Tubo-ovarian abscess: contemporary approach to management

Two hundred and thirty-two patients with tubo-ovarian abscesses (TOAs) were evaluated. Ruptured TOAs were documented in seven (3%) of the patients. One hundred and seventy-five patients with TOAs were treated with antibiotics alone; for 15 of these patients, TOAs were confirmed by laparoscopy. The remaining 57 patients required surgical intervention: drainage (five patients), unilateral salpingo-oophorectomy (19) and total abdominal hysterectomy and bilateral salpingo-oophorectomy (33). A unilateral TOA was present in 163 patients (70%). Seventy-six patients with TOAs used intrauterine contraceptive devices, and in this group, 54 (71%) patients had unilateral TOAs. The most common microorganisms that were recovered from these TOAs were Escherichia coli, Bacteroides fragilis, Bacteroides species, Peptostreptococcus, Peptococcus, and aerobic streptococci. Sixty-eight percent of the patients treated with an antimicrobial regimen that included clindamycin had a decrease in the size of the TOA, while only 36.5% of those receiving antimicrobial regimens without clindamycin had a decrease in the size of the TOA (P less than .01). Long-term follow-up information (two to 10 years) was available for 58 of the patients treated with antibiotics alone. Eighteen (31%) required subsequent surgery; 12 had persistent TOAs; and six, chronic salpingo-oophoritis. Intrauterine pregnancy was documented in eight (13.8%) patients. Of the 19 patients treated with unilateral adnexectomy, two ultimately required hysterectomy and contralateral adnexectomy, while three patients in this group subsequently became pregnant (one ectopic and two intrauterine).

Ovarian hemorrhage in women with Von Willebrand's disease. A report of two cases

Two sisters of reproductive age with Von Willebrand's disease experienced ovarian hemorrhage. The possibility of such a hemorrhage should be considered in such patients even though it is rare.

Follow-up of patients with tubo-ovarian abscess(es) in association with salpingitis

The medical records of 143 patients hospitalized with a diagnosis of salpingitis over a five-year period were reviewed. Ninety-three patients had salpingitis without clinical evidence of a tubo-ovarian abscess. Seven (7.5%) of these women had surgical treatment; five of the seven were found to have tubo-ovarian abscesses which had not been detected clinically. Eighty-six of 93 (92.5%) patients with a clinical diagnosis of salpingitis and no abscess responded to medical management alone. Fifty patients had salpingitis and clinical evidence of a tubo-ovarian abscess(es); five of these patients had medical management only, 27 had medical treatment followed by surgery, and 18 had surgery initially before receiving antibiotics. There was a significant difference in age but not in parity between patients with evidence of a tubo-ovarian abscess that was managed medically and those who had surgery. There was no significant difference in surgical procedure performed, chronic symptoms, subsequent gynecologic surgery, or subsequent pregnancy among the groups with an abscess. There was a trend toward more surgical complications among women who had delayed surgical intervention for an abscess. Among women with a unilateral tubo-ovarian abscess, those who had a unilateral salpingo-oophorectomy had a higher pregnancy rate than those who received antibiotics alone. In this study, women with a tubo-ovarian abscess in association with salpingitis did not respond well to antibiotic treatment alone. This may be the most reliable way of distinguishing these patients from women with salpingitis alone or salpingitis in association with a tubo-ovarian inflammatory complex, who, as a group, did respond well to medical management alone.

Ovarian remnant syndrome

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Clinical staging of acute bacterial salpingitis and its therapeutic ramifications

The use of single-drug therapy results in an overall 13% to 17% failure rate, and even this figure is misleading, because of the high prevalence of patients with uncomplicated disease. In patients with polymicrobial peritonitis, the failure rate varies between 30% and 60%, depending upon whether Neisseria gonorrhoeae can be concomitantly isolated from the cul-de-sac and the criteria used to define therapeutic cure. THe complexity of disease as we now understand it requires a corresponding degree of therapeutic individualization. In the Gainesville staging, acute salpingitis is subdivided into five stages. Stage I is acute endometritis-salpingitis without peritonitis. Stage II is salpingitis with peritonitis. Stage III is acute salpingitis with superimposed tubal occlusion or tuboovarian complex. Stage IV is where a tuboovarian abscess has ruptured. Stage V is a repository category for different etiologic agents which may emulate acute salpingitis, i.e., Mycobacterium tuberculosis. Each stage of disease differs by virtue of its therapeutic goal and the means by which this goal is achieved.

