Tubo-ovarian Abscess

General Data
● J.V. ● J.D.
● 41/F ● 45/F
● G1P1 (1001) ● G2P2 (2002)
● Married ● Married
● Filipino ● Filipino
● Roman Catholic ● Roman Catholic
● Minglanilla, Cebu ● Lapu-lapu City, Cebu
 Chief Complaint

HYPOGASTRIC PAIN LEFT LOWER

RADIATING TO THE BACK QUADRANT PAIN
 History of Present Illness
2 weeks PTA 2 months PTA
● (+) painful urination with dribbling of urine ● diagnosed case of Ovarian New Growth, left,
● (+) urgency probably endometriotic cyst
● (+) intermittent, crampy, hypogastric pain radiating to ● Dienogest 2 mg, 1 tab PO OD
the flank area and towards the lower lumbar area PS
8/10 3 weeks PTA
● (+) menstruation
1 week PTA
● (+) crampy LLQ pain, intermittent, PS 5/10
● (+) intermittent, crampy, hypogastric pain ● tramadol + paracetamol (algesia) 37.5mg/523
● (+) bilateral adnexal pain radiating to the lumbar area mg tab with temporary relief
● menses lasted 12 days, using 3 moderately
PS 8/10
● - sought consult with previous OB-GYN soaked panty liner per day
● UA showed WBC of 179
● Urine GS & C/S: No growth after 48 hrs incubation 1 week PTA
● FF-up consult with AP, advised TVS on 2/27/23
● UTZ of lower abdomen showed
& continue meds
right pelvocaliectasia and bilateral ovarian cyst (L
3 days PTA,
5.4x4.7x4.2cm, 58ml; R 7x4.6x4.8cm, 83ml) ● (+) crampy LLQ pain, PS 8/10
● (+) undocumented fever
Afternoon PTA
● (+) hypogastric pain, PS 8/10
02/27/23 J.D.
I. UTERUS: 5.7 × 4.8 × 5.0 cm Anteverted
IV. CERVIX: 3.2 x 2.6 x 3.3 cm
MYOMA: There is a well-circumscribed heterogeneous structure measuring 3.41 x 2.72 x
2.55 cm (previously measures 2.95 x 3.05 x 2.79 cm) noted within the right lateral V. OTHERS:
segment of the myometrium suggestive of a pedunculated subserous myoma (Grade 7). (-) free fluid in the cul de sac.
ADENOMYOSIS: The posterior myometrial wall is thicker than the anterior myometrial Both ovaries are adherent to the uterine wall
wall measuring 3.0 cm and 0.8 cm respectively demonstrating coarse echo pattern with Nabothian Cyst: absent
fan-shaped shadowing suggestive of posterior wall adenomyosis.

lI. ENDOMETRIUM: Thickness 5.2 mm Hyperechoic

DIAGNOSIS:
Compatible with: non-specific phase of the cycle Normal sized anteverted uterus
III. ADNEXAE: Myoma uteri, as described
RIGHT OVARY: 3.2 x 2.3 x 1.8 cm Posterior wall adenomyosis, as described
Located: Lateral to the uterus
Follicles: Present Thin endometrium
volume = 7.1 ml Normal right ovary
LEFT OVARY: 3.0 x 2.6 x 2.3 cm Tubo-ovarian complex of endometriosis, left
volume = 10.0 ml
Located: Lateral to the uterus

There is a complex mass at the left adnexa measuring 8.72 x 7.11 x 6.80 cm
(Volume=220.00 cc) (previously measures 8.87 × 7.93 × 6.81 cm) wherein the ovary and
fallopian tube are inseparable but can be distinctly visualized. The fallopian tube
measures 7.94 x 6.95 x 6.14 cm (previously measures 4.72 × 3.53 × 2.16 cm) suggestive of
tubo-ovarian complex of endometriosis.
 Past Medical History
● Non-hypertensive ● (+) Hypertension, 2017
● ○ Nevibolol 5mg/tab, 1 tab PO OD 6AM
Non-diabetic
○ Irbesartan 300mg/tab, 1 tab PO OD 8PM
● Non-asthmatic ○ Trimetazidine 35mg/tab, 1 tab PO BID
● No previous hospitalizations or (8AM & 8PM)
○ Atorvastatin 20mg/tab, 1 tab PO OD after
surgeries.
dinner
● (+) Hypothyroidism, 2017
○ Levothyroxine 100mg/tab, 1 tab PO OD
6AM
● (+) Diabetes Mellitus, Oct 2022
○ Dapagliflozin/Metformin HCl (Xigduo XR)
10mg/1000mg, 1 tab PO OD 6AM
○ Sitagliptin+Metformin (Janumet)
50mg/500mg 1 tab, PO OD before dinner
Past Medical History
● Previous Hospitalizations:
○ 2006 at MDH CSD for breech
presentation
○ Dec 2022 - UTI, Gastritis, ONG (L)
● COVID-19 Vaccine:
○ Pfizer x 2 doses
○ Astrazeneca x 1 dose
 Personal and Social History
● Non-smoker
● Non-alcoholic beverage drinker
● Non-illicit drug user
● No known food and drug allergies
● Non-smoker
● Non-alcoholic beverage drinker
● Non-illicit drug user
● No known food and drug allergies
 Family History
● No known heredofamilial diseases ● HDF: (+) hypertension, both sides
on both sides of the family. ● No other heredofamilial diseases on
both sides of the family.
 Menstrual History
M - 12 y.o. M - 13 y.o.
I - irregular I - regular
D - 5-7 days D - 7 days
A - 6 pads per day A - 3 pads per day
S - (+) hypogastric pain S - (+) hypogastric pain

