GYNAECOLOGICAL AND

RH EMERGENCIES
• Abortion
• Ectopic Pregnancy
• Ovarian/tubal Torsion
• Testicular Torsion
 Abortion
• Refers to termination of
pregnancy before viability, that is
28 weeks gestation.
• In advanced setups it may be
termination of pregnancy to a
fetus weighing less than 500gms
or before 20 weeks gestation
• Abortion is one of the reasons
for early pregnancy bleeding.
Others include ectopic
pregnancy, abnormal uterine
bleeding, hydatidiform mole,
infections in pregnancy,
neoplasms
• Abortion can occur
spontaneously (Miscarriage) or it
may be induced(purposefully
started by drugs/mechanical
means)
• Delivery of a viable fetus before
37 completed weeks is a
Preterm Delivery

• Death of a viable fetus

intrauterine leads to a stillbirth
which could be MSB or FSB
 Types of Abortion
• Threatened Abortion
• Complete Abortion
• In-Complete Abortion
• Septic Abortion
• Missed Abortion
• Therapeutic Abortion
• In-evitable Abortion
• Induced Abortion (Criminal)
• Habitual Abortion
• Molar Abortion
 Threatened Abortion

• There is little vaginal bleeding

• Mild lower abdominal rhythmic

pain and backache
• On speculum vaginal exam – the
cervical os is closed

• The size of the uterus

corresponds with gestational
dates, is soft and is not tender
 Management
• History taking and general
physical exam
• Lab investigations : CBC, ABO
Rhesus, Pregnancy Test,
Urinalysis, VDRL, BS for mps,
Progesterone assay, thyroid
function tests
• Imaging – Pelvic u/s to confirm
fetal status

• Complete bed rest, may need

sedation
• Pain relief – bascopan,
paracetamol

• Treat the infections

• Avoid coitus for atleast 2 weeks

after cessation of symptoms
• The outcome could be stopage of
bleeding and continuation of the
pregnacy or progression to in-
evitable, imcomplete or
complete abortion
 In-evitable Abortion
• This is characterized by moderate
to severe uterine cramping pain
which doesn’t respond to
analgesics
• There is heavy uterine bleeding
of more than 7 days
• The cervical os dilatation is
greater than 3cm with
effacement but the products of
conception are not yet
expelled.
• The membranes may have
ruptured there is draining of
liquor
• The uterine size corresponds
with gestational age
• POCs may be protruding at the
cervical os
 Management
• Allow to progress
• Augmentation with oxytocin
drip and help prevent excessive
bleeding
• Pain relief as necessary
• Counseling and psychological
support
 Complete Abortion
• The products of conception are
all expelled (fetus, placenta,
membranes)
• Mild or no per vaginal bleeding
• No abdominal pain
• The cervical os is closed but
patulous(features of having been
passed through)

• Well contracted uterus with

empty cavity
 Management
• If client presents with shock –
resuscitation (ABC)
• If anemic – Hematinics or BT as
necessary
• Prevent further excessive
bleeding – oxytocin injection
• Antibiotics may be given as
prophylaxis to prevent sepsis
(Augumentin + Metronidazole)
• Abd/Pelvic U/S to rule out
retained POCs
• Psychological support and
counseling; partner involvement
• Contraception services to allow
time for endometrial
healing/dual protection
• If spontaneous refer to
gynecologist for further
investigations and possible
intervention to prevent future
abortion
 In-Complete Abortion
• Most common type abortion
• There is heavy bleeding
• Severe low abdominal pain which
is labor like cramping pain.
• The uterus is enlarged and boggy
– not contracted
• The cervical os is open
• The products of conception are
partially expelled (Some are
retained)
• It may be as a result of
spontaneous abortion or induced
 Management
• Incomplete abortion with heavy
bleeding is live threatening
• Most common with unsafe
abortions and one of the
leading causes of maternal
mortality
• Clients come in shock, anemic
and some with sepsis
• First intervention is to
stabilize/resuscitate the patient –
ABC
• Fix large bore iv line, set up iv
fluids
• Take samples for GXM, Initiate
blood transfusion as necessary
• Start parenteral Antibiotics
immediately
• Do pain relief
• Abd/Pelvic U/S for diagnosis
• Evacuate the POCs:
–Use of drugs – Oxytocin,
Misoprostol(Cytotec)
Mifepristone
–Visible POCs can be digitally
removed or by use of forceps
–Mannual Vacuum Aspiration
(MVA)
–Dilatation and Curretage
• MVA is the preferred due to
reduced risk of post-evacuation
complications, Less
expensive/reusable equipment
used, emergency PAC can be
provided at remote sites (small
clinics) not just in urban centers
Postabortion Care 30
• Psychological support and
counseling

