GYNECOLOGIC EMERGENCIES

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GYNECOLOGIC EMERGENCIES

• P.Zubor, M.D., PhD
• Obstetrics Gynecology, NMCSD

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Gynecologic Emergencies

• Ruptured Hemorrhagic Cyst
• Adnexal Torsion
• Ectopic pregnancy
• Septic Shock
• Septic abortion
• Ruptured Tubo-ovarian Abscess

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Acute Pelvic Pain

• HCG ()
• ECTOPIC PREGNANCY
• ECTOPIC PREGNANCY ECTOPIC PREGNANCY
• Abortion
• Corpus Luteum Cyst
• Fibroid Tumors
• Urinary Tract Dx
• All on - HCG list

• HCG (-)
• Cyst
• Torsion
• Mass cancer or benign
• Endometriosis
• CPP- exacerbation
• PID, cervicitis, abscess
• UTI, urolithiasis
• Appendicitis, ileus, IBS etc...
• Dysmenorrhea usually cyclic

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Benign Pelvic MassesNonneoplastic adnexal masses

• Physiologic
• Corpus luteum cyst
• Follicular cyst
• Theca lutein cyst
• Nonovarian
• Appendiceal
• Diverticulitis abscess
• Pelvic Adhesions
• Pyosalpinx-hydrosalpinx
• Uterine fibroids

• Nonfunctional Cysts
• Ectopic pregnancy
• Paraovarian
• Endometrioma
• Polycystic ovaries
• Germinal inclusion cysts
• Teratomas
• Inflammatory cysts
• Fallopian tube/broad ligament cysts
• Luteoma of pregnancy

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Ovarian Cysts

• Fluid-filled sac arising from the ovary
• common, asymptomatic if lt3cm
• typical ovarian function folliculogenesis
• 95 resolve spontaneously
• Occasionally, ovarian cysts cause
• delaying menstruation
• rupture
• torsion
• adnexal pain

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Ovarian Cyst

• Follicular cysts
• clear fluid, lt6cm, ovulating reproductive age
  women
• regress spontaneously in 1-3 months
• Corpus luteum cysts
• less common than follicular cysts
• more symptoms bleeding and pain
• may rupture, acute abdomen
• larger size
• intra-peritoneal bleeding, transfusion,
  adnexectomy?

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ADNEXAL CYST

• Hemorrhagic Ovarian Cyst
• unilateral sudden onset adnexal pain
• history consistent with mid-cycle pain
• symptoms may resolve with rest alone
• serial abdominal exams, follow hematocrit
  values
• if acute abdomen prepare for surgery
• if unresolving and continued drop in hematocrit
• prepare for shock supportive care, analgesia

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Functional Ovarian Cyst

• Unruptured ovarian cyst -most asymptomatic
• Detailed menstrual history gives clue to the
  diagnosis if no u/s available
• may cause pain ex. with exercise or sex
• distention of ovarian capsule
• once ruptured symptoms gradually resolve
• straw colored fluid only in peritoneal cavity
• supportive care, analgesia, explanation

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Functional Ovarian Cyst

• Watchful waiting
• serial exams, follow up until resolution
• time course approximately 5 days
• suggest hormonal contraception to prevent further
  recurrences
• treatment involves rest and analgesics
• occasionally non-urgent surgical intervention
  with cystectomy is required
• Middle sized tumors (8-12cm) may torse

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Torsion Ovarian Cyst

• occurs in an enlarged or abnormal adnexa
• twisting its vascular stalk
• disrupting the blood supply
• causing necrosis and pain
• requires surgical intervention
• to remove necrotic adnexa or
• emergent in order to possibly salvage adnexa
• If surgery is unavailable, then bedrest, IV
  fluids and pain medication
• Recovery may be satisfactory yet prolonged

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Torsion - Ovarian Cyst

• colicky, progressive, unilateral pain
• pain is usually opposite the involved side
• recurrent nausea and vomiting
• vagal response to twisted, stretched mesentary
• normal bowel sounds and no anorexia
• tachycardia, afebrile, normal u/a, (-)hcg
• WBC normal- mildly elevated, no bands

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Acute Pelvic Pain

• HCG ()
• ECTOPIC PREGNANCY
• ECTOPIC PREGNANCY
• ECTOPIC PREGNANCY
• Abortion
• Corpus Luteum Cyst
• Fibroid Tumors
• Urinary Tract Diagnosis
• All on - HCG list

• HCG (-)
• Cyst
• Torsion
• Mass cancer or benign
• Endometriosis
• CPP- exacerbation
• PID, cervicitis, abscess
• UTI, urolithiasis
• Appendicitis, ileus, IBS etc...
• Dysmenorrhea usually cyclic
• Mittleschmerz

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Bleeding and HCG ()

• ECTOPIC PREGNANCY
• or
• THREATENED ABORTION
• Possible Spontaneous Abortion (SAB)
• follow with serial BHCG or sonography
• ideally pathology will confirm POC
• dont be fooled by decidual casts

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Ectopic Pregnancy

• Most common cause of maternal death in the first
  half of pregnancy 13-15
• Incidence 2 (80,000/yr) - 3x increase
• 97.7 occur in fallopian tube
• 78 ampulla, 12 isthmus, 2 cornual
• Major cause is histologic salpingitis
• any mechanism that impairs tubal motility
• blastocyst remains in tube at implantation