LMP: 12/11/2022 LMP: 01/13/2023

PMP: unrecalled PMP: unrecalled
 Contraceptive & Sexual History

C - 20 yo C - 21 yo
P -1 P -1
C - none C - OCP
P - none P - 2023, normal
S - none S - none
 Obstetrics History
● G2P2 (2002)
● G1P1 (1001)

Mode of Mode of
Year AOG Sex BW Status Remarks Place Year AOG Sex BW Status Remarks Place
Delivery Delivery

G1 1997 NSD FT M - living No cx G1 1992 NSD FT M 2.7kg living No cx CMH

1° LSTCS,
G2 2006 breech FT F 2.4kg living No cx MDH
 Review of Systems
General: no loss of appetite. no malaise. no General: no loss of appetite. no malaise. no
fever. no chills. no weight loss. fever. no chills. no weight loss.
Skin: no jaundice, no rashes, or edema Skin: no jaundice, no rashes, or edema

HEENT: HEENT:
● Head: no headache ● Head: no headache
● Eyes: no visual loss and double vision. ● Eyes: no visual loss and double vision.
anicteric sclerae. anicteric sclerae.
● Ears: no hearing loss, tinnitus, and ear ● Ears: no hearing loss, tinnitus, and ear
discharge discharge
● Nose: no nasal discharge, sneezing, and ● Nose: no nasal discharge, sneezing, and
runny nose runny nose
● Throat: no dysphagia and sore throat ● Throat: no dysphagia and sore throat
 Review of Systems
Neck: no lumps, pain, and swollen glands
Respiratory: no cough, hemoptysis, and
shortness of breath
Cardiovascular: no chest pain, chest
discomfort, and palpitations
GIT: no nausea, no anorexia, (+) abdominal
pain, no vomiting, diarrhea, & bloody stool
GUT: no vaginal bleeding, no dysuria,
polyuria, nocturia and hematuria
Musculoskeletal: no myalgia, arthralgia, and
stiffness
Psychiatric: no depression or history of
psychiatric consultations
Neurologic: no headache, dizziness, paralysis,
and syncope
Hematology: no bruising. no bleeding
Neck: no lumps, pain, and swollen glands
Respiratory: no cough, hemoptysis, and
shortness of breath
Cardiovascular: no chest pain, chest
discomfort, and palpitations
GIT: no nausea, no anorexia, (+) abdominal
pain, no vomiting, diarrhea, & bloody stool
GUT: no vaginal bleeding, no dysuria,
polyuria, nocturia and hematuria
Musculoskeletal: no myalgia, arthralgia, and
stiffness
Psychiatric: no depression or history of
psychiatric consultations
Neurologic: no headache, dizziness, paralysis,
and syncope
Hematology: no bruising. no bleeding
 Physical
Examination
 Physical Examination
General Survey: awake, alert, General Survey: awake, alert,
responsive, and not in respiratory responsive, and not in respiratory
distress with the following vital signs: distress with the following vital signs:

BP: 110/70 mmHg BP: 147/95 mmHg

HR: 100 bpm HR: 86 bpm
RR: 20 cpm RR: 19 cpm
Temp: 36.6 C Temp: 36.7 C
Ht: 159 cm Ht: 168 cm
Wt: 55.4 kg Wt: 79.5 kg
BMI: 21.9 kg/m2 (normal) BMI: 28.2 kg/m2 (overweight)
 Physical Examination
Skin: Warm to touch, good skin turgor and
mobility, no rashes lesions
HEENT: Normocephalic, anicteric sclera, pink
palpebral conjunctiva, moist oral mucosa.
Neck: Supple, no neck vein distention, no
lymphadenopathy.
C/L: Equal chest expansion, clear breath
sounds, resonant on both lung fields.
CVS: Adynamic precordium, distinct heart
sounds, no murmurs.
Abdomen: Non-distended, soft, flabby
abdomen, with no scars or lesions. NABS.
Tympanitic. No palpable masses. (+) direct
tenderness on hypogastric area on deep
palpation
Skin: Warm to touch, good skin turgor and
mobility, no rashes lesions
HEENT: Normocephalic, anicteric sclera, pink
palpebral conjunctiva, moist oral mucosa.
Neck: Supple, no neck vein distention, no
lymphadenopathy.
C/L: Equal chest expansion, clear breath
sounds, resonant on both lung fields.
CVS: Adynamic precordium, distinct heart
sounds, no murmurs.
Abdomen: Non-distended, soft, flabby
abdomen, with low segment transverse scar 3
cm above the superior border of symphysis
pubis. NABS. Tympanitic. No palpable masses.
(+) direct tenderness on LLQ.
 Physical Examination
GUT: GUT:
I - parous, no lesions I - parous, no lesions
C - closed, smooth, no lesions, firm, C - closed, smooth, no lesions, firm,
midposition, (+) cervical motion midposition, (+) cervical motion
tenderness tenderness
U - small U - small
A - (+) tenderness on R & L adnexa, no A - (+) direct tenderness LLQ, (+)
palpable mass palpable adnexal mass, L
D - (+) minimal greenish discharge D - (+) minimal whitish discharge

