Gynaecological Emergencies

Dr. A. BaraiMBBS, MRCS Ed, MSc

INTRODUCTION

• Common presentations in Emergency Department

• Could be a challenge sometimes!

• Mostly simple cases which are discharged

• Few can be life threatening

PRESENTATIONS

• Acute pelvic pain

• PV bleeding

• Shock

• Vomiting

• Fever

ACUTE PELVIC PAIN

TOPICS

• Ectopic pregnancy

• Miscarriage and threatened miscarriage

• Dysfunctional uterine bleeding

• Pelvic Inflammatory Disease

• Ovarian pathology

ECTOPIC PREGNANCYECTOPIC PREGNANCY

• 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

SITES

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

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

SIGNS

• Adnexal tenderness and masses

• State of cervix and material passing through it

• Fetal heart sounds (almost never heard in ectopic pregnancy)

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

DIAGNOSTIC CRITERIABelow 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.

SURGICAL MANAGEMENTIndications:• Unstable patient• Large gestational sac• Peritonitis

Options:• Emergency laparotomy/ laparoscopy• Salpingectomy/ salpingostomy

Things to consider:• Completed family• Check other fallopian tube• Counselling

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

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• 1st dose: IM Methotrexate 50mcg/m2/kg• Repeat beta HCG on day 4and 7. Expect a minimum

decrease of 15%

COUNSELLING

• Recurrence rate 12-20%

• Early confirmation of future pregnancy

• Early Ultrasound to confirm intrauterine pregnancy

MISCARRIAGEMISCARRIAGE

• “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

• 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.

TYPES

• Threatened miscarriage

• Inevitable miscarriage

• Incomplete miscarriage

• Complete miscarriage

• Missed miscarriage

• Septic miscarriage

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)

SYMPTOMS

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

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

DYSFUNCTIONAL UTERINE DYSFUNCTIONAL UTERINE BLEEDINGBLEEDING

• 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.

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

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.

• 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.

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.

PELVIC INFLAMMATORY DISEASEPELVIC INFLAMMATORY DISEASE

• 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.

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.

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

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

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.

CDC CRITERIAMinimum 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

INVESTIGATIONS

• Swabs for Chlamydia, Gonorrhoea

• Blood tests: FBC, CRP, ESR

• Ultrasound scan to view the reproductive organs.

• Endometrial biopsy

• Laparoscopy

TRIPLE SWABS

TREATMENTAntibiotics: • 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

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.

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

OVARIAN PATHOLOGYOVARIAN PATHOLOGY

• 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.

• 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.

SYMPTOMS

• Abdominal pain

• Abdominal distension

• DUB

INVESTIGATIONS

• Ultrasound

• Urine dipsticks

• Pregnancy test

• Blood tests: to exclude other abdominal pathology

TREATMENT

Surgical:• Laparoscopy• Laparotomy

Medical:• Hormone treatment• Supportive treatment

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

Thank you.