Emergency gynaecology

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Chapter 35 Emergency gynaecology

History includes last normal menstrual period (LMP), past pregnancy history, sexual activity, contraception, pregnancy signs and symptoms, preventative health strategies (PAP smear, breast examination) as well as characteristics of presenting symptoms (commonly pain, abnormal vaginal bleeding plus or minus pregnancy, vaginal discharge, fever).

Management includes excluding pregnancy for every female of reproductive age, and early attention to vital signs, anticipating that certain conditions are associated with immediately life-threatening presentations.

Sensitivity and attention to patient comfort mandates conducting gynaecological history and pelvic examinations in a private area (when the patient’s condition is stable), using a warmed speculum, and offering analgesia early.

Investigations often will involve ultrasound and serum beta human chorionic gonadotrophin (bhCG) estimation (see Table 35.1).

Table 35.1 Interpretation of quantitative serum hCG results

Reference intervals
	Serum hCG (U/L)
Females	< 2.0	Pre-menopausal
	< 10	Post-menopausal
Males	< 2.0
Pregnancy test
	Serum hCG (U/L)	Interpretation
	< 2	Negative (if taken after first missed period)
	2–25	Borderline result (suggest repeat in 48 hours)
	> 25	Consistent with pregnancy
Pregnancy staging
Weeks since LMP	Approximate hCG range (U/L)	Comment
3–4	0–130	Week prior to first missed period
4–5	75–2600	Week after first missed period
5–6	850–20,800
6–7	4000–200,000
7–12	11,500–289,000
12–16	18,300–137,000
16–29	1400–53,000	Second trimester
29–41	940–60,000	Third trimester

LMP, last normal menstrual period

COMMON PRESENTATIONS

Pain

Ruptured ectopic pregnancy

• Incidence of ectopic pregnancy is increasing worldwide, mainly due to the increased incidence of pelvic inflammatory disease (PID) caused by Chlamydia trachomatis.

• History includes abdominal pain (97%), missed period (80%), vaginal bleeding (79%), infertility (15%), use of an intrauterine contraceptive device (IUCD) (14%), previous ectopic pregnancy (11%).

• Presenting signs include abdominal tenderness (91%), adnexal tenderness (54%), less frequently, shoulder tip pain, syncope and hypovolaemic shock (5%).

• Commonly presents between the 5th and 8th week following the LMP.

Diagnosis made by positive bhCG (see Table 35.1), and ultrasound (US) negative for intrauterine pregnancy. (Heterotopic pregnancy—an ectopic pregnancy together with an intrauterine pregnancy—occurs in approx 1 in 30,000 pregnancies.)

Management

• Unstable vital signs, signs of haemoperitoneum: resuscitate with O₂, large-bore IVC and fluids, crossmatch blood, urgent obstetrics and gynaecological (O&G) consult for operative management.

• Stable: insert IVC, perform group-and-hold (G&H), consult O&G. Management may be expectant, medical or surgical, depending on initial serum titre of bhCG and trend in titres, and local practice.

Acute salpingitis (PID)

(See also the section ‘Pelvic inflammatory disease’ in Chapter 41, ‘Infectious diseases’.)

• Often sexually acquired. Infection usually due to Chlamydia trachomatis or Neisseria gonorrhoea. Other organisms from vaginal flora may subsequently be involved.

• May result from mechanical interruption of the normal cervical barrier, e.g. postabortal, postpartum, postoperative infection, or in association with IUCDs. Infection may be caused by mixed pathogens including anaerobes, facultative bacteria and Mycoplasma species. Any IUCD or retained products must be removed as soon as possible.

• Risk factors include history of previous episode, multiple sexual partners, adolescence and IUCD.

• Long-term sequelae may include chronic pelvic pain, dyspareunia, infertility, tubo-ovarian abscess, increased risk of ectopic pregnancy.

• Clinical presentation includes lower abdominal pain, adnexal and cervical motion tenderness, fever, generalised malaise, purulent or mucopurulent vaginal discharge.