Rectal Exam: No fullness on posterior cul Rectal Exam: No fullness on posterior cul
de sac de sac
Extremities: No bipedal edema, strong Extremities: No bipedal edema, strong
peripheral pulses, CRT <2 secs. peripheral pulses, CRT <2 secs.
 Physical Examination
Neurologic Examination:
Mental Status Exam: awake,coherent,
cooperative, oriented to time place and
person
Cranial Nerves:
I: Able to identify the smell through each
nostrils
II: no visual field defects
II, III: (+) direct and consensual Pupillary Light
Reflex
III, IV, VI: Full range of EOM
V: Good temporalis and masseter muscle tone
Neurologic Examination:
Mental Status Exam: awake,coherent,
cooperative, oriented to time place and
person
Cranial Nerves:
I: Able to identify the smell through each
nostrils
II: no visual field defects
II, III: (+) direct and consensual Pupillary Light
Reflex
III, IV, VI: Full range of EOM
V: Good temporalis and masseter muscle tone
 Physical Examination
VII: able to wrinkle the forehead, close
eyelids with resistance, puff out cheeks,
smile, wrinkle skin of neck with
resistance, symmetric; no nasolabial fold
flattening
VIII: able to hear and respond to
whispered voice at 2ft distance
IX, X: Intact articulation of words
XI: Able to shrug shoulders and turn
neck with resistance
XII: Tongue midline upon protrusion, no
atrophy, no fasciculations
VII: able to wrinkle the forehead, close
eyelids with resistance, puff out cheeks,
smile, wrinkle skin of neck with
resistance, symmetric; no nasolabial fold
flattening
VIII: able to hear and respond to
whispered voice at 2ft distance
IX, X: Intact articulation of words
XI: Able to shrug shoulders and turn
neck with resistance
XII: Tongue midline upon protrusion, no
atrophy, no fasciculations
12/28/22 J.D. CASE 1
I RIGHT OVARY: not visualized
There is a complex mass at the left adnexa measuring 8.87 x 7.93 x
6.81 cm (Volume=250.8 cc) wherein the ovary and fallopian tube
are inseparable but can be distinctly visualized. The fallopian tube
measures 4.72 x 3.53 x 2.16 cm suggestive of tubo-ovarian
complex of endometriosis. (+) tenderness left adnexa on probe
manipulation
DIAGNOSIS:
Normal sized anteverted uterus
Myoma uteri, Grade 7 as described
Posterior wall adenomyosis, as described
Thin endometrium
Normal right ovary
Tubo-ovarian complex of endometriosis, left
CASE 2 ADNEXAE:
Within the right ovary is a complex mass measuring 8.5 x
6.0 × 6.3 cm (Volume= 174.9 cc), thick-walled
containing low to medium level echoes and incomplete
septations. Findings suggestive of a tubo-ovarian
complex.
LEFT OVARY: not visualized
Within the left ovary is a complex mass measuring 7.7 x
6.1 x 5.4 cm (Volume= 135 cc), thick-walled containing
low to medium level echoes and incomplete septations.
Findings suggestive of a tubo-ovarian complex.
DIAGNOSIS:
Normal sized anteverted uterus
Posterior wall adenomyosis, as described
Thin endometrium (7.4mm)
Bilateral tubo-ovarian complexes
Suggest repeat scan after 2 weeks of medical treatment.
 Clinical
Formulation
 Primary Impression
G1P1(1001), Pelvic Inflammatory Disease
● 41/F
● Hypogastric pain
● ●
Radiation to the lower lumbar area
● Hypogastric tenderness
● Mucopurulent greenish discharge
● (+) cervical motion tenderness
● (+) bilateral adnexal tenderness
G2P2(2002), Ovarian New Growth, Left,
Probably Endometriotic Cyst
T/C Torsion vs Rupture
45/F
● Diagnosed case of ovarian new growth
● Crampy left lower quadrant pain
● LLQ tenderness
● (+) cervical motion tenderness
● (+) left adnexal tenderness
● (+) adnexal mass
 Differential Diagnoses
ECTOPIC PREGNANCY MYOMA UTERI

RULE IN: RULE IN:

● Irregular menstruation
● Sudden onset of hypogastric
tenderness
● bilateral adnexal tenderness
● Pre-menopausal
● Mucopurulent greenish vaginal
discharge
RULE OUT:
● Request pregnancy test
● No sexual history
● prolonged menstrual bleeding
● Left lower quadrant pain
● Increasing age
RULE OUT:
● No masses palpated
● No hypogastric fullness or
bloatedness
● Uterus is small in bimanual pelvic
examination
● Sonography, to further rule out
myoma.
 Differential Diagnoses
ACUTE PYELONEPHRITIS OVARIAN FIBROMA

RULE IN: RULE IN:

● (+) Dysuria ● Average age of diagnosis is 40s
● (+) Urgency ● Prolonged menstrual bleeding
● (+) Hypogastric pain radiating to ● Left lower quadrant pain
the flanks ● Unilateral adnexal mass
● (+) Pyuria
RULE OUT:
RULE OUT: ● Typical sonographic feature is a
● (-) Fever hypoechoic mass with clear
● (-) Dark, cloudy, or bloody urine border
● Pathologic examination is
required
 Differential Diagnoses
ACUTE APPENDICITIS DIVERTICULITIS

RULE IN: RULE IN:

● (+) Hypogastric pain especially ● (+) Left lower quadrant pain
during palpation
RULE OUT:
RULE OUT: ● (-) fever
● (-) fever ● (-) change in bowel habits
● (-) anorexia/vomiting ● (-) nausea or vomiting
● (-) right lower quadrant pain
● (-) rebound tenderness
● CBC to further rule out
Course in the
Wards
CASE 1
 J.V HOSPITAL DAY 0 (12/15/22) J.V HOSPITAL DAY 1 (12/16/22)

