Gynaecological emergencies

Common emergencies seen in the Emergency Department.

1. Gynaecological Emergencies
Dr. A. Barai
MBBS, MRCS Ed, MSc

2. INTRODUCTION
•Common presentations in Emergency Department
•Could be a challenge sometimes!
•Mostly simple cases which are discharged
•Few can be life threatening

3. PRESENTATIONS
•Acute pelvic pain
•PV bleeding
•Shock
•Vomiting
•Fever

4. ACUTE PELVIC PAIN

5. TOPICS
•Ectopic pregnancy
•Miscarriage and threatened miscarriage
•Dysfunctional uterine bleeding
•Pelvic Inflammatory Disease
•Ovarian pathology

6. ECTOPIC PREGNANCYECTOPIC PREGNANCY

7. •Incidence 1-2% of all pregnancy
•Mortality rate 13-15%
•More common before 20/40
•97.7% occur in Fallopian tubes
•Delay in diagnosis can be catastrophic
•Major cause fallopian tube salpingitis

8. SITES

9. RISK FACTORS
•70% Tubal ligation failure ends up as ectopic
pregnancy
•History of ectopic pregnancy
•Previous tubal infection
•Fallopian and endometrial anomalies
•Fertility treatment
•Endometriosis
•IUCD’s

10. SYMPTOMS
•PV bleeding (50-80%)
•Abdominal/pelvic pain (90%)
•Shock (15-20%)
•6-8 weeks LMP
•Shoulder tip pain (large amount of bleeding)
•Postural symptoms

11. SIGNS
•Adnexal tenderness and masses
•State of cervix and material passing through it
•Fetal heart sounds (almost never heard in ectopic
pregnancy)

12. INVESTIGATIONS
•TV Ultrasound scan
•HCG (should almost double every 2 days)
•If HCG is > 1500 and there is no intra-uterine
pregnancy = probable ectopic
•bloods to rule out other causes of abdominal pain
•Rh status
•MSU

13. DIAGNOSTIC CRITERIA
Below the discriminatory zone:
•If the serial hCG level does not rise appropriately
across at least three measurements 48 to 72 hours
apart and there is no evidence on TVUS that confirms
an IUP
• If the serial serum hCG level is rising appropriately,
the patient is followed until the hCG is above the
discriminatory zone.
Above the discriminatory zone:
The diagnosis is made based upon the absence of
TVUS findings that diagnose an IUP OR findings at an
extrauterine site that confirm an ectopic pregnancy.

14. SURGICAL MANAGEMENT
Indications:
•Unstable patient
•Large gestational sac
•Peritonitis
Options:
•Emergency laparotomy/ laparoscopy
•Salpingectomy/ salpingostomy
Things to consider:
•Completed family
•Check other fallopian tube
•Counselling

15. CONSERVATIVE MANAGEMENT
•If HCG suggests non-viable ectopic
•If ‘unruptured’ and asymptomatic
•If patient lives nearby and able to comply with follow
up
•< 3.5cm

16. MEDICAL MANAGEMENT
•If gestational sac < 3.5cm and no fetal heart activity
•If patient is stable and NO pelvic free fluids in
ultrasound
•Patient staying nearby and ready to comply with
follow up
•1
st
dose: IM Methotrexate 50mcg/m2/kg
•Repeat beta HCG on day 4and 7. Expect a minimum
decrease of 15%

17. COUNSELLING
•Recurrence rate 12-20%
•Early confirmation of future pregnancy
•Early Ultrasound to confirm intrauterine pregnancy

18. MISCARRIAGEMISCARRIAGE

19. •“Expulsion of product of conception less than 500gm
or before 22 weeks of pregnancy with no evidence of
life at delivery”
•Habitual miscarriage is someone having 3
consecutive miscarriages
•Very early miscarriages can be assumed as delayed
periods

20. •According to the March of Dimes, as many as 50% of
all pregnancies end in miscarriage
•More than 80% of miscarriages occur within the first
three months of pregnancy.

