Gynecological

Emergencies
Dineshwaran Naidu
20110066
 Objectives
1. Introduction
2. Types of gynecological emergencies
3. Investigations
4. Management
5. Rapid assessment and management (RAM)
 Introduction
● Gynaecological disorders are a common cause of morbidity
among women of reproductive age worldwide.
● Acute gynaecological emergencies are conditions of the female
reproductive system that threaten the woman’s life, her sexual
function or her fertility.
● The most common gynaecological emergencies are ectopic
pregnancy, acute pelvic inflammatory disease, miscarriages and
complicated ovarian cysts.
 Ectopic pregnancy
● An ectopic pregnancy occurs when a fertilized egg implants outside the
uterus, typically in a fallopian tube.
● It can lead to life-threatening internal bleeding and requires immediate
medical intervention.
● Risk factors
○ Previous ectopic pregnancy
○ Cigarette smoking
○ Endometriosis
○ Age older than 35 years
Ectopic pregnancy
 Ectopic pregnancy
Symptoms of ruptured ectopic pregnancy
● Sudden, severe pain in the abdomen or pelvis
● Shoulder pain
● Weakness, dizziness, or fainting
 Ectopic pregnancy
Management of ectopic pregnancy
● Making the diagnosis
○ Transvaginal ultrasound
○ Serial serum β-hCG (> 3000 mIU/mL)
 Ectopic pregnancy
Management of ectopic pregnancy
● Treatment (Pharmacological)
○ Single dose of IM methotrexate, 50mg/m²
○ Measure serum β-hCG after 4 to 7 days
○ Repeat regimen if β-hCG if not reduced by 15% of the initial
reading on day 1
○ Highly contraindicated if
■ Gestational sac is >3.5 cm
■ Embryonic cardiac motion
 Ectopic pregnancy
Management of ectopic pregnancy
● Treatment (Non-Pharmacological)
○ Laparoscopic surgery
 Ectopic pregnancy
Management of ruptured ectopic pregnancy
1. Emergency evaluation to determine the severity of the situation
○ Physical examination
○ Vital signs assessment
○ Laboratory tests (e.g., blood count, blood type, and Rh status)
2. Ultrasound to locate the ectopic pregnancy
3. Surgical Intervention
 Acute Pelvic Inflammatory Disease
● Acute PID is the inflammation of the uterus, fallopian tubes, ovaries
and pelvic area caused by an infection
● Risk factors
○ Being sexually active and younger than 25 years old.
○ Having multiple sexual partners
○ Douching regularly
○ Having a history of pelvic inflammatory disease or a sexually
transmitted infection
Acute Pelvic Inflammatory Disease
 Acute Pelvic Inflammatory Disease
Diagnosis

➔ Clinical evaluation

◆ History

◆ Physical examination

◆ Assessment of symptoms
 Acute Pelvic Inflammatory Disease
Investigations
➔ Laboratory Tests to determine the severity and type of infection
◆ Complete blood count (CBC)
◆ C-reactive protein (CRP) level
◆ Sexually transmitted infection (STI) testing
◆ Testing for chlamydia and gonorrhea
● Nucleic Acid Amplification Tests (NAATs)
● Vaginal swab
 Acute Pelvic Inflammatory Disease
Imaging
➔ Transvaginal or
abdominal ultrasound
may be performed to
evaluate the reproductive
organs and rule out other
conditions.

Tubo-ovarian abscess
 Acute Pelvic Inflammatory Disease
Imaging
➔ CT scan

Tubo-ovarian abscess with extension to the recto-uterine pouch

 Acute Pelvic Inflammatory Disease
Treatment
➔ Inpatient vs. Outpatient depending on the severity of the infection
◆ High fever
Treat as inpatient
◆ Abscess formation
➔ Antibiotic therapy
◆ Gonorrhea - Single 500 mg IM dose of Ceftriaxone
◆ Chlamydia - Doxycycline 100 mg orally twice a day for 7 days
 Miscarriages

● Pregnancy loss or spontaneous abortion

● Diagnosis based on clinical symptoms, including vaginal bleeding
and abdominal pain, in conjunction with ultrasound findings.
 Miscarriages
● Diagnosis
○ Ultrasound is used to confirm
■ Presence of a nonviable pregnancy
■ Assess the gestational age
■ Determine the type of miscarriage (e.g., incomplete, complete,
missed).
Miscarriages
 Miscarriages
● Management Options
○ Misoprostol (a prostaglandin analog) for cases of missed
miscarriage or incomplete miscarriage
■ Oral/vaginal/sublingual 800 micrograms
■ Repeat every 3 hours for up to 3 doses
 Miscarriages
● Management Options
○ Surgical Management
■ Dilation and curettage (D&C)
● Indications
○ Severe bleeding
○ Signs of infection
○ Missed or incomplete
miscarriage.
 Ovarian cysts
● Ovarian cysts are fluid-filled sacs that can develop on or within
the ovaries.
● Found in females between age 20 and 40 years
● Symptoms:-
○ Severe and sharp pain pelvic pain
○ Pain during intercouse
○ Heavy or irregular periods
○ Difficulty in urinating
○ Abdominal tenderness
 Ovarian cysts
● Diagnosis
○ Transvaginal Ultrasound
○ Abdominal Ultrasound
 Ovarian cysts
● Diagnosis
 Ovarian cysts
● Diagnosis
 Ovarian cysts
● Investigations
○ Tumor markers, such as CA-125
■ CA-125 normal range falls between 0 and 35 U/mL
 Ovarian cysts
● Management of ovarian cyst

○ Observation and Monitoring (some resolve on their own)

○ Asymptomatic cysts in premenopausal women

■ Monitored with regular pelvic ultrasounds to assess changes

in size or characteristics

■ Reduce the risk of rupture

 Ovarian cysts
● Management of ovarian cyst (surgical options)
○ Laparoscopic Surgery (Laparoscopy)
■ Indications
● Large Cyst Size
● Persistence
● Complex Cysts
● Severe pelvic pain, bloating, or pressure
● Torsion Risk
 Ovarian cysts
● Management of ovarian cyst (surgical options)
Rapid assessment and management (RAM)

Presented with Access danger signs Consider

Cyanosis, respiratory Severe anaemia, heart

Airway/Breathing difficulties distress, skin pallor,lung fields failure,asthma,

Circulation(signs of shock) Skin cool & clammy, pulse, Shock

BP

Vaginal bleeding Gestational age Abortion, ectopic pregnancy,

molar pregnancy

Gestational age, temperature, Malaria, epilepsy, meningitis,

Unconscious BP, Blood sugar diabetes, hypertensive
disorders
Rapid assessment and management (RAM)
Assess Danger signs Consider

Weak,lethargic,frequent Severe anaemia, heart

painful micturition, failure,asthma,
High fever unconscious, neck stiffness,
lungs, abdominal tenderness,
vaginal discharge

Gestation age, BP, Pulse, Ovarian cyst, appendicitis &

Abdominal Pain temperature, size of uterus pregnancy, ectopic
pregnancy

Vaginal bleeding without Age, Pallor, pulse, BP, size of DUB,myomas, endometrial
pregnancy uterus, speculum hyperplasia, Neoplasms
(Cx, uterus,ovary).