GYNECOLOGIC

EMERGENCIES
P.Zubor, M.D., PhD
Obstetrics & Gynecology, NMCSD
 Gynecologic Emergencies

 Ruptured Hemorrhagic Cyst

 Adnexal Torsion
 Ectopic pregnancy
 Septic Shock
» Septic abortion
» Ruptured Tubo-ovarian Abscess
 Acute Pelvic Pain
 HCG (+)  HCG (-)
 ECTOPIC PREGNANCY  Cyst
 ECTOPIC PREGNANCY  Torsion
ECTOPIC PREGNANCY  Mass: cancer or benign
 Abortion  Endometriosis
 Corpus Luteum Cyst  CPP- exacerbation
 Fibroid Tumors  PID, cervicitis, abscess
 Urinary Tract Dx  UTI, urolithiasis
 All on - HCG list  Appendicitis, ileus, IBS etc...
 Dysmenorrhea usually cyclic
 Benign Pelvic Masses
Nonneoplastic 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
 Ovarian Cysts

Fluid-filled sac arising from the ovary

common, asymptomatic if <3cm
typical ovarian function: folliculogenesis
95% resolve spontaneously
Occasionally, ovarian cysts cause:
 delaying menstruation
 rupture
 torsion
 adnexal pain
 Ovarian Cyst
Follicular cysts
clear fluid, <6cm, 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?
 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
 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
 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
 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
 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
 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
 Bleeding and HCG (+)

 ECTOPIC PREGNANCY
or
 THREATENED ABORTION
» Possible Spontaneous Abortion (SAB)
» follow with serial BHCG or sonography
» ideally pathology will confirm POC
» don’t be fooled by decidual casts
 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
 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
 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%
 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!!
 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
 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
 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
 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
 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
OTHER OBGYN URGENCIES

Trauma
Abnormal Uterine Bleeding
Infection - PID
Precipitous Delivery
Emergency Contraception
 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
 Abnormal Uterine Bleeding
“TIPSBIT”

 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
 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
Obstetrical Emergencies
Precipitous Delivery
Concealed Pregnancy
 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
 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
 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