S Hypogastric pain (7/10)

Mucopurulent greenish discharge, non-foul smelling, non pruritic
Hypogastric pain (5/10)
Mucopurulent greenish discharge, non-foul smelling, non pruritic

BP: 110/70 mmHg BP: 110/60 mmHg

HR: 110 bpm HR: 76 bpm
RR: 10 cpm RR: 23 cpm
Temp: 37.0 C Temp: 36.8 C
O SpO2: 98% room air SpO2: 96% room air
K: ↓ 3.20 mmol/L Urine C/S: Gram Stain: Pus cells 0-1/OIF, Cervicovaginal C/S:
Crea: 0.70 mg/dL No Microorganisms seen Gram Stain: Pus cells 5-10/OIF
No growth after 24 hours of incubation Epithelial cells 4-8/LPF
Gram + Bacilli: rare
A Hospital Day 0
Stable vital signs
Hospital Day 1
Stable vital signs

Labs taken include: RT-PCR, DIA-A, TVS, GS and culture of Medications given:
cervicovaginal discharge, urine culture and sensitivity, K, Crea, CBC 1. Gentamycin 240mg+100cc PNSS to run in 2hrs once a day via IV drip
Medications given: 2. Paracetamol 500mg/tab 1 tab every 4 hours for temp >/= 37.8 C
3. Etoricoxib (Arcoxia) 120mg/tab 1 tab OD
1. Clindamycin 900mg+100cc PNSS q8hrs via amp to run in 2hrs
per dose Referred to life and health affiliated nephrologist
P 2.
3.
Gentamycin 240mg IVTT once a day
Ibuprofen (Faspic) 400mg/tab 1 tab q 12 hours for 2 doses
then PRN
4. K-Lyte tablet 1 tab every 8 hours for 6 doses
5. Omeprazole 40 mg cap once a day before breakfast
Daily full body bath and proper perineal care
Refer for severe abdominal pain, temp >/= 38 C, or any unusalties
 12-15-22 Reference Range

WBC 17.98 4.5-11.0 g/L

Neutrophils 86 45-65

Lymphocytes 8 20-40

Monocytes 5 2-9

Complete Blood Eosinophils 1 0-6

Count Basophils 0 0-2

RBC 4.3 3.7-5.1 x 10*12/L

Hemoglobin 11.8 12.0-15.0 g/L

Hematocrit 35.3 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 531 150-450 x 10*9/L

TVS Results (12-16-22)

DIAGNOSIS:

Normal sized anteverted uterus

Posterior wall adenomyosis, as described Thin endometrium
Bilateral tubo-ovarian complexes
Suggest repeat scan after 2 weeks of medical treatment Please correlate clinically
 J.V HOSPITAL DAY 2 (12/17/22) J.V HOSPITAL DAY 3 (12/18/22)

S No abdominal pain
No other subjective complaints
Hypogastric pain 4/10
Yellowish vaginal discharge
Non-foul smelling, non pruritic

BP: 100/60 mmHg BP: 110/70 mmHg

HR: 80 bpm HR: 88 bpm
RR: 20 cpm RR: 18 cpm
Temp: 36.1 C Temp: 36.7 C
O SpO2: 99% room air SpO2: 96% room air
K: 3.70 mmol/L
Crea: 0.70 mg/dL
Urine C/S: No growth after 48 hours of incubation

A Hospital Day 2
Stable vital signs
Hospital Day 3
Stable vital signs

Labs taken include: K, Crea Labs taken: CT SCAN whole abdomen with contrast

P
 12-18-22 Reference Range

WBC 13.97 4.5-11.0 g/L

Neutrophils 82 45-65

Lymphocytes 11 20-40

Monocytes 5 2-9

Complete Blood Eosinophils 2 0-6

Count Basophils 0 0-2

RBC 3.7 3.7-5.1 x 10*12/L

Hemoglobin 10.4 12.0-15.0 g/L

Hematocrit 30.8 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 514 150-450 x 10*9/L

 J.V HOSPITAL DAY 4 (12/19/22) J.V HOSPITAL DAY 5 (12/20/22)

S Crampy abdominal hypogastric pain (3/10)

Voids freely
No abdominal pain
Minimal vaginal discharge noted
No vaginal bleeding
Minimal vaginal discharge noted
With bowel movement

BP: 110/80 mmHg BP: 110/80 mmHg

HR: 82 bpm HR: 73 bpm
RR: 20 pm RR: 19 cpm
Temp: 36.5 C Temp: 36.7 C
O SpO2: 97% room air SpO2: 98% room air
Abd: (+) hypogastric tenderness

Cervicovaginal C/S: No bacterial pathogens isolated

A Hospital Day 4
Stable vital signs
Hospital Day 5
Stable vital signs

Labs taken include: DIA A Follow-up CT Scan results

P
CT Scan Results (12-20-22)
Impression:
HEPATOMEGALY WITH SMALL NONENHANCING, HYPODENSE ILL-DEFINED AREA IN SEGMENT IV-B
WHICH MAY RELATE TO AN AREA OF FOCAL FATTY INFILTRATION