• Contraception services to
allow time for endometrial
healing/ dual protection
• Refer other RH services eg
counseling, HTS, Ca cervix
screening
• If spontaneous refer to
gynecologist for further
investigations and possible
intervention to prevent future
abortion
 Septic Abortion
• This is incomplete abortion with
evidence of infection

• There is fever, foul lochial

discharge, pelvic pain and
tenderness
• Mostly associated with criminal
induced abortion/clandestine
abortions

• Clients are mostly in septic

shock compounded by blood
loss
• There is marked suprapubic
tenderness with signs of
peritonitis
• There may be signs of sytemic
septicemia eg jaundice due to
hemolysis
• Associated with genital tract
trauma as induction is normally
done using crude objects in
clandestine cases
• Mostly as a result of prolonged
period between the onset of
abortion to complete uterine
evacuation
• Most causative microbes are
Streptococcus A, H.
Influenzae, Clostridium
perfingens, klebseiella,
pseudominas, compylobacter
 Management
• First intervention is to
stabilize/resuscitate the patient –
ABC
• Fix large bore iv line, set up iv
fluids
• Take samples for GXM, Initiate
blood transfusion as necessary
• Start parenteral Antibiotics
immediately – Broad
spectrum(Cephalosporins,
metronidazole,
Vancomycin,clindamycin,
meropenem)
• Do pain relief
• Lab samples: CBC – Hb, WBC &
Platelet count crucial to rule out risk
of DIC; Culture & Sensitivity
• Abd/Pelvic U/S for diagnosis
• Prevent further bleeding – oxytocin
drip
• Do immediate evacuation by MVA
(Most preferred) or D&C in theatre
• Hysterectomy is considered if:
–Severe infection with distorted
uterus eg by clostridium
(Gangrenous uterus)
–Evidence of uterine perforation
–Evidence of abcess
–No improvement on treatment
and sepsis persists
• Psychological support and
counselling; Family support

• Contraception services to allow

time for endometrial healing/
dual protection
• Refer other RH services eg
counselling, HTS, Ca cervix
screening

• Refer for further investigations

and possible intervention to
prevent future abortion
 Induced Abortion
• Illegal interference with pregnancy
on demand, done by unqualified
medical personnel without any legal
justification
• Mostly associated with
incompleteness, sepsis, genital
trauma, severe hemorrhage and
even death
• Clandestine or unsafe abortion
– done in inappropriate
conditions/environments
leading to infection
 Therapeutic Abortion
• Is a form of induced abortion
• This is medically done to save
the life of the mother
• It has to be recommended by
two registered medical doctors,
a gynaecologist and a
psychiatrist

• It has to be done by a qualified

and licensed medical personnel
• Some medical conditions which
may warrant therapeutic
abortion include Persistent
heart disease, renal disease,
invasive cervical carcinoma,
psychiatric illiness, SGBV,
Evidence of gross fetal
abnormalties
• There must be consent and be
done in a standard health
facility

• Psychological support for the

client and family
• Commonly used methods
depending on gestation age:
–Use of drugs Mifepristone,
Misoprostol,
Oxytocin,Methotrexate,
–MVA
–D&C
–Hysterotomy if the above fail
 Missed Abortion
• Retained dead products of
conception (less than 8wks) in
utero due to progesterone
which reduces uterine
contractility –viable developing
placenta
• There is spotting of dark blood
or brownish vaginal discharge
with no abdominal pain