• Fever is usually low grade, with only one-third of patients presenting with a temperature greater than 38°C.

• No correlation between extent of disease and symptom severity.

Diagnosis is made by a combination of clinical findings and some or all of the following: positive microbiology from cervical secretions (swabs taken specifically for gonococcus and Chlamydia), leukocytosis, US documenting inflammatory adnexal mass or retained products.

Management

1. Severe infection or systemically unwell or requires removal of retained products or IUCD: admit for IV antibiotics (consult local guidelines, but generally tetracyclines, metronidazole, third-generation cephalosporins while awaiting culture results).

2. Milder infections may be discharged on oral therapy (antibiotics as above).

3. Must treat sexual partner.

Adnexal cyst or mass complications

Ruptured ovarian cyst

• Ovarian cysts are asymptomatic until complications occur.

• Physiological cysts such as corpus luteum cysts (in pregnant or non–pregnant women) and follicular cysts rupture at different points in the menstrual cycle, giving a clue to aetiology:

• Rupture of a follicular cyst with the extrusion of an ovum occurs midcycle, and gives rise to the unilateral pain of mittelschmerz. Discomfort may last 2–3 days, may be associated with mild general malaise, and may be associated with vaginal spotting.

• Corpus luteal cyst rupture in the non-pregnant woman occurs just prior to menses, is usually associated with some intraperitoneal bleeding, and may require differentiation from ectopic pregnancy.

• In pregnancy, the corpus luteum may persist until 10 weeks, so that spontaneous rupture typically occurs during the first trimester. Characteristic findings are unilateral pain and adnexal tenderness; fever and leukocytosis are uncommon (approximately 20%). Diffuse peritoneal irritation occurs with spillage of fluid into peritoneal cavity.

• Laparoscopy may be indicated.

Other gynaecological causes of lower abdominal or pelvic pain

• Endometriosis

• Uterine perforation: typically after intrauterine instrumentation, may present acutely due to intraperitoneal irritation secondary to intraperitoneal blood, or as delayed diffuse pain with diffuse peritonitis

• Severe dysmenorrhoea: manage with antiprostaglandins and paracetamol

• Denial of pregnancy and unanticipated labour: estimated at 1 in 2000–5000 births, the diagnosis is made when the woman presents in labour, putting both mother and fetus at risk

• Vulvovaginitis

BLEEDING

In early pregnancy

Ectopic pregnancy

See ‘Ruptured ectoptic pregnancy’ section above.

Spontaneous abortion or miscarriage

• Spontaneous abortion is common in early pregnancy.

• Several stages are recognised: threatened, bleeding occurs, cervical os closed; incomplete, products of conception in uterus, at os or in vagina; completed, when all products expelled from uterus and os closed.

• Presenting symptoms include intermittent vaginal spotting progressing to heavy bleeding with passage of clots and gestational tissue; midline, cramping abdominal discomfort occurring after bleeding has commenced.

• Signs include unremarkable abdominal examination, with possible midline suprapubic tenderness on deep palpation, uterine enlargement consistent with pregnancy.

• Shock or bradycardia may occur rarely due to products sitting in the cervical os. These will require urgent gentle removal.

Management involves assessment of vital signs and management of blood loss (may occasionally require IV fluids and, rarely, ergometrine or oxytocin), confirmation of pregnancy, assessment of state of cervical os (if open, uterus is unable to contract to limit bleeding adequately), ultrasound examination to confirm diagnosis, assessment of Rh status, and administration of Rh (anti-D) immunoglobulin if Rh-negative.

Miscarriages are frequently associated with grieving, and referral for counselling may be offered to the patient while she is in the emergency department.

In later pregnancy (> 20 weeks)

Placental abruption, or separation of the placenta from the uterine wall, is usually associated with characteristically dark vaginal bleeding, uterine pain and tenderness. Complications include fetal distress or death, disseminated intravascular coagulation (DIC), maternal haemorrhage.

Placenta praevia, or implantation of the placenta over the cervical os, is usually associated with painless fresh vaginal bleeding, which may become severe with cervical probing.