BILATERAL MULTILOCULAR CYSTIC ADNEXAL MASSES WITH MILD INFLAMMATORY CHANGES IN

BOTH PELVIC REGIONS AND MINIMAL PELVIC ASCITES

RIGHT MODERATE URETEROHYDRONEPHROSIS SECONDARY TO EXTRINSIC COMPRESSION OF

THE DISTAL URETER BY THE RIGHT ADNEXAL MULTILOCULAR CYSTIC MASS

SMALL RIGHT RENAL CYST

INCIDENTAL NOTE OF SUBSEGMENTAL ATELECTASIS VERSUS FIBROSIS IN BOTH LUNG BASES A N

D VERY MINIMAL BILATERAL PLEURAL EFFUSION
 J.V HOSPITAL DAY 6 (12/21/22) J.V HOSPITAL DAY 7 (12/22/22)

S No abdominal pain
No other subjective complaints
No abdominal pain
No other subjective complaints

BP: 100/70 mmHg BP: 110/80 mmHg

HR: 86 bpm HR: 75 bpm
RR: 19 cpm RR: 20 cpm
O Temp: 36.8 C Temp: 36.5 C
SpO2: 95% room air SpO2: 98% room air
UO: UO:

A Hospital Day 6
Stable vital signs
Hospital Day 7
Stable vital signs

Shift meds to oral Take home medications:

Encourage proper perineal care and hygiene, full body bath 1. Doxycycline (Doxin/Doxicon) 100mg cap 1 cap q12 for 14 days
2. Omeprazole (Omepron) 40mg cap 1 cap OD before breakfast for 2 weeks
3. Ferrous sulfate (Sorbifer) durule, 1 durule once a day 2 hours after
P 4.
breakfast
Etoricoxib (Arcoxia) 120 mg tab 1 tab OD as need for pain
Follow up with attending physician on January 4 2023.
Discharged.
Course in the
Wards
 J.D. HOSPITAL DAY 0 (02/24/23) J.D. HOSPITAL DAY 1 (02/25/23)

S PS 5/10 Crampy left lower quadrant pain with radiation to the left lower back and anterior
thigh (pain score 5- 8/10)
No vaginal bleeding
No fever.

BP: 136/83 mmHg HbA1c 6% BP: 140/90 mmHg

HR: 85 bpm iCa: 1.21 HR: 87 bpm
RR: 20 cpm ALT 25 RR: 18 cpm
Temp: 36.4 C K 3.99 Temp: 37.1 C
SpO2: 98% room air Crea 0.70 SpO2: 99% room air
O Bleeding time: 5 min 30 s
Blood type O POS
HBsAg NR
Soft abdomen
APTT 34.6 NT-proBNP 814.0
PT 12.1 CXR AP: cardiomegaly, bilateral minimal pleural effusion
INR 1.01

A Patient is stable Patient is stable

Labs: Dialysis Panel Continue medications

Medications Additional medication
1. Dienogest 2mg/tab, - Ferrous sulfate (Sorbifer) 310mg/durule, 1 durule at bed time
2. Tramadol + Paracetamol (Algesia) 37.5mg/325mg/tab, - Spironolactone 5mg/tab
3. Meformin + Sitagliptin (Janumet) - Sacubitril + Valsartan 50mg/tab
4. Dapagliflozin + Metformin - Amlodipine 10mg/tab
5. Trimetazidine 325 mg/tab - Bisacoldyl (Dulcolax) 10mg suppositories
P 6.
7.
Atorvastiatin 20mg/tab
Levothyroxine 100mg/tab
-
-
CElecoxib 200mg/tab
Losartan + Amlodipine discontinued
8. Nebivolol 5mg/tab - Atorvastatin increased to 80mg/tab
9. Amlodipine + Losartan 5mg/50mg - Nebivolol shifted to Carvedilol 6.25mg/tab
For TVS on February 27, 2023 Laboratories: proBNP
For stress echo Total fluid intake limited to 1.2L per day
IVF decreased to 10cc/hr
 02-24-2023 Reference Range

WBC 12.3 4.5-11.0 g/L

Neutrophils 74 45-65

Lymphocytes 17 20-40

Monocytes 6 2-9

Complete Blood Eosinophils 3 0-6

Count Basophils 0 0-2

RBC 4.3 3.7-5.1 x 10*12/L

Hemoglobin 11.2 12.0-15.0 g/L

Hematocrit 35.7 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 448 150-450 x 10*9/L

 J.D. HOSPITAL DAY 3 (02/26/23) J.D. HOSPITAL DAY 4 (02/27/23)

S Patient complains of left lower quadrant abdominal pain PS 2/10

Voids freely
Minimal abdominal pain
No vaginal bleeding

BP: 110/70 mmHg BP: mmHg

HR: 90 bpm HR: bpm
RR: 20 cpm RR: cpm
Afebrile Temp: C
FB +470cc SpO2:9% room air
Soft abdomen
O ECE, CBS, no murmur, no edema
I 3900cc Dobutamine Stress test: augmentation of contractility in all left ventricular
O 2050cc regions with increase of ingestion fraction to 61% to 48% indicative of good
FB 1850cc contractile reserve. All regions are viable. Normal stress test. Premature
ventricular contractions in trigeminy at stage 2 and 3.
TSH 0.180
FT4 28.98