21. TYPES
•Threatened miscarriage
•Inevitable miscarriage
•Incomplete miscarriage
•Complete miscarriage
•Missed miscarriage
•Septic miscarriage

22. CAUSES
•60% due to chromosomal abnormality
•Maternal illnesses
•Uterine structural abnormality
•Congenital infection
•Autoimmune disease
•Chemotherapy
•Radiation
•Induced termination of pregnancy Doctor or patient
(Abortion)

23. SYMPTOMS
•PV Bleeding that progresses from light to heavy
•Cramps
•Abdominal or pelvic pain
•Fever
•Passing of tissue

24. INVESTIGATIONS
•Blood tests, genetic tests, or medication may be
necessary if a woman has more than two
miscarriages in a row
•Endometrial biopsy, a procedure involving the
removal of a small amount of tissue from the lining
of the uterus for study under a microscope
•Hysterosalpingogram
•Hysteroscopy
•Laparoscopy

25. DYSFUNCTIONAL UTERINE DYSFUNCTIONAL UTERINE
BLEEDINGBLEEDING

26. •Dysfunctional uterine bleeding (DUB) is irregular
uterine bleeding that occurs in the absence of
recognizable pelvic pathology, general medical
disease, or pregnancy.
•It reflects a disruption in the normal cyclic pattern of
ovulatory hormonal stimulation to the endometrial
lining.
•The bleeding is unpredictable in many ways. It may
be excessively heavy or light and may be prolonged,
frequent, or random.
•About 1-2% of women with improperly managed
anovulatory bleeding eventually may develop
endometrial cancer.

27. SIGNS AND SYMPTOMS
•DUB should be suspected in patients with
unpredictable or episodic heavy or light bleeding
despite a normal pelvic examination.
•Typically, the usual symptoms that accompany
ovulatory cycles will not precede bleeding episodes.
•DUB is essentially a diagnosis of exclusion

28. PATHOPHYSIOLOGY
•Patients with dysfunctional uterine bleeding (DUB)
have lost cyclic endometrial stimulation that arises
from the ovulatory cycle.
•As a result, these patients have constant, noncycling
oestrogen levels that stimulate endometrial growth.
•Proliferation without periodic shedding causes the
endometrium to outgrow its blood supply.
•The tissue breaks down and sloughs from the uterus.
Subsequent healing of the endometrium is irregular
and dyssynchronous.

29. •Chronic stimulation by low levels of oestrogen will
result in infrequent, light DUB.
•Chronic stimulation from higher levels of oestrogen
will lead to episodes of frequent, heavy bleeding.

30. COMPLICATIONS
•Iron deficiency anaemia: Persistent menstrual disturbances
might lead to chronic iron loss in up to 30% of cases.
•Endometrial adenocarcinoma: About 1-2% of women with
improperly managed anovulatory bleeding eventually might
develop endometrial cancer.
•Infertility: associated with chronic anovulation, with or
without excess androgen production, is frequently seen in
these patients.

31. PELVIC INFLAMMATORY DISEASEPELVIC INFLAMMATORY DISEASE

32. •Pelvic Inflammatory Disease (PID) is an infection of
the female reproductive organs
•PID is one of the most serious complications of a
sexually transmitted disease in women
•It can lead to irreversible damage to the uterus,
ovaries, fallopian tubes, or other parts of the female
reproductive system
•It is the primary preventable cause of infertility in
women.

33. CAUSES
•If the cervix is exposed to a sexually transmitted
disease, the cervix itself becomes infected and less able
to prevent the spread of organisms to the internal
organs.
•PID occurs when the disease-causing organisms travel
from the cervix to the upper genital tract.
•Untreated gonorrhea and chlamydia cause about 90%
of all cases of PID.
•Other causes include abortion, childbirth and pelvic
procedures.

34. The most common etiologic agents in PID are:
•Neisseria gonorrhoeae,
•Chlamydia trachomatis
•Anaerobic bacterial species found in the vagina,
particularly Bacteroides spp.,
•Anaerobic gram-positive cocci, (Peptostreptococci),
•E. coli
•Mycoplasma hominis

35. SYMPTOMS
•Dull pain or tenderness in the lower abdominal area,
or pain in the right upper abdomen
•Abnormal vaginal discharge that is yellow or green in
colour or that has an unusual odour
•Painful urination
•Chills or high fever
•Nausea and vomiting
•Pain during sex

36. RISK FACTORS
•Women with sexually transmitted diseases, specially
gonorrhea and chlamydia, are at greater risk for
developing PID.
•Women who have had a prior episode of PID are at
higher risk for another episode.
•Sexually active teenagers are more likely to develop
PID than are older women.
•Women with many sexual partners are at greater risk
for sexually transmitted diseases and PID.

