gynecology emergency

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GYNAECOLOGICAL
EMERGENCY

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What is an Emergency?
Under this definition, a medical emergency is,
“the sudden onset of a medical condition
manifesting itself by acute symptoms of
sufficient severity such that the absence of
immediate medical attention could reasonably
be expected to result in: placing the patient's
health in serious jeopardy, serious impairment..

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What is Surgical Emergency?
emergency for which immediate surgical intervention is
the only way to solve the problem successfully. The
following conditions are surgical emergencies: acute
trauma,acute abdomen,shock etc

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LEARNING OBJECTIVES

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Shock
 Hypovolemic shock tachycardia.feeble puls
Cold ,clammy,restless
 Septic shock fever,blotchy.hypotensive
 Cardiogenic shock
SOB,chest pain,hypotensive

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TOXIC SHOCK SYNDROME
 Life threatning condition
 Acute septecaemia caused by bacterial infection
 One or more organ dysfunction
 Risk factors
 Post delivery
 Septic abortion
 Retained tampon
 Recent pelvic surgery
 Infected IUCD ( foreign body)
 ACUTE PRESNTATION
 Temperature <38c (98.6 F)
 Pulse more then 90bpm
 Respiratory rate >20 breaths/min
 WBC greater then 12,000/mm3
 Altered mental status
 Hypotension BP <90mmhg ,MAP <70mmhg
 SpaO2 decreased
 Acute oliguria

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MANAGEMENT
GOAL
 To deliver oxygen systemically
 Blood pressure support
 Optimizing stroke volume
 Assess airway
 Breathing (100%oxygen)
 Circulation;
 maintain double IV line with 14 G
 Send blood for FBC,B/G cross match,
 Give warm colloid and crystalloid
 Atropine 600microgm if heartrate <60bpm
 Monitor pulse,BP and urine output
 Vasoactive agents to maintain arterial BP (
NE,dopamine,epinephrine,nitroglycerine)
 Blood transfusion to Hct>12%
 Ionotropes (dobutamine)
 Antibiotics (pipperacelline,gentamicin)

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LIST OF GYNAECOLOGY EMERGENCY
1. INEVITABLE ABORTION
2.SEPTIC ABORTION
3.RUPTURED ECTOPIC PREGNANCY
4.MOLAR PREGNANCY
5.ADENEXAL TORSION
6.ACUTE PID
7.ACUTE UTERINE INVERSION

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1st
scenario
If a women presents in emergency who is :
Semiconscious
Tachycardia or feeble pulse
Hypotension
Heavy PV bleeding
You must have two D/Ds in mind
1.incomplete abortion
2.molar pregnancy

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1.INCOMPLETE MISCARRIAGE
is an abortion that has only been partially successful. The pregnancy has ended— no fetus will
develop, but your body has only expelled part of the tissue and products of pregnancy.
PRESENTATION
 Tachycardia,feeble pulse
 Bradycardia due to vagal shock
 pale
 heavy PVB
 breathlessness
 O/E : Os open and rpocs felt in vagina
 On USS: RPOCs seen

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MANAGEMNET
 maintain double IV line
 Investigations FBC,clotting profile,B/G cross
match
 100% oxygen
 Give crystalloids and colloids
 Arrange 2POB
 Shift to OT for suction evacuation or D n C

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3.Molar pregnancy abnormal chromosomal
complement of fetus (46xx/xy ,69xxx)
PRESENTATION
 History of Amenorrhea
 Hyperemesis
 Uterine size enlarged for dates
 Vaginal spotting
 And possibility of passing of grape like tissue
ACUTE PRESENATAION
 Hypovolemic shock
 tachycardia/ feeble pulse
 Cold clammy
 Passage of heavy grapes like tissue ( heavy PVB)

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MANAGEMENT
Maintain two large IV lines and take blood for
INVESTIGATION
 Cbc ,
 PTT,INR
 Blood type and cross match
 RFTs,LFTs,TFTs
 Treat shock with colloids and crystalloids
 Blood arrangement and
 evacuation of uterus with suction and evacuation
 Start oxytocin (10 units per 1000 ml NS)
 Monitor with Bhcg weekly till it gets normal and
then 4 weekly for 6 monthly