A Patient is stable Patient is stable

Labs: TSH, FT4 Labs: serum albumin

Medications continued Levothyroxine 1oomg/tab put on hold
For TVS on 2/27 Medications continued
P For stress echo 2/27 2 units pRBC secured
Amino acid cap (Moriamin) tab
TRANSVAGINAL ULTRASOUND 02/27/2023:
I. UTERUS: 5.7 × 4.8 × 5.0 cm Anteverted
● MYOMA: There is a well-circumscribed heterogeneous
structure measuring 3.41 x 2.72 x 2.55 cm (previously
measures 2.95 x 3.05 x 2.79 cm) noted within the right lateral
segment of the myometrium suggestive of a pedunculated
subserous myoma (Grade 7).
● ADENOMYOSIS: The posterior myometrial wall is thicker than
the anterior myometrial wall measuring 3.0 cm and 0.8 cm
respectively demonstrating coarse echopattern with fan-
shaped shadowing suggestive of posterior wall adenomyosis.
lI. ENDOMETRIUM: Thickness 5.2 mm, Compatible with: non-specific
phase of the cycle, Hyperechoic
III. ADNEXAE:
● RIGHT OVARY: 3.2 x 2.3 x 1.8 cm
● Located: Lateral to the uterus
● Follicles: Present
● volume = 7.1 ml
● LEFT OVARY: 3.0 x 2.6 x 2.3 cm
● volume = 10.0 ml
● Located: Lateral to the uterus
● There is a complex mass at the left adnexa measuring 8.72 x
7.11 x 6.80 cm (Volume=220.00 cc) (previously measures
8.87 × 7.93 × 6.81 cm) wherein the ovary and fallopian tube
are inseparable but can be distinctly visualized. The fallopian
tube measures 7.94 x 6.95 x 6.14 cm (previously measures
4.72 × 3.53 × 2.16 cm) suggestive of tubo-ovarian complex of
endometriosis.
V. OTHERS:
● CERVIX: 3.2 x 2.6 x 3.3 cm
● (-) free fluid in the cul de sac.
● Both ovaries are adherent to the uterine wall
● Nabothian Cyst: absent
DIAGNOSIS:
● Normal sized anteverted uterus
● Myoma uteri, as described
● Posterior wall adenomyosis, as described
● Thin endometrium
● Normal right ovary
● Tubo-ovarian complex of endometriosis, left
TRANSVAGINAL ULTRASOUND 12/28/22
TRANSVAGINAL ULTRASOUND
I. UTERUS: 5.5 x 5.2 x 4.5 cm, Anteverted
IV. CERVIX: 2.8 x 2.3 x 2.2 cm
● MYOMA: There is a well-circumscribed heterogeneous structure measuring 2.95
× 3.05 × 2.79 cm noted within the right lateral segment of the myometrium
suggestive of a pedunculated subserous myoma (Grade 7). V. OTHERS:
● ADENOMYOSIS: The posterior myometrial wall is thicker than the anterior
myometrial wall measuring 2.9 cm and 0.7 cm respectively demonstrating coarse
echopattern suggestive of posterior wall adenomyosis.
● (-) free fluid in the cul de sac.
● Nabothian Cyst: absent
lI. ENDOMETRIUM: Thickness 6.7 mm, Compatible with: non-specific phase of the cycle,
Hyperechoic
DIAGNOSIS:
III.ADNEXAE:
● Normal sized anteverted uterus
● RIGHT OVARY: 2.7 x 2.7 x 1.9 cm
● Located: Lateral to the uterus ● Myoma uteri, as described
● Follicles: Present
● volume = 1.9 ml ● Posterior wall adenomyosis, as
● LEFT OVARY: 8.0 x 7.8 x 5.1 cm
● volume = 171.9 ml
described
● Located: Adherent to the uterine wall ● Thin endometrium
● There is a complex mass at the left adnexa measuring 8.87 x 7.93 x 6.81 cm
(Volume=250.8 cc) wherein the ovary and fallopian tube are inseparable but can ● Normal right ovary
be distinctly visualized. The fallopian tube measures 4.72 x 3.53 x 2.16 cm
suggestive of tubo-ovarian complex of endometriosis. (+) tenderness left adnexa ● Tubo-ovarian complex of
on probe manipulation
endometriosis, left
 J.D. HOSPITAL DAY 5 (02/28/23)

S No dizziness, no chest pain

Intermittent LL1 pain PS 0-2/10
Comfortable in supine position
No chest pain, dyspnea

BP: 130/90 mmHg

Soft, nontender abdomen
Albumin 3.5
O

A Patient is stable

Labs: FT4, FT3 prior to surgery

Levothyroxine on hold
Janumet discontinued
P
 J.D. HOSPITAL DAY 6 (03/01/23) J.D. HOSPITAL DAY 7 (03/02/23)

S Stable vs
Patient able to ambulate
Stable vs
Steady, crampy, LLQ pain but tolerable, PS 2/10
Still with intermittent LLQ pain, PS 8/10 No other subjective complaints
Currently no pain No vaginal bleeding
No vaginal bleeding

BP: 120/80 mmHg BP: 110/70 mmHg

HR: 80-90 bpm HR: 89 bpm
RR: 1cpm RR: 20 cpm
Temp: 36.2-36.5 C Temp: 37.2 C
SpO2: 100% room air SpO2: 99% room air
O FT4: 23.21 H
FB: 255cc/hr, clear, yellow urine
FT3: 2.5

A Patient is stable Patient is stable

Please get Rapid Antigen Test 24hrs prior to OR Repeat FT4 tomorrow

P
 J.D. HOSPITAL DAY 8 (03/03/23) J.D. HOSPITAL DAY 9 (03/04/23)

S Stable vs
Intermittent crampy LLQ pain, PS 2/10
Stable vs
LLQ pain PS 2/10
No vaginal bleeding With spotting upon wiping with tissue
Able to ambulate (+) Dysmenorrhea
No chest pain or dyspnea 1st day of menses