Abdominal actinomycosis

Four cases of abdominal actinomycosis managed during a two year period at Ndola Central Hospital are reported with a review of relevant literature. Difficulties associated in diagnosing this form of the disease are stressed. It is suggested that a limited form of surgery in combination with parenteral penicillin therapy is usually effective in the management of abdominal actinomycosis.

Laparoscopy in the diagnosis and treatment of pelvic inflammatory disease with abscess formation

Laparoscopy has developed significantly as both a diagnostic and therapeutic procedure. A series consisting of 20 patients is presented to describe its use in diagnosis and therapy of pelvic inflammatory disease with tubo-ovarian abscess formation. The results obtained are presented and the various methods available for treatment discussed.

Treatment of ovarian hyperstimulation syndrome: the physiologic basis for a modified approach

A case of severe ovarian hyperstimulation syndrome (OHSS) secondary to human menopausal gonadotropin-human chorionic gonadotropin therapy is presented. Draining 4000 ml of exudate by abdominal paracentesis under real-time B-scan imaging induced a marked improvement in the patient's condition. Fluids from the third space were rapidly excreted, renal function improved, and the patient's weight decreased substantially. The underlying physiologic factors responsible for these changes are discussed. Other modes of treatment, including salt and water restriction and the use of volume expanders and diuretics, had no significant effect on the course of the syndrome. Paracentesis has a definite therapeutic value and is recommended in cases of OHSS with tense ascites.

Tubo-ovarian abscess: a retrospective review

The charts of 160 patients with tubo-ovarian abscesses (TOAs) were reviewed. Patients were divided into two groups according to their response to initial medical therapy. Predictive factors were identified for the two groups. Prognosis was predictable on the basis of extent of disease at diagnosis and the initial response to medical therapy. There was no apparent association between a unilateral TOA and the use of an intrauterine contraceptive device. A minimum pregnancy rate of 8% was observed in patients maintaining reproductive function. No patient with a bilateral TOA conceived. Of all patients admitted to the hospital with TOA, 53% ultimately required surgical therapy. High residual morbidity and/or resultant infertility mandates more aggressive attempts at prevention.

A study of tubo-ovarian abscess at Howard University Hospital (1965 through 1975)

Unruptured tubo-ovarian abscess was diagnosed in 40 patients over ten years. This was three percent of 1,154 patients admitted to Howard University Hospital for pelvic inflammatory disease. The admitting diagnosis was 33 percent correct.The treatment was individualized with 23 percent receiving total abdominal hysterectomy with bilateral salpingo-oophorectomy. Twelve young women received unilateral salpingo-oophorectomy.We feel that early detection and aggressive medical treatment for pelvic inflammatory disease will decrease the incidence of tubo-ovarian abscess and the necessity for surgery.

Ovarian hemorrhage in patients receiving anticoagulant therapy

During a 10-year period, five laparotomies were performed on three patients for hemorrhage from nonneoplastic ovarian lesions that occurred while the patients were on anticoagulant therapy. The patients were stabilized with blood transfusions, given medication to reverse the anticoagulants and underwent immediate surgery. Nineteen similar patients have been reported on previously. During the brief follow-up a 31% incidence of recurrent hemorrhage was observed in those patients continued on anticoagulants postoperatively. All physicians caring for women on anticoagulants should be on the alert for this life-threatening complication.

Pregnancy complicated by pelvic abscess

Tuboovarian abscess in pregnancy is a rare occurrence. The case presented and discussed is one in which a tuboovarian abscess was diagnosed and managed conservatively, with subsequent delivery of a viable infant.

