MANANGEMENT OF TUBO-OVARIAN ABSCESS Tarafdari MD, OB & GYN Assistant Professor , TUMS
TOA A tubo-ovarian abscess is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs (eg, bowel, bladder). These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. Tubo-ovarian abscess is usually a complication of pelvic inflammatory disease.
EPIDEMIOLOGY AND RISK FACTORS Women with a TOA are most likely to be between the ages of 15 and 40 years, but age should not exclude the diagnosis. The risk factors for TOA are the same as for PID: multiple sexual partners, age between 15 to 25 years , OPU, and a prior history of PID.
CLINICAL PRESENTATION (TOA) is typically considered a complication of pelvic inflammatory disease (PID), and the classic presentation is the same as for PID alone, including acute lower abdominal pain, fever, chills, and vaginal discharge. However, the presentation of some women with TOA differs from the classic scenario.
ESTABLISHING A DIAGNOSIS OF TOA is a po tentially life -th reat ening condition. Once a woman has been dia gn ose d with PID, it is a clinical priority to decide whether s he requires furth er e valuation for TOA. I m ag ing studie s are recomended for women with a diagnosi s of PID who have on e or mo re of the following characteristics: ●A cutely ill ●Significant abdominopelvic tenderness precluding a complete pelvic exa min at ion ●A dnexal mass not ed on examination, particularly a tender mass ●Lack of, or poor response to, antibiotic therapy
MANAGEMENT OF TOA Intensive antibiotic therapy Minimally-invasive drainage procedures Invasive surgery A combination of these interventions
CANDIDATES FOR ANTIBIOTIC THERAPY ALONE ● Hemodynamically stable with no signs of a ruptured TOA (acute abdomen, sepsis) ● Abscess <9 cm in diameter ● Adequate response to antibiotic therapy ● Premenopausal
AB THERAPY Women who are immunosuppressed (eg , HIV patients) should be treated as the same. In some patients with large abscesses (≥ 9 cm): Ø A history of pelvic surgery that suggests the presence of pelvic adhesions Ø Desire to preserve fertility Ø Otherwise appear clinically stable.
WOMEN WHO FAIL ANTIBIOTIC THERAPY After 48 to 72 hours of treatment with antibiotics alone, patients with TOA who: ● New onset or persistent fever ● Persistent or worsening abdominopelvic tenderness ● Enlarging pelvic mass ● New onset, persistent, or further elevation of the white blood cell count ● Signs of sepsis
ANTIBIOTIC THERAPY Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control (CDC). Antibiotic therapy is effective alone in approximately 70 percent of women, as noted above. Antibiotic therapy for TOA is similar to treatment for pelvic inflammatory disease (PID). Patients require close observation for at least 48 to 72 hours due to the serious nature of the infection, the potential for abscess rupture and ensuing sepsis, and occasional diagnostic uncertainty.
DURATION OF THERAPY The duration of antibiotic therapy required for treatment of a TOA is not well-established. When antibiotics alone are the chosen therapy, a minimum of two weeks is most commonly used. In cases in which the patient is improving on antibiotics alone, but the abscess has not completely resolved, longer courses of outpatient antibiotics may be given. After imaging-guided drainage procedures and/ surgery , 10 to 14 days of total antibiotic therapy is usually effective. Finishing the course of therapy with oral antibiotics as an outpatient is reasonable in select patients. Ideal candidates for outpatient therapy should meet the following criteria: demonstrate clear clinical improvement, tolerate oral medications, and be able to comply with follow-up communication and appointments.
MINIMALLY-INVASIVE DRAINAGE PROCEDURES Minimally-invasive imaging-guided drainage procedures appear to be appropriate for patients who do not worsen, but fail to clearly improve on antibiotics alone. No studies have directly compared surgical intervention with minimally invasive drainage procedures in this clinical scenario.
MINIMALLY-INVASIVE … It is recommended to move promptly to surgery when the patient is clearly clinically worsening using the clinical parameters listed above. In addition, surgical intervention is required in patients who are not improving on antimicrobial therapy and in whom minimally invasive drainage is not feasible (eg, mass is multiloculated or difficult to access or a physician experienced in these procedures is not available)
MINIMALLY-INVASIVE … guided by either computed tomography or ultrasonography anatomic approaches, including percutaneous, transvaginal, transrectal, and transgluteal. In general, studies have reported higher success rates (defined as clinical improvement without the need for surgery) for smaller, unilocular fluid collections.
INDICATIONS FOR IMMEDIATE SURGERY Suspected intraabdominal rupture of a tubo-ovarian abscess (TOA) is a life-threatening emergency and requires prompt surgical intervention. Clinical findings suggestive of intraabdominal rupture include, but are not limited to: hypotension, tachycardia, tachypnea, acute peritoneal signs, or acidosis. Even in the absence of evidence of abscess rupture, surgical exploration and treatment are advisable in any woman with overt signs of sepsis and a large abscess. In our experience, most women who are acutely ill will not improve without surgical removal of the nidus of infection. In women who are treated surgically, antibiotics should also be started as soon as possible, either before or during the urgent operative intervention. Importantly, in an unstable patient with the presumptive diagnosis of abscess rupture, surgery should not be delayed for the administration of antibiotics.
RUPTURED TOA § Preoperative phase : § Heamodynamic Stabilization § Broad spectrum AB: - piperacillin-tazobactam 3. 75 mg QID + - entrapenem 1 g daily § Foley catheter § Oxygen administration &ABG
RUPTURED TOA Operative phase Low midline inscision Smear & culture of pus Usually definitive surgery is indicated Exploration of upper abdomen Irrigation with warm saline Closed suction drains (Jackson- Pratt) Vagina vault should be left open for drainage
RUPTURED TOA Postoperative phase Monitor the patients for symptoms of DIC & ARDS Respiratory & hemodynamic support Semi-Fowler position Close attention to fluid balance & blood chemistry
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