• The cervical os is firm and

closed
• The uterine size is smaller than
gestational age and there is no
further increase in abdominal
girth

• The signs and symptoms of

pregnancy disappear
• Pelvic u/s shows a wrinkled sac
containing a macerated fetus

• High risk of deveping

coagulation abnormalties -DIC
 Management
• Pelvic u/s confirms diagnosis
• Lab investigations for indications
of DIC- Platelet count, clotting
time
• Use of antibiotics for treatment
or prevention of sepsis
• Management is by evacuating
the uterus - use of
prostaglandins or D&C

• Blood transfusion as necessary

 Habitual Abortion
• Occurrence of three or more
consecutive abortions in one
client
• Usually due to:
–anatomical abnormalties eg
cervical incomptence,
congenital uterine
abnormalties, fibroids/polyps,
asherman syndrome.
- Hormonal abnormalties eg
Thyroid dysfunction, Diabetes,
progesterone insuficiency

- Infections eg gonorrhea,
chlamydia, Syphylis, Herpes
- Genetic congenital
abnomalties

- Immunological factors

- Systemic diseases eg HTN,

DM, Renal
 Management
• Comprensive history taking,
physical exam and
investigations to determine the
cause
• Manage immediate
complictions eg anemia,
infections
• Management depends on the
specific identified cause eg
controlling the underlying
medical condition, cervical
cerclage(Mac Stitch) incase of
cervical incompetence
• Refer to gynecologist for follow
up
• Counseling and psychological
support
• Family and community support
in case of childlessness –
explore available options
 Molar Abortion
• Is suspected when there is
threatened abortion in which
bleeding does not settle within
one week of bed rest

• The uterine size is larger than

gestational age
• No palpable fetal parts

• No fetal movements are felt

at gestation of 20weeks
• It may also present as
incomplete abortion i.e the
cervical os is open, there is
heavy bleeding with passage of
typical grape-like vesicles which
confirms the diagnosis
• Early Signs of pregnancy are
still present and severe even
after 3 months gestation i.e
hyperemesis gravidarum
 Management
• Lab test check for sustained
high levels of HCG
• Pelvic U/S to confirm diagnosis
• Resuscitation as indicated –
ABC
• Put up oxytocin drip
• Molar evacuation in theatre–
D&C
• Evacuation repeated at 2 weeks
to make sure all remains of the
mole have been removed
• Sample molar tissues are taken
for histology to rule out
choriocarcinoma which is
suspected if there is recurrent
bleeding, PT is positive 3
months after evacuation (Beta-
HCG test
• Contraception for 1 yr as the
client is being followed up by
gynecologist
 General possible causes of
spontaneous Abortion
• Fetal development
abnormalities eg neurotube
defects, anencephaly,
autosomal chromosome
abnormalities eg down
syndrome
• Infections eg syphylis, rubella,
malaria, HIV, Herpes simplex,
peritonitis
• Endocrine abanormalties eg
uncontrolled DM, insufficieint
progesterone release by corpus
luteam or placenta
• Drug use eg smoking, excessive
alcohol
• Environment factors eg
exposure to radiation and
chemicals eg arsenic, lead,
formaldehyde,
diethylstillbestrol(DES)
• IUCD incase of contraceptive
failure

• Uterine defects eg uterine

synechiae/scarring, congenital
abnormalties, Fibroids, Cervical
incompetence
• Trauma to the mother

