Initial resuscitation using the airway, breathing and circulation approach may need to be employed simultaneously with the initial assessment.
- Fluids – intravenous crystalloid infusion
- Analgesia – systemic opiates may be required and should not be delayed purely for fear of 'masking' symptoms
- Antibiotics – where a woman is pyrexial or has systemic features of sepsis, broad spectrum antibiotics should be commenced with aerobic and anaerobic cover. Ideally this should be once appropriate cultures have been taken, but should not be delayed for cultures if there is to be significant delay.
- Oxygen – where a woman is short of breath or has low oxygen saturation, oxygen should be administered by mask or nasal cannulae
- Urinary catheter – where a woman is haemodynamically compromised, urine output must be monitored hourly by urometer
- Central venous pressure – where initial fluid resuscitation is unsuccessful or a woman is acutely unwell, fluid management is best guided by monitoring central venous pressure.
Ovarian torsion, cyst rupture or haemorrhage
- Most cases of ovarian cyst haemorrhage or rupture can be managed expectantly if the diagnosis is fairly certain and there is no haemodynamic compromise
- Torsion should be managed with laparoscopic detorsion (ovarian cysts).
- Classical teaching recommended that all abscesses should be drained by laparotomy and, more recently, by laparoscopy
- More evidence is now emerging of the efficacy of broad-spectrum antibiotics to treat the abscess and sometimes avoid surgical intervention
- Where it is not possible to clarify the diagnosis, it may be necessary to perform laparoscopy or laparotomy to make a diagnosis
- If the woman is stable, however, transvaginal ultrasound has a high sensitivity for confirming the diagnosis and allows for a trial of conservative management.
Women with advanced ovarian cancer may present with obstruction of either the large or small bowel, this occurs in up to 50% of patients in epithelial ovarian cancer at some point during their disease. Generally for bowel obstruction to occur, disease is at an advanced stage (FIGO III-IV) and is more common with relapsed disease. Uncommonly this may be the initial presentation for some women. Peri-operative imaging is essential to guide management. Where appropriate, primary debulking surgery may be required by a gynae-oncologist. It should be considered though, that palliation may be a better option in some, given the high morbidity and mortality with surgery in late stage disease.
Joint surgical approach
In the woman with an acute abdomen, where the diagnosis can not be confirmed, laparoscopy may be indicated in conjunction with the surgical team.
Informed consent is difficult in this situation as the outcome is unknown. In the emergency situation, acting in the best interests of the patient may necessitate a discussion of what may be encountered and the likely surgical possibilities including diagnostic laparoscopy with or without laparotomy, salpingoophorectomy, appendectomy and bowel resection or colostomy/ileostomy.