BP: 125/72 mmHg BP: 110/70 mmHg

HR: 62 bpm HR: 87 bpm
RR: 19-20 cpm RR: 19 cpm
O Temp: 36.4C
SpO2: 100% room air
Temp: 36.5 C

FT4 18.9

A Patient is stable Patient is stable

Increase Carvedilol to 12.5mg/tab 1 tab BID Soft diet at lunch

Resume Levothyroxine 50mcg tab OD ACBF starting tomorrow
P 1.
Clear liquids at dinner
NPO post midnight
Pre op Meds:
2.
Cefoxitin 2g IVTT on call to OR
Omeprazole 40mg IVTT on call to OR
3. Metoclopramide 10mg IVTT on call to OR
Compression stockings, midthigh once at OR
For scheduled TAHBSO on March 6, 2023
Continue all PO meds until NPO
 J.D. HOSPITAL DAY 10 (03/05/23) J.D. POST OP DAY 0 (03/06/23)

S Stable vs
Intermittent crampy LLQ & hypogastric pain, PS 2/10
Stable vs
LLQ pain PS 2/10
(+) vaginal spotting With spotting upon wiping with tissue
No dyspnea
No other complaints

BP: 125/72 mmHg BP: 110/70 mmHg

HR: 62 bpm HR: 89 bpm
RR: 19-20 cpm RR: 20 cpm
Temp: 36.4C Temp: 37.2 C
O SpO2: 100% room air
K 3.9
SpO2: 99% room air
Na 140
Crea 0.7
COVID19 RAT NEG

A Patient is stable Patient is stable

For TAHBSO tomorrow at 7am Soft diet at lunch

Start Ivabradine 5g 1 tab BID oral Clear liquids at dinner
For Dia A NA today NPO post midnight
Give the ff meds tomorrow on call to OR: Pre op Meds:
P 1.
2.
Carvedilol 12.5g 1 tab
Spironolactone 50mg 1 tab 1 tab
1.
2.
Cefoxitin 2g IVTT on call to OR
Omeprazole 40mg IVTT on call to OR
3. Sacubitol + Valsartan 50mg 1 tab 3. Metoclopramide 10mg IVTT on call to OR
4. Ivabradine 5mg 1 tab Compression stockings, midthigh once at OR
For scheduled TAHBSO on March 6, 2023
Continue all PO meds until NPO
 03-05-2023 Reference Range

WBC 14.76 4.5-11.0 g/L

Neutrophils 67 45-65

Lymphocytes 17 20-40

Monocytes 6 2-9

Complete Blood Eosinophils 3 0-6

Count Basophils 0 0-2

RBC 4.3 3.7-5.1 x 10*12/L

Hemoglobin 11.7 12.0-15.0 g/L

Hematocrit 37.0 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 567 150-450 x 10*9/L

FROZEN SECTION DIAGNOSIS (March 6, 2023)
● LEFT ADNEXA (A):
○ Consistent with endometriosis cyst with chronic and acute inflammation
○ Remarks: await permanent paraffin sections for a more adequate sampling and for a more
definitive diagnosis
Surgical Pathology Report (March 6, 2023) Final Diagnosis:

Left Adnexa (A)

● Consistent with endometriotic cyst with severe chronic and acute inflammation, left ovary
● Chronic salpingitis, left fallopian tube

Uterus, Cervix, Right Ovary, Right Fallopian Tube, Pedunculated Myoma (B):
● Consistent with leiomyoma, recovered mass
● Stromal-glandular dissociation of the endometrium
● Chronic cervicitis
● Endometriotic cyst, cystic follicles, and germinal inclusion cysts, right ovary
● Chronic salpingitis, right fallopian tube

Posterior cul de sac Implants (C):

● Fibrocollagenous to fibromuscular tissue with focal endometriosis
 J.D. POST OP DAY 1 (03/07/23) J.D. POST-OP DAY 2 (03/08/23)

S Stable vital signs

Soft diet tolerated
Post-op pain (PS 5/10)
With flatus, no BM for 2 days
Post op pain (PS 2/10) Verbalized she wants to defecate
No BM No other subjective complaints

BP: 125/72 mmHg BP: 110/70 mmHg

HR: 62 bpm HR: 89 bpm
RR: 19-20 cpm RR: 20 cpm
Temp: 36.2-36.5 C Temp: 37.2 C
SpO2: 100% room air SpO2: 99% room air
UO: 30-53cc/hr, clear, yellow urine UO: 30-53cc/hr, clear, yellow urine
O Clean and dry dressing Clean dry dressing
Soft abdomen, with flatus Flabby, NABS, soft-non-tender
NABS
K 4.1
Crea 0.8

A Post-op Day 1
Patient is stable
Post-op Day 2
Patient is stable

Continue IV antibiotics Continue medications

Hold Amlodipine, Increase FeS04, Dec. Carvedilol Give Dulcolax tablets
Maintain FBC Remove FBC now, due to void
P May sit upright
No objections to remove arterial line
For daily wound dressing
For possible discharge tomorrow
Patient may have full diabetic diet
Keep compression stockings
 03-07-2023 Reference Range

WBC 21.65 4.5-11.0 g/L

Neutrophils 85 45-65

Lymphocytes 11 20-40

Monocytes 6 2-9

Complete Blood Eosinophils 3 0-6

Count Basophils 0 0-2

RBC 4.3 3.7-5.1 x 10*12/L

Hemoglobin 9.5 12.0-15.0 g/L

Hematocrit 30.4 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 471 150-450 x 10*9/L

