GYNAECOLOGICAL CAUSES OF ACUTE ABDOMINAL PAIN

Obstetric and Gynaecological Emergencies 379

(b) follow patients with a positive pregnancy test, an empty

uterus but no ultrasound signs of an ectopic with serial

-hCG examinations every 48 h.

(ii) Ultimately, a laparoscopy or laparotomy confirms the condition

and allows definitive management, although the occasional case

can be managed medically with i.m. methotrexate.

(iii) Therefore refer all cases to the gynaecology team.

3 Give all rhesus-negative mothers anti-D immunoglobulin 250 units i.m. to
prevent maternal formation of antibodies from isoimmunization.

Pelvic inflammatory disease (acute salpingitis)

DIAGNOSIS

1 Pelvic inf lammatory disease (PID) includes any combination of endometri-
tis, salpingitis, tubo-ovarian abscess or pelvic peritonitis. It is usually a
sexually transmitted disease caused principally by chlamydial or gonococcal
infection.
(i) It may also follow instrumentation of the cervix, or recent
insertion of an IUCD (10% of cases).
(ii) Recurrent infections are increasingly likely to cause infertility,
and an increased risk of ectopic pregnancy.

2 It presents acutely with fever (30%), malaise, bilateral lower abdominal pain,
dyspareunia, menstrual irregularities and mucopurulent vaginal discharge.

3 On examination there is an elevated temperature with bilateral lower
abdominal tenderness and guarding.
(i) Vaginal examination reveals a cervical discharge, adnexal
tenderness and cervical motion tenderness (excitation pain on
moving the cervix).

4 Send an endocervical and urethral swab for gonococcal culture, and an
endocervical swab for Chlamydia antigen, nucleic acid amplification by
polymerase chain reaction (PCR) or culture.

5 Send blood for FBC and blood culture if there is a high fever. Perform a
pregnancy test t hat should be negative.

6 Send an MSU for microscopy, culture plus gonococcal and chlamydial PCR.

7 Request an ultrasound to help identify a tubo-ovarian abscess, and to
exclude other causes of lower pelvic pain.

Warning: PID is a notoriously difficult diagnosis to make, being easily

missed or conversely diagnosed when not present. Laparoscopy is the gold

standard but is reserved for complicated cases and when the diagnosis is

unclear.

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