Management of hyperstimulation syndrome

A case of hyperstimulation syndrome secondary to Pergonal therapy is presented. Successful management was based principally on severe sodium and fluid restriction without the use of volume expanders. The rationale for this therapeutic approach is presented and discussed. Although this iatrogenic disease should be virtually eliminated with the monitoring of daily urinary estrogens, severe hyperstimulation may still occur as a result of laboratory error.

Acyclicity and dyscyclicity in mares

Two trotter stud farms were visited on Mondays, Wednesdays, and Fridays during 1972 and 1973. A total of 356 mares were bored on these farms during these breeding seasons. There were 194 nursing, 113 barren, and 49 maiden mares. Of the 356 mares, 78 (21.9%) had functional disorders of the ovaries at one time or another. The functional disorders consisted of: 27 anoestrous mares after early embryonic death, 20 with low ovarian activity, 19 with multifollicular ovaries, and 12 mares with persistent corpora lutea. The following therapies were used: (a) 1000 I.U. PMSG i.v. + 10 mg stilboestrol i.m. Of 13 treated mares, 3 (23.1%) came into heat and all 3 became pregnant in the first oestrus following treatment. (b) Intra-uterine infusion of 0.5 - 1 liter physiological saline solution. Of the 26 treated mares, 19 (73.1%) came into oestrus and 14 (53.9%) became pregnant in the first oestrus following treatment. (c) Chlormadinone acetate, 10 mg. orally for 17 days. Of 38 treated mares, 35 (92.4%) came into oestrus and 22 (57.9%) became pregnant in the first oestrus following treatment. This therapy was also used in early spring (February-March) in 15 mares, of which 10 (66.7%) came into oestrus and 4 (26.7%) became pregant in the first oestrus following treatment. (d) Prostaglandin F2alpha, 25 mg intra-uterine. Of the 9 mares treated, al came into oestrus and 8 (88.9%) became pregnant in the first oestrus following treatment. (e) Curettage of the uterus. In this treatment group, none of the 5 treated mares showed improvement. Altogether, 54.7% of the treated mares became pregnant in the first oestrus after treatment, and 76.9% of the mares became pregnant after one of more breedings.

Ovarian hyperstimulation syndrome

Eighteen patients hospitalized for excessive ovarian hyperstimulation syndrome are reported. In 14 cases the ovarian hyperstimulation was induced by human menopausal -onadotropins and in 4 cases by combined treatment with clomiphene and HCG. In 5 patients the hyperstimulation was associated with conception, which resulted in 1 quintuplet delivery, 1 early quintuplet abortion, 1 twin abortion, 1 normal delivery, and 1 missed abortion. The regimen of treatment was a conservative one. The patients were hospitalized and treated with infusion of plasma expanders. Anticoagulant therapy was administered only in cases that showed clinical evidence of thromboembolic pheomena or laboratory evidence of severe hemoconcentration. The pathogenesis of the ovarian hyperstimulation syndrome, prevention, and management are discussed. This syndrome should be diagnosed early and treated intensively.

[Ovarian hyperstimulation syndrome. Notes on the physiopathology and treatment apropos of 3 cases]

Hyperstimulation appeared in one case on the 10th 11th day after ovulation, allowing by its presence the very precocious diagnosis of successful fecondation. The study of blood coagulation revealed that hypercoagulability was mainly related to hyperactivity of the thrombocytes and of the coagulation proteins. The pathogenesis of the syndrome is discussed. Increase in the permeability of the capillary vessels and hypovolemia seem to be responsible for the main accidents. Unfortunately as we have no real mean of decreasing the permeability of the capillary vessels, the treatment can be directed only against hypovolemia and its results. The infusion of macromolecular fluids, the restriction of sodium and water intake, together with the prescription of spironolactone have been successfully employed in those three cases.

[Percoelioscopy biopsy of the ovary. A propos of 121 cases]

One hundred and twenty-one records of percoelioscopy biopsy of the ovary performed in the Gynaecology and Obstetrics Department of the Hopital Beaujon, Clichy, have been studied by the author. Technical modalities and incidents of the method have been described, and the diagnostic as well as therapeutical implications of this interesting procedure have been stressed.