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2.septic abortion
abortion associated with serious infection of the products of
conception and of theuterus, leading to generalized infection
; it is usually caused by pathogenic organisms of the bowel
/vagina esp E.coli
PRESENTATION
 Foul smelling vaginal dischare
 PV bleeding
 Fever
 Lower abdominal pain or tenderness
ACUTE PRESENTATION
 Peritonitis
 Sepsis

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 MANAGEMENT
When a pt presents in emergency:
 If signs of septic shock then
 Start with fluid resuscitaton according to urine
output of 30ml/hr,
 100% oxygen
 Investigations
(CBC,urinanalysis,electrolytes,RFTS)
(Gram stain of vaginal discharde,blood
culture,CXR and PT/APTT)
 Combination IV antibiotcs,
 Oxytocin (10-30 units in 1000ml R/L)
 If sepsis persist or if there is suspicion of visceral
perforation performLaparotmy
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2nd
scenario
A young sexually active pt comes in
emergency LR with
 Severe pain lower abdomen
 Peritonitis and
 Hemopertoneum
D/D:
ectopic pregnancy (until proved otherwise)
adenexal torsion

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2.Ectopic pregnancy
A SEXUALLY ACTIVE WOMEN WHEN PRESENTS IN
SHOCK ,AND HEMOPERITONEUM → Ruptured
Ectopic Pregnancy

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MANAGEMENT
A pt diagnosed with Ruptured ectopic will be in
hypovolemeic shock so
 Maintain 2 IV line (14G) and take blood for FBC ,
clotting ,and cross match for 2 pints atleast
 Give warm crystalloid (0.9% NS,and colloid till
waiting for blood)
 Prop up
 100% Oxygen
 Urinary catheter placement with monitoring of urine
output
 Monitor pulse ,BP,temp
 Shift the pt to OT as blood is arranged ,
 Em.laparotmy
 Salpingectomy/salpingostomy ?

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4.ADENEXAL TORSION
Acounts for 3% of all gyaecological emergencies
 Compromises the lymphatic and venous
drainage with loss of arterial perfusion
 RISK FACTORS:
 Pregnany
 Ovarian stimulation
 Ovarian enlargement
 ACUTE PRESENTATION
 Severe lower abdominal pain
 Nausea and vomiting
 Peritoneal signs( Guarding and rigidity)
 ACUTE ABDOMEN

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DIFFERNTIAL DIAGNOSIS
 Ectopic pregnancy
 Tubo-ovarian torsion
 Hemorrhagic cyst

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MANAGEMENT
After stabilization of pt
 Two large IV lines and take sample for
 FBC (fall in Hb and raised WBCS)
 B/G and cros match
 Lfts,Rfts and Electrolytes
 USS to rule out the diagnosis
DEINITIVE TREATMENT
Laparotomy with ovarian cystectomy or oophorectomy

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5.ACUTE PID
 Acute infection
 Leading to endometritis,salpingitis,pelvic
peritonitis and formation of pelvic abcess
 Chlamydia and gonorrhea are causative
organisms
ACUTE PRESENTATION
 High grade fever >38c
 Pelvic peritonitis
 Generalized sepsis

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MANAGEMENT
 Urgent hospitalization
 Resuscitate with ABCs and IV fluids (crystalloid and
colloid) if shocked
 Maintain double IV line and send FBC,B/G and cross
match
 ESR
 urinanalysis
 Remove IUCD if in situ and send for culture
 Start with IVantibiotic cover (
doxycycline,metronidazole,and ceftrizxone)
 4 hourly observation of pulse,BP,temperature,
 Urine output record
 If pt not responding to medical therapy go for
Lparoscopy/laparotomy

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6.ACUTE UTERINE INVERSION
 Acute emergency
 Uterus passes through the cervix and turns inside
outwards
 RISK FACTORS:
 Uterine prolapse
 Old age
 Multiparity
 Morbidly adherent placenta
ACUTE PRESENTATION
 Shock out of proportion of bleeding
 Bradycardia

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MANAGEMENT
 call for help
 assess airway,breathing,circulation
 give 100% oxygen
 maintain circulation with 2 large IV bore
cannulas
 send blood for FBC,4 units cross match clotting
 give warm crystlloid,colloids
 atropine 600microgm if heart rate <60bpm
 monitor pulse,bp ,temp,urine output
 adequate analgesia

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 shift the pt to OT
 250microgm
Terbutaline manual replacement
 G/A
 Glycerol trinitrate hydrostatic replacement
 If all fails then go for laparotomy.

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