PELVIC PAIN ASSOCIATED WITH HEMOPERITONEUM

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PELVIC PAIN ASSOCIATED WITH HEMOPERITONEUM

• Dr. Julio Guillermo Voget
• Sanatorio Pasteur- Catamarca

Simposio FASGO, Córdoba 11/9/2006   
FICO Sala 3 9.00 a 10.30 hs.        
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DEFINITION

• It is the pain provoked by the presence of blood
  in abdominal cavity in sufficient quantity to
  cause pain, hypotensión and abdominal symptoms of
  peritoneal irritation .

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CLASIFICATION

• Genital Causes
• Gynecological Obstetrics
• No Genitals Causes
• Portal hypertensión
• Rupture of diverticulos
• Others

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HEMOPERITONEUM More Prevalent Gynecological
Causes

• Tubal rupture for ectopic pregnancy
• Folicular rupture o corpus luteum rupture
• Rupture of ovarian endometrioma
• Post surgery bleeding
• Uterine rupture for provoked abortion
• Retrograde menstruation

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ALGORITHM

• When a peritoneal hemorrhage happens it is
  accompanies of pain, defense of the abdominal
  wall and hipotensión or shock.
• The suspicion diagnostic forces to urgent
  analyses of laboratory, transvaginal ultrasound
  scan and abdominal, diagnostic or therapeutic
  Laparoscopia ó Laparotomía if the previous one
  does not solve

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DIAGNOSIS

• MEDICAL ANAMNESIS
• PHYSICAL EXAMINATION
• COMPLETE HEMOGRAM-HEMATOCRIT- Beta HCG ,
  TRANSVAGINAL ULTRASOUND EXPLORATION OR ABDOMINAL
  ( if trasvaginal is negative)
• DOUGLAS POUCH PUNCTURE.
• LAPAROSCOPY 

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COMPLICATED ECTOPIC PREGNANCY
G.An.
US SCAN DRA. MARIEL BENÍTEZ
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COMPLICATED ECTOPIC PREGNANCY
G. Cris.
EMBRION WITHOUT HEART BITS
US SCAN DRA. MARIEL BENÍTEZ
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COMPLICATED ECTOPIC PREGNANCY
G. Cris.
G.CRIST.
EMBRION SIN LATIDOS
ABSENT HEART RATE
ECOGRAFÍA DRA. MARIEL BENÍTEZ
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COMPLICATED ECTOPIC PREGNANCY
G.Crist.
UTERUS
UTERUS
ORGANIZED BLOOD
RECENT BLOOD
US SCAN DRA. MARIEL BENÍTEZ
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COMPLICATED ECTOPIC PREGNANCY
G.C.
HEMOPERITONEUM
Bowel
US SCAN DRA. MARIEL BENÍTEZ
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REIMPLANTED ECTOPIC PREGNANCY
ÚTERO
O V A R Y
ÚTERUS
EE. ROTO
ECTÓPIC
Picture from Atlas of Endometriosis Dan C. Martin
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FOLICULAR RUPTURE
CH.V.
Hemoperitoneum
Úterus
Trilaminar endometrium
US Scan Dra. Mariel Benítez
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ENDOMETRIOTIC CYST

• Placed generally behind the uterus.
• The edges between cyst and uterus are not clear
  and the adhesion is vague to vicinity.
• Monolobar, hipoecogénico and homogeneous.
• Without capsule, because it is actually a cyst of
  retention. (The tumor has capsule)
• Carbognin G, Girardi V, Pinali L, Raffaelli R,
  Bergamini V, Pozzi Mucelli Assessment of pelvic
  endometriosis correlation of US and MRI with
  laparoscopic findings.Radiol Med (Torino). 2006
  Aug111(5)687-701.

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ENDOMETRIOMA
Dan C.Martin ATLAS OF ENDOMETRIOSIS,pag. 12.3
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HEMOPERITONEUM UNCOMMON CAUSES I

• Meckel's Hemoperitoneum A Rare Case of Meckel's
  Diverticulitis Causing Intraperitoneal
  Hemorrhage.Burt BM, Tavakkolizadeh A, Ferzoco
  SJ. Dig Dis Sci. 2006 Sep51(9)1546-1548.
  Epub 2006 Aug 22.
• Intraabdominal bleeding attributed to ruptured
  periumbilical varices. A case report and a review
  of the literature. Sato H, Kamibayashi S,
  Tatsumura T, Yamamoto K. 1 Jpn J Surg. 1987
  Jan17(1)33-
• Silent, massive haemoperitoneum during labour
  secondary to a spontaneous rupture of a
  utero-ovarian vessel. Garg M, Hudeyin S, Aquilina
  J. The Royal London Hospital, London, UK. J
  Obstet Gynaecol. 2003 Mar23(2)208-9

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HEMOPERITONEUM UNCOMMON CAUSES II

• Spontaneous intra-abdominal bleeding during
  pregnancy.Choobun T, Pinjaroen S, Getpook C.
• Department of Obstetrics and Gynecology, Faculty
  of Medicine, Prince of Songkla University, Hat
  Yai, Thailand. cthanapa_at_yahoo.com
• They communicate 2 cases of hemoperitoneum
  spontaneously caused by break of vessels of the
  uterine plexus during the second and third
  quarter of the pregnancy. PubMed - indexed for
  MEDLINE

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HEMOPERITONEUM UNCOMMON CAUSES III

• Uterine rupture during second-trimester abortion
  associated with misoprostol.Berghahn L,
  Christensen D, Droste S. Obstet Gynecol. 2001
  Nov98(5 Pt 2)976-
• First-trimester uterine rupture from a placenta
  percreta. A case report.
• Liang HS, et al. Department of Obstetrics and
  Gynecology, Cathay General Hospital, Taipei
  Medical University Hospital, Mackay Memorial
  Hospital, Taipei, Taiwan, R.O.C.

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OBSTETRIC HEMOPERITONEUM UTERINE RUPTURE

• Abdominal pain and hemoperitoneum in the gravid
  patient a case report of placenta percreta.
• Smith L, Mueller P. Am J Emerg Med. 1996
  Jan14(1)45-7.
• Spontaneous rupture of a primigravid uterus
  secondary to placenta percreta. A case report.
• Imseis HM, et al J Reprod Med. 1998
  Mar43(3)233-6.

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PLACENTA PERCRETARISK FACTORS

• In multíparas with precedents of Caesarean,
  myomectomy, cornual resection, scraped uterus,
  manual extraction of placenta, endometritis.
• In primiparas no precedent and only abdominal
  sudden pain hypotensión maternal tachycardia
  foetal bradycardia Suspect hemoperitoneum
  for percreta!
• Imseis HM, et al J Reprod Med. 1998
  Mar43(3)233-6.

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ALGORITMO
ALGORITHM IMAGINATION
ACUTE ABDOMEN
L A B O R A T
U S S C A N
P A I N
H Y P O T E N
L A P A R O S
D E F E N S E
C O A G U L A T
S U R G E R Y
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TREATMENT

• PACKED RED CELLS OR FLOW REPOSITION
• CONTROL OF THE HEMORRHAGE
• CONSERVATION OF THE FALLOPIAN TUBE IN ECTOPIC
  PREGNANCY
• ENDOMETRIOSIS's COAGULATION
• UTERINE SUTURE IN PERFORATION OR MYOMA
• SUBTOTAL HYSTERECTOMY OR
• WHOLE EMBOLIZATION BLEEDING VESSELS

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THANK YOU VERY MUCH

• DR. JULIO GUILLERMO VOGET
• OBGYN STAFF
• SANATORIO PASTEUR
• CATAMARCA- ARGENTINA