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ECTOPIC PREGNANCY

• Pain with bleeding and HCG
• Risky history
• PID, chlamydia, tubal surgery, hx ectopic
• infertility, endometriosis, IUD
• 75 tubal ligation failures are ectopic
• Calculate dates LMP ( 6-8 wk)
• If possible quantitative HCG BHCG
• If possible sonogram mass, blood in cul de sac,
  empty uterus

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Ectopic pregnancy

• 90 pelvic or abdominal pain
• 50-80 vaginal bleeding
• 30 adnexal mass on pelvic exam
• 80-95 adnexal tenderness to palpation
• U/S cul de sac fluid, empty uterus
• QHCG usually less than 6,000
• Luckily, shock present only 15-20

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ECTOPIC PREGNANCY

• How do you rule out an ectopic pregnancy?
• RULE IN AN INTRAUTERINE PREGNANCY !!!!
• IF PAIN and ()HCG ........ plan to operate
• Diagnostic and possible operative laparoscopy
• Salpingostomy vs Salpingectomy
• Be as conservative as possible, ruptured 20
• If limited time and resources..... ex lap!!

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Ectopic Pregnancy

• If diagnostic criteria met for ectopic pregnancy,
  methotrexate 50mg/m2 IM may be used for selected
  candidates
• QHCG less than 15,000
• adnexal mass less than 3.5 cm
• normal liver and renal function, normal platelets
  and WBC
• no evidence of surgical abdomen
• desired fertility
• no fetal heart beat on u/s in adnexa
• reliable follow up for serial QHCG

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Septic Abortion

• Obtain thorough history including
• dating, location of procedure, symptoms
• high index of suspicion
• make no assumptions
• assess vital signs and pelvic exam
• broad spectrum intravenous antibiotics
• fluid resuscitation - prepare to transfer

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Septic Shock

• Gram negative organism 30-80
• facultative anaerobic bacteria
• E Coli, Klebsiella, Serratia,Enterobacteriaceae
• Gram positive organism 6-24
• Streptococci,Staphylococci, Prevotella,
  Bacteroides
• Endotoxin stimulate macrophages to produce
  cytokines (TNF and IL)
• Endometritis,UTI,septic abortion, TSS,
  necrotizing fascitis,chorioamnionitis, PID

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Clinical Manifestations of Septic Shock

• Cardiovascular Hypotension, cardiac
  dysfunction
• Pulmonary Hypoxemia, (ARDS)
• Renal Oliguria, ATN ,Interstitial
  nephritis
• Hematologic DIC, leukocytosis
• Neurologic Mental status changes
• Fever TNF effect on hypothalamus

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Management of Septic Shock

• Maintain adequate oxygenation
• Maintain adequate circulating volume
• Transfer to ICU
• Obtain appropriate lab data
• Begin inotropic or vasopressor treatment to
  maximize cardiac performance
• Administer broad spectrum antibiotics
• Surgically remove infected abscess or drain
  abscess or both, if necessary

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OTHER OBGYN URGENCIES

• Trauma
• Abnormal Uterine Bleeding
• Infection - PID
• Precipitous Delivery
• Emergency Contraception

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TRAUMA

• Accidental straddle injuries, blunt
• Intentional not operational gyn
• Sexual assault
• rape kits for evidentiary exam
• External repairs, evacuate hematoma
• Assess for other internal injuries

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Abnormal Uterine BleedingTIPSBIT

• T- Tumor polyp, fibroid
• I - Iatrogenic meds, surgery
• P - Pregnancy Check Urine HCG
• S - Systemic renal , liver, thyroid, anorexia
• B- Bleeding
• I - Infection
• T- Trauma

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Pelvic Inflammatory Disease

• Diagnose with abdominal pain, CMT and bilateral
  adnexal tenderness to palpation
• Treat with CDC recommendations
• If unsure of diagnosis laparoscopy / empiric tx
• OR for abscess, peritoneal signs or ?dx
• Admit for peritoneal signs, pt unreliable or
  unable to take po medications well
• If operate TAH/BSO vs adnexectomy

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Obstetrical Emergencies

• Precipitous Delivery
• Concealed Pregnancy

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Precipitous Delivery

• Stay calm - accept the reality
• Safety - call for help - supportive care
• Suction - Dry - Stimulate - Supply O2
• Temperature regulation - skin to skin
• Natural oxytocin - infant begins suckling
• Await spontaneous separation placenta
• Clean procedure, not sterile

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Emergency Contraception

• Goal is to treat within 72 hours of unprotected
  intercourse to reduce the risk of pregnancy by
  75
• If 100 women have sex in middle two weeks ot
  their cycles, 8 would become pregnant.This method
  reduces 8 to 2 women.
• ? likelihood that she is already pregnant
• High dose estrogen with antiemetics
• If within 5 days of event consider IUD

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Emergency Contraception

• Yuzpe Method
• Ingestion of 0.1mg ethinyl estradiol and
• 1.0mg DL- norgestrel or its equivalent
• in 2 doses 12 hours apart
• Antiemetic one hour prior to each dose
• There is neither evidence of increased risk nor
  evidence of safety among women who have
  contraindications to oral contraceptives.
• No evidence of any teratogenic effects
  HCG is a contraindication

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