tenderness (excitation) and adnexal tenderness on bimanual examination.
Many cases are mild or silent, yet still damage the tubes.
Investigations
- Pregnancy test (exclude ectopic).
- Endocervical / vulvovaginal swabs for NAAT (nucleic acid amplification) for Chlamydia and gonorrhoea; culture for gonococcal sensitivity. A negative swab does not exclude PID.
- FBC, CRP; urinalysis; HIV and syphilis screening.
- Transvaginal ultrasound: hydrosalpinx, pyosalpinx, tubo-ovarian abscess.
- Laparoscopy if the diagnosis is uncertain or the patient fails to improve (red, swollen tubes, pus).
Treatment
- Start empirical antibiotics as soon as swabs are taken; delay increases infertility.
- Typical outpatient regimen: ceftriaxone (single IM dose) plus doxycycline and metronidazole for 14 days (an alternative is ofloxacin with metronidazole).
- Admit if: severe illness, high fever, vomiting, tubo-ovarian abscess, pregnancy, diagnosis uncertain (surgical emergency not excluded), or no response to oral therapy. Give IV antibiotics.
- IUCD: consider removal in severe cases (after considering emergency contraception needs).
- Contact tracing and treatment of partners; abstain until all are treated.
- Tubo-ovarian abscess: IV antibiotics; drainage (ultrasound-guided or laparoscopic) if large or not improving; rupture causes generalised peritonitis and needs laparotomy.
Local resistance patterns (including gonococcal resistance) vary, and Pakistani STI guidance may differ from Western regimens; check the current national or hospital guideline.
Chlamydia is the commonest cause of PID and is often silent; tubal damage can occur without any remembered illness, which is why young women with risk factors are screened and partners are treated.
Complications
| Complication | Note |
|---|---|
| Tubal infertility | About 1 in 5 after PID; risk rises with each episode |
| Ectopic pregnancy | Several-fold higher risk from tubal scarring |
| Chronic pelvic pain | Adhesions, hydrosalpinx |
| Tubo-ovarian abscess | May rupture → peritonitis |
| Fitz-Hugh–Curtis syndrome | Perihepatitis: right upper quadrant pain worse on breathing; "violin-string" adhesions between liver capsule and abdominal wall; mimics cholecystitis |
| Reactive arthritis | With Chlamydia |
A young woman with right upper quadrant pain, a normal gallbladder on ultrasound and a history of pelvic infection probably has Fitz-Hugh–Curtis syndrome.
Other pelvic surgical problems
- Ovarian torsion: twisting of an enlarged ovary (cyst, dermoid) on its pedicle; sudden severe one-sided pain with vomiting; Doppler ultrasound helps but a normal flow does not exclude it. Urgent laparoscopy to untwist and remove the cyst; remove the ovary only if it is necrotic. Always document the other ovary before any oophorectomy.
- Ruptured or haemorrhagic ovarian cyst: mid or late cycle; usually conservative; surgery for heavy bleeding.
- Pelvic abscess (after appendicitis, PID, diverticulitis or pelvic surgery): swinging fever, diarrhoea with mucus, tenesmus, tender boggy mass on rectal or vaginal examination; drain radiologically, transrectally or through the posterior fornix.
- Endometriosis: cyclical pain, deep dyspareunia; can cause rectosigmoid strictures or bleeding with menses.
Expect: pregnancy test as the first step in women with lower abdominal pain; risk factors for ectopic (previous PID most important, IUCD, tubal surgery, IVF); ampulla as the commonest site; triad of amenorrhoea, pain and bleeding; shoulder-tip pain; TVUSS findings and the hCG 48-hour rise and discriminatory level; criteria and follow-up for methotrexate; salpingectomy versus salpingostomy; immediate surgery for shock; anti-D. For PID: Chlamydia as commonest cause, bilateral pain with cervical excitation and discharge, empirical antibiotics, tubo-ovarian abscess, infertility and ectopic risk, and Fitz-Hugh–Curtis perihepatitis.
Quick revision
- Woman of reproductive age with pain: pregnancy test first.
- Ectopic: tube (ampulla) commonest; previous PID biggest risk.
- Amenorrhoea + pain + bleeding; shoulder-tip pain = haemoperitoneum.
- TVUSS empty uterus + hCG above about 1500 IU/L = ectopic likely; normal hCG rises about two-thirds or more in 48 h.
- Methotrexate: stable, small, no heartbeat, low hCG; 50 mg/m²; no pregnancy for 3 months.
- Unstable: resuscitate and operate; salpingectomy if the other tube is normal.
- PID: Chlamydia; bilateral pain, discharge, cervical excitation, fever; treat at once for 14 days; treat partners.
- Fitz-Hugh–Curtis: RUQ pain, violin-string adhesions.
Written by The House Job from standard references (Bailey & Love; Ten Teachers Gynaecology).
FAQ
What is the most important first test in a young woman with lower abdominal pain?
A pregnancy test. If it is positive and the uterus is empty on transvaginal ultrasound, ectopic pregnancy must be assumed until proved otherwise.
When can an ectopic pregnancy be treated with methotrexate?
When the woman is stable with minimal pain, the pregnancy is unruptured and small with no heartbeat, the hCG is low (under about 3000 IU/L), and she can return for repeated hCG checks.
Why is salpingectomy usually preferred to salpingostomy?
When the other tube is healthy, removing the affected tube avoids persistent trophoblast and repeat ectopic in the same tube, with similar later pregnancy rates.
How is PID treated?
With empirical broad-spectrum antibiotics started as soon as swabs are taken, usually a cephalosporin with doxycycline and metronidazole for 14 days, plus treatment of sexual partners.
What is Fitz-Hugh–Curtis syndrome?
Inflammation of the liver capsule after PID, causing right upper quadrant pain and fine adhesions between the liver and the abdominal wall.