Case 5

1. Case 5 Shannon Armbruster Jen Ha Dana Foradori Sobia Raja

2. Chief Complaint • 26 y.o. F came into the OB/Gyn with complaint of vaginal spotting and lower abdominal pain. • PMH – previous pregnancy w/o incident and pelvic infection 3 years prior to pregnancy • HCC- no significant vaginal discharge (other than spotting). • No trauma • No recent intercourse

3. Physical Exam • Vital signs: • BP – 90/60 • Pulse – 110 • Rhythm – Regular • Temeprature - 98.6°F • Respiratory rate – 17 • Height – 5’3’’ • Weight – 125 lbs.

4. HEENT Exam • Lungs/CV/Abdominal /Musculoskeletal/Neurologic exam were normal except for: • Moderate tenderness in the right lower quadrant of the abdomen. • Transvaginal sonogram showed an empty uterus with free fluid in the “cul-de-sac”

5. Cecum Appendix Right ovary Right Fallopian Tube Right ureter

6. RIGHT LOWER QUADRANT (RLQ) CecumAppendix Right ovary and tubeRight ureterLEFT LOWER QUADRANT (LLQ) Part of descending colonSigmoid colon Left ovary and tube Left ureterLeft spermatic cord MIDLINE Aorta Uterus (if enlarged) Bladder (if distended) RIGHT UPPER QUADRANT (RUQ ) Liver Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon LEFT UPPER QUADRANT (LUQ) Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon University of Pittsburgh

7. Appendicitis • Symptoms: acute abdominal pain moving to lower right abdomen, nausea, vomiting, diarrhea, low-grade fever

8. Ectopic Pregnancy • Consider due to unidentified pelvic disease • Rule out due to no reported recent intercourse and no unusual pregnancy shown by ultrasound

9. Pelvic Exam • External examination of vulva • Internal examination/palpation of vagina and cervix • Pap smear • Transvaginal palpation of uterus and ovary • Retrovaginal exam: insertion of index finger into vagina and another finger into rectum, assess for uterus and ovaries On pelvic exam, external genitalia was normal and uterus was palpable and normal.

10. Transvaginal Sonogram • Type of pelvic ultrasound in which probe is inserted into vagina • Used to identify source of pelvic pain, infertility, abnormal bleeding • Creates images of vagina, cervix, uterus, fallopian tubes, and ovaries A transvaginal sonogram showed an empty uterus with free fluid in the “cul-de’sac”.

11. Pelvic Inflammatory Disease • Infection of uterus or fallopian tubes due to bacteria entering through vagina -Gonorrhea and Chlamydia greatly increase risk -Increases risk of ectopic pregnancy and infertility • Symptoms: pelvic pain, irregular vaginal bleeding, fever, abnormal discharge -Diagnosis: painful palpation, enlargement of structures on ultrasound

12. Ovarian Cancer • Symptoms: pressure or pain in the abdomen, pelvis, back, or legs, a swollen or bloated abdomen, nausea, indigestion, diarrhea, feeling very tired all the time • Symptoms usually do not present until cancer has advanced • Appears in ultrasound, biopsy may confirm diagnosis • Antigen 125 (CA-125) in blood

13. Endometriosis • Retrograde menstruation: shedding endometrium flows backward through fallopian tubes and into peritoneal cavity • May implant on any mucous membrane in cavity, most likely in the rectouterine pouch • Deposited tissue responds to estrogen, progesterone, LH, and FSH in the same way as the endometrium

14. Symptoms include pelvic pain, dysmenorrhea, infertility, painful intercourse, abnormal menstrual bleeding, chronic fatigue, cyclical bowel or bladder symptoms Most common tenderness is upon palpation of posterior fornix Endometriosis

15. Very common but may cause pelvic pain if they exceed 2 centimeters in diameter (may be detected by ultrasound) Several types of cysts, type can only be determined by histological techniques Follicular cysts are most common. They are caused by a follicle that did not rupture during ovulation. These generally degenerate in a few days or months. Granulosa luteal cysts form from the corpus luteum and therefore do not hold an egg. They are normal in the ovary but may rupture and cause peritoneal irritation Laparoscopy is most effective diagnostic procedure Ovarian Cysts

16. Ovarian Cysts • Symptoms: onset of unilateral lower abdominal pain, light vaginal bleeding (spotting), possible pressure on rectum or bladder, possible nausea and vomiting • Vaginal bleeding may be caused by elevated estrogen produced by persistent theca cells. This causes endometrial abnormalities.

17. Culdocentesis • Sampling of ascites in cul-de-sac • Use aspiration • Needle pierces the posterior fornix of the vagina • Ultrasound generally preferred over culdocentesis due to risks: -bowl perforation -trauma to pelvic cavity -infection from vagina transmitted to peritoneal cavity

18. Cul-de Sac • Also called Rectouterine Pouch and Pouch of Douglas • Lowest point of peritoneal cavity when standing • Excess fluid (ascites) accumulates here, indicative of abnormality within peritoneal cavity

19. Laparoscopy • Small scope inserted through a 2-centimeter incision below umbilicus, inert gas pumped into pneumoperitoneum, and pelvis is elevated so that intestines slide toward head, insert laparoscope • May be used to view and take pictures of fluid accumulation, scar tissue, adhesions

20. Nerve Supply • Ascites causes pressure on and irritation to the parietal peritoneum • Peritoneum around Cul-de-Sac is innervated by visceral afferent nerves of the uterovaginal plexus, a division of the inferior hypogastric plexus • Ovarian Plexus is sympathetic innervation to the ovary and fundus of the uterus. It comes from the renal plexus.

21. Ascites • Depending on the results of the laparoscopy, the type of fluid can be determined • Fluid from a ruptured cyst would be serous or mucous • Fluid caused by hemorrhage from surrounding vessels would be bloody

22. Arterial/Venous/Lymphatics to Uterus • Uterus: • Arterial: common illiacinternal iliacanterior internal iliacuterine arteries (and some collateral supply from ovarian arteries) • Venous: uterine venous plexusuterine vein internal iliac common iliac vein • Lymphatics: 3 main routes • Fundus and superior uterine body lumbar lymph nodes lumbar lymph trunkschyle cisternthoracic duct • Fundus near uterine tube entrance  superficial inguinal lymph nodes • Uterine body  external iliac lymph nodes • Uterine cervix  Internal iliac lymph nodes/sacral lymph nodes

26. Arterial/Venous/Lymphatics to Uterus Uterus: Arterial: common illiacinternal iliacanterior internal iliacuterine arteries (and some collateral supply from ovarian arteries) Venous: uterine venous plexusuterine vein internal iliac common iliac vein Lymphatics: 3 main routes Fundus and superior uterine body lumbar lymph nodes lumbar lymph trunkschyle cisternthoracic duct Fundus near uterine tube entrance  superficial inguinal lymph nodes Uterine body  external iliac lymph nodes Uterine cervix  Internal iliac lymph nodes/sacral lymph nodes

27. Uterine Body

29. Fallopian tube • Arterial: uterine and ovarian arteries  anastomosing terminal branches  tubal branches • Venous: tubal veins uterine venous plexus/ovarian veins • Lymphatics: lumbar lymph nodes

30. Ovary • Arterial: ovarian artery enter suspensory ligament  branches through mesovarium to ovary • Veinous: ovarian veins  pampniform plexus of veins  ovarian vein • Right ovarian vein IVC • Left ovarian vein  left renal vein IVC • Lymphatics: follow ovarian blood supply (of uterine tubes & fundus of uterus)  lumbar lymph nodes