• Other systemic conditions eg

severe anemia
 Complications Of
Abortion
• Severe hemorrhage which is life
threatening or may cause severe
morbidity eg Sheehan Syndrome
• PID
• Intrauterine scarring/synechia–
Asherman Syndrome
• Infertility
• Ectopic pregnancy
• Social and family problems
• NB: Abortion care services
should aim to manage the client
holistically. Currently this
services are organized into a
minimum package called
Comprehensive Abortion Care
(CAC) services as a component of
Reproductive Health Care
• The key elements of CAC services are:
1. Emergency treatment( Resuscitation,
evacuation of the uterus, antibiotics,
restore injured organs)
2. Family planning and dual protection
3. Linkage and referral to other health
services eg HTS, CCC, YFS, counselling
4. Community involvement
 Possible Nursing Diagnosis
for Abortion client
• Deficient fluid volume related
to hemorrhage as manifested
by a low BP…., high pulse of
…… and a cold clammy
skin…….Possible interventions
• Risk for infection related to
retained intrauterine products
of conception …..possible
interventions
• Ineffective peripheral tissue
perfusion related to low blood
oxygen carrying capacity as
manifested by a low Hb of
…..Possible interventions
• Interrupted family processes
related to the loss of pregnancy
as manifested by client
verbalization of fear of
significant others’ opinion and
refusal to take Fp
Method…..possible interventions
END
ECTOPIC PREGNANCY
• It refers to implantation of the
zygote outside the uterine cavity
• Common types of Ectopic
Pregnancy
Tubal Pregnancy
Abdominal Pregnancy
Cervical Pregnancy
 Ovarian – very rare
 Tubal Ectopic Pregnancy
• Implantation takes place in the
fallopian tubes

• Most common type of ectopic

pregnancy
• Due to failure of the fertilized
ovum to move into the uterine
cavity hence implantation may
take place at the Ampulla, Isthmus
or interstitial portion. This is as a
result of alteration in the normal
function of the oviduct in
transporting the zygote
• The zygote penetrates through the
endosalphinx and gets implanted in
the mesosalphinx
• It grows and extends the muscle
layer and there is increase network
of maternal blood vessels, the
increased pressure can destroy the
embryo since there is no extensive
decidua for implantation.
• The trophoblast invades maternal
blood vessels thus causing local
hemorrhage and subsequent
hematoma formation.
• The muscle wall of the tube does
not have the capacity for
hypertrophy and distension.
• As the pregnancy grows there is
increased risk of tubal rupture
and death of the ovum.

• Rupture may be spontaneous,

due to coitus, trauma or
iatrogenic eg during bimanual
exam
• Tubal ectopic pregnancy can be
acute (ruptured/un-ruptured) or
chronic –slow leaking
 Possible outcomes of tubal
ectopic
• Tubal Abortion – it may detach
and be released into the pelvic
peritoneal cavity through the end
of oviduct
• Tubal Rapture – Most common.
The tube tears due to pressure of
the enlarging pregnancy
• Tubal Mole – Bleeding around
the embryo with formation of
clots. The embryo dies off.

• Pelvic Hematocele- collection

of blood in pouch of douglas
• Secondary Abdominal ectopic
pregnancy where the tubal
rapture releases the embryo in
the peritoneum where it
continues to grow
 Causes/Risk factors
• Congenital abnormalities of
the fallopian tube eg
hypoplasia (Incomplete
development), tubal
diverticula(Outpouch)
• Infections eg PID (salpingitis),
Postabortal/peurperal sepsis. This
may alter the cilia and peristaltic
action of the tube slowing down
zygote movement towards uterine
cavity. Infections also cause
partial tubal blockage: sub-
infertility
• Peritubal adhesions which cause
the tubes to kink and narrowing
of the lumen

• Previous surgery where integrity

of the tubes may be altered eg
CS, Failed BTL, tuboblasty
• Use of IUCD
• In-Vitro fertilization – the
embryo is wrongly implanted
in the tube
• Endometriosis
• Previous history of ectopic
pregnancy

• Tumors that distort the tube eg

uterine myomas and adnexal
masses
• Hormonal alteration effects on
the peristaltic smooth muscle
movements eg frequent use of
high-dose Emergency pills