 J.D. POST OP DAY 3 (03/09/23)

S Stable vs
Post-op pain (PS 3/10), upon movement
Voids freely, with BM 3x yesterday
No other subjective complaints

Clean and dry dressing

Soft non-tender abdomen
Minimal vaginal bleeding (Day 5 of menses)
O BUN 9
K 3.4 L
Crea 0.7 L

A Post-op Day 3
Patient is stable

MGH if okay with other APs

THM: Metronidazole, Co-amoxiclav, Dienogest, Calcium + Vit.D, FeS04
Daily wound dressing
Follow up after 1 week
P
MICROBIOLOGY (March 9, 2023) Preliminary report:
Specimen: Left Ovarian Fluid
● Smear of culture: Gram Negative bacilli
 03-09-2023 Reference Range

WBC 11.75 4.5-11.0 g/L

Neutrophils 63 45-65

Lymphocytes 27 20-40

Monocytes 6 2-9

Complete Blood Eosinophils 3 0-6

Count Basophils 0 0-2

RBC 4.3 3.7-5.1 x 10*12/L

Hemoglobin 9.8 12.0-15.0 g/L

Hematocrit 31.6 38-48%

MCV 83.1 70-90 fL

MCH 27.8 23-31 pg

MCHC 33.4 11-16%

Platelet Count 501 150-450 x 10*9/L

Discussion
Tubo-ovarian
Abscess
 Tubo - Ovarian Abscess

Complication arising from Complication arising from Infected

Pelvic Inflammatory Disease* Endometriotic Cyst*

*Epidemiology, clinical manifestations anddiagnosis. UPTODATE April 19, 2022

 Tubo-ovarian Abscess
● Inflammatory mass involving the fallopian tube & ovary

● Seen in sexually active women of reproductive age

● Results from upper genital tract infection

- numerous etiologic agents --> endogenous anaerobic bacteria

- polymicrobial
● Potentially life threatening
 Tubo-ovarian Abscess
PATHOPHYSIOLOGY:
● Tubal destruction & necrosis --> anaerobic progression

- low reduction oxidation potential

- low oxygen tension

- abundance of nutrient supply

● Pelvic Inflammatory Disease, CPG.
How is TOA managed?
 Management:
● Hospitalization
- close monitoring --> complications --> rupture
peritonitis
sepsis
- IV antibiotics --> anaerobic coverage
What are the recommended
regimen in PID + TOA?
● Clindamycin 900 mg IV Q8H + Gentamycin 2 mg / kg IV LD,
1 mg / kg IV Q8H

● Cefoxitin 2 grams IV Q6H + Doxycycline 100 mg IV / PO BID

● Cefotetan 2 grams IV Q12H + Doxycycline 100 mg IV / PO BID

● Ertapenem 1 gram IV OD

● Piperacillin – Tazobactam 3.375 mg IV Q6H

 What are the parameters that
indicates response to treatment?
●Decreasing or resolution of pain

●Decreasing WBC count

●Defervescence
● Clindamycin

- advantage:

* actively transported into PMN leukocytes & macrophages

* high concentration in abscesses

- disadvantage

* increasing resistance
 When is surgical
intervention for TOA
warranted?
● PID + Acute abdomen --> immediate surgical exploration (stabilize first)

--> consider non – gynecologic causes

● Failed medical management

- no improvement within 48 – 72 hours

- new onset fever or worsening fever
- persistent or worsening abdominal pain
- enlarging pelvic mass
- new onset / persistent / worsening leukocytosis
- signs of sepsis
 No universal cut – off TOA size or volume which
would automatically warrant surgical intervention
● Surgery in terms of TOA size

- several studies --> > 5 cm (shows benefit)

- most experts --> > 8 cm (greatest risk of complications)

- FRENCH guideline --> > 3 cm

● Postmenopausal women with TOA

- rule out malignancy

● Procedure

- Exploratory laparotomy & pelvic clean up

- midline, vertical incison

- presence of a gynecologic surgeon is important

- Young, desirous of fertility --> laparoscopic drainage of TOA

- benefit of confirming the Dx

- effective treatment under

magnification

- faster recovery

- shorter hospitalization

- Imaging guided drainage of pelvic abscess

- less invasive
● Important things to remember

- Obtain culture (fluid, abscess wall tissue)

- histopathologic evaluation

- consider leaving a closed – suction drain

- hysterectomy --> vaginal vault is left open

How do we follow – up patient with TOA?
● No single recommendation as to the monitoring of TOA treated medically

● Periodic assessment (UTZ)

- 3, 7, 14, and 30 from start of treatment

- size and characteristic of the mass

● CPG recommendation --> repeat UTZ after 1 weeks of antibiotic Tx

--> mass < 20 cc vol --> resolved after 1 week

--> mass > 50 cc vol --> persisted
--> extend Tx for 21 days
●Beigi & colleagues --> imaging studies every 3 days then less
frequently once patient shows clinical
improvement

* Pelvic Inflammatory Disease, CPG.

“PID and TOA occur more frequently in women with
Endometrioses than those without endometriosis,
however it is unclear if women with endometriosis
are more prone to PID or vise versa.”
- Kobayashi H. Similarities in PAthogenetic Mechanisms Underlying the
Bidirectional Relationship between Endometrioses and PID.
https://doi.org/10.3390/diagnostics13050868. 2023
Thank you!