37. CDC CRITERIA
Minimum findings:Minimum findings:
Cervical motion tenderness and uterine and adnexal Cervical motion tenderness and uterine and adnexal
tenderness, along with WBCs seen on vaginal wet tenderness, along with WBCs seen on vaginal wet
mountmount
Additional supportive criteria:Additional supportive criteria:
- Oral temperature higher than 101ºF (38.3ºC)- Oral temperature higher than 101ºF (38.3ºC)
- Abnormal cervical or vaginal discharge- Abnormal cervical or vaginal discharge
- Elevated erythrocyte sedimentation rate- Elevated erythrocyte sedimentation rate
- Elevated C-reactive protein level - Elevated C-reactive protein level
- Laboratory documentation of cervical infection - Laboratory documentation of cervical infection
with with N. gonorrhoeaeN. gonorrhoeae or or C. trachomatisC. trachomatis

38. INVESTIGATIONS
•Swabs for Chlamydia, Gonorrhoea
•Blood tests: FBC, CRP, ESR
•Ultrasound scan to view the reproductive organs.
•Endometrial biopsy
•Laparoscopy

39. TRIPLE SWABS

40. TREATMENT
Antibiotics:
•Doxycycline/ IV Cefuroxime/ Azithromycin plus
Metronidazole
•Sexual partner (s) also must be treated even if they
do not have any symptoms. Otherwise, the infection
will likely recur.
Surgery:
•When PID causes an abscess
•Laparoscopic surgery
•Laparotomy

41. COMPLICATIONS
•Recurrent episodes of PID can result in scarring of
the fallopian tubes, which can lead to infertility,
ectopic pregnancy (tubal), or chronic pelvic pain.
•Infertility occurs in about one in eight women who
have PID.

42. PREVENTION
•Avoid multiple sexual partners.
•Use barrier methods (condoms and/or a diaphragm)
and spermicides
•Avoid IUDs if you have multiple sexual partners.
•Seek treatment immediately
•Have regular gynaecologic check-ups and screenings

43. OVARIAN PATHOLOGYOVARIAN PATHOLOGY

44. •Cysts are fluid-filled sacs that can form in the ovaries.
They are very common. They are particularly
common during the childbearing years.
•There are several different types of ovarian cysts.
•The most common is a functional cyst. It forms
during ovulation. That formation happens when
either the egg is not released or the sac in which the
egg forms does not dissolve after the egg is released.

45. •Polycystic ovaries. In polycystic ovary syndrome
(PCOS), the follicles in which the eggs normally
mature fail to open and cysts form.
•Endometriosis. In women with endometriosis, tissue
from the lining of the uterus grows in other areas of
the body. This includes the ovaries. It can be very
painful and can affect fertility.
•Cystadenomas. These cysts form out of cells on the
surface of the ovary. They are often fluid-filled.
•Dermoid cysts. This type of cyst contains tissue
similar to that in other parts of the body. That
includes skin, hair, and teeth.

46. SYMPTOMS
•Abdominal pain
•Abdominal distension
•DUB

47. INVESTIGATIONS
•Ultrasound
•Urine dipsticks
•Pregnancy test
•Blood tests: to exclude other abdominal pathology

48. TREATMENT
Surgical:
•Laparoscopy
•Laparotomy
Medical:
•Hormone treatment
•Supportive treatment

49. REFERENCES
•Fylstra, DL. (2012). Ectopic pregnancy not within the (distal) fallopian tube: etiology,
diagnosis and treatment. American journal of obstetrics and gynecology. Elsevier.
•Harris, NS (2012). Gynaecology Emergencies. Slideshare. [Online].
http://www.slideshare.net/limgengyan/gynaecology-emergencies
•Tulandi, T. (2014). Ectopic pregnancy. UpToDate. [Online]. www.uptodate.com/?
source=machineLearning&Search=ectopic+prenancy&selectedTitle=1%7E150&
•Yao, M. and Tulandi, T (1997). Current status of surgical and nonsurgical management of
ectopic pregnancy. Fertility and sterility. Elsevier.
•Ectopic pregnancy. WebMD. [Online]. http://www.webmd.com/baby/guide/pregnancy-
ectopic-pregnancy

50. Thank you.