• Cigarette smoking and

excessive alcohol use
 Signs and symptoms of
tubal ectopic
• History of Amenorrhea
• Vaginal spotting or bleeding
• Localized acute, sharp,
stabbing lower abdominal
pain
• Signs of peritoneal bleeding i.e
dizziness, shoulder pain due to
hemoperitoneal diaphragmatic
irritation of cervical sensory
nerves, nausea
• Signs of shock/hypovolemia –
low BP, low temp, high pulse
• Signs of anemia – syncope
(fainting)
• Lower abdominal tenderness on
examination
• On pelvic exam – cervical motion
tenderness
• Lateral and posterior fornix
tenderness, boggy mass and
vascular pulsation
• For chronic slow leaking there is
irregular vaginal bleeding of dark
blood
• Due to hormones the uterine
size corresponds to gestation
during the first 3months
• Positive Pregnancy Test
• The ectopic is confirmed on
pelvic U/S
 Differential Diagnosis
• PID Salpingitis
• Abortion
• Ruptured ovarian cysts
• Ovarian Torsion
• Appendicitis
• Peritonitis
 Management
• Ectopic pregnancy is an
emergency; it is one of the
common causes of maternal
mortality due to severe
hemorrhage and sepsis
• Quick targeted history taking and
physical exam
• High index of suspicion.
‘Always think of ectopic
pregnancy in a woman of
reproductive age in whom
there is a possibility of
pregnancy’.
Always
‘Think of ectopic pregnancy in a
woman with anemia, unusual
complaints and shock’.
• First intervention is to resuscitate
the patient

• Take blood samples for CBC, GXM,

Initiate blood transfusion as
necessary; Autotranfusion can be
done
• Start parenteral Antibiotics
immediately

• Do pain relief
• Paracentesis is done – a postive
result is aspiration of non-clotting
blood. With experience
culdocentesis can also be done –
mostly in chronic ectopic(Dark
blood)
• Abd/Pelvic U/S or Pregnancy Test
for diagnosis
• Immediately prepare for an
emergency explorative
laparotomy in theatre. This
should be done in the emergency
department
• Salpingectomy Is done in theatre
- surgical procedure where one or
both of a woman's fallopian
tubes are removed
• Salpingotomy or salpingostomy
can also be done – prone to future
ectopic
• Resection and anastomosis –
incase of isthmic ectopic
• Documentation of the state of the
other tube and ovaries is vital
• Provide post-operative nursing
care

• Cytotoxic drugs may be used by

the gynecologist eg
methotrexate - high failure rates
and bad side effects
• Psychological support and
counselling on client concerns
about future need for children

• Link to other RH services eg Fp,

HTS, Cancer screening , follow
up at GOPC
 Abdominal Ectopic
Pregnancy
• Refers to implantation of the zygote
on the peritoneal surface

• Mostly due to ruptured tubal where

the embryo is released into the
peritoneal cavity but remains
attaechde on the tube
• The embryo grows in the
peritoneal cavity though
survival chances are minimal. If
it survives it can grow upto 30
weeks. This is a rare form of
ectopic
 Signs & symptoms
• Persistent lower abdominal
pain

• Feeling of constipation

• Urinary frequency
• Nausea and vomiting

• Painful fetal movements

• On palpation, fetal parts are

obviously and superficially felt
• Abnormal fetal lie

• Very audible fetal heart sounds

• Abd u/s confirms diagnosis

 Management
• General interventions as for
tubal ectopic pregnancy

• Delivery by explorative
laparatomy
• Fetus may not be viable

• Anticipate severe hemorrhage

• If placenta has spread to

intestines , it may be left in situ
but there is high risk of sepsis
and DIC
 Cervical Ectopic
Pregnancy
• Refers to implantation of
zygote in the cervical canal

• Very rare ectopic which won’t

last beyond 20wks
• The bleeding is painless and
starts immediately after
implantation

• Palpable cervical mass with a

thin wall of the cervix
• There is slight dilatation of the
external cervical os

• Pelvic u/s can help in diagnosis

• Management is by first
stabilizing the patient
• Definitive treatment is by D&C
of the cervical canal to remove
the POCs. Packing is done after
D&C

• Hysterectomy is also an
option.
end