Patients presenting with bleeding in later pregnancy should have immediate obstetric consultation, with emergency department treatment focusing on maternal stabilisation (oxygen, IVC and fluids, blood crossmatch, full blood count (FBC), coagulation status, Rh status). Vaginal examination must be left to the obstetrician.

Bleeding in the non-pregnant woman

Dysfunctional uterine bleeding may be associated with ovulatory or anovulatory menstrual cycles.

• Assessment of blood loss may be difficult, but menorrhagia is indicated by anaemia, use of two pads concurrently or tampon and pad, pads/tampons changed every 1–2 hours when flow is heaviest, episodic flooding with staining of clothes or sheets, frequent clots.

• Complete history (including symptoms of clotting disorder) and physical examination are required to establish signs of endocrine dysfunction, obesity (associated with polycystic ovarian syndrome) or lifestyle or exercise contributors.

• Exclude pregnancy or pelvic infection, measure Hb if anaemia likely on history or examination findings.

• Consider clotting disorders and abnormal platelet function in women < 20 years old.

• Refer for further gynaecological assessment (causes may include fibroids, malignancy).

Genital bleeding

Profuse bleeding may result from trauma. Emergency department management includes patient stabilisation, examination to discover bleeding origin and early consultation.

Vaginal foreign bodies may be associated with bleeding and/or infection.

OTHER COMPLICATIONS OF LATER PREGNANCY (> 20 WEEKS)

Preeclampsia

Preeclampsia is a multisystem disorder potentially affecting the maternal liver, kidneys, brain and clotting system, as well as leading to impaired placental function.

It is defined as hypertension developing after 20 weeks in a patient with normal blood pressure prior to pregnancy, associated with proteinuria or hyperuricaemia. There is no history of hypertension or renal disease, and blood pressure returns to normal within 3 months postpartum. It is more common in nulliparous women.

Hypertension in pregnancy is a systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg or a rise in SBP of 25 mmHg or more and/or a rise in DBP of 15 mmHg or more from the patient’s first-trimester BP.

Features of severe preeclampsia are BP > 170/110, proteinuria > 300 mg/day, hyperuricaemia, serum creatinine > 0.09 mmol/L. Other features include liver pain, elevated transaminases or bilirubin, persistent headaches, visual disturbances, hyperreflexia or clonus, thrombocytopenia.

Eclampsia is the onset of convulsions in pregnancy or the postnatal period, usually preceded by preeclampsia.

Management

Severe preeclampsia and eclampsia are medical and obstetric emergencies. Magnesium sulphate infusion is the agent of choice for seizure prophylaxis. Other agents may be required for BP control. Urgent obstetric consultation is obtained, and general resuscitative measures (maintenance of airway, O₂ therapy, IV access, nurse patient on side) are undertaken.

Trauma in pregnancy

The risk to the pregnancy in ‘minor’ trauma is significant, with pre-term labour occurring in 8%, abruption in 1%, and fetal death in 1% of occurrences. In severe trauma, the fetal death rate rises to 20% or greater.

Main determinant of fetal outcome is maternal outcome, thus ensuring maternal oxygenation and tissue perfusion is the primary goal. Positioning of the third-trimester patient with a left lateral tilt (as an entire unit to maintain cervical spine stability) is essential to displace the uterus and prevent vena caval compression.

All patients with minor trauma should be admitted to hospital for at least 24 hours. Careful fetal monitoring is essential once fetal viability has been established.

Sexual assault

Sexual assault is a common, and underreported, violent crime. Women presenting to the emergency department following a sexual assault are preferably referred to a sexual assault service, where expertise in obtaining forensic samples, documenting the physical examination, offering pregnancy and STD prophylaxis and providing psychological support exists. Occasionally, victims require management of other injuries prior to assessment by the sexual assault service.

EMERGENCY CONTRACEPTION: MORNING-AFTER PILL

Administration of 100 μg of ethinyloestradiol and 500 μg levonorgestrel to a woman within 72 hours of unprotected intercourse, with the dose repeated 12 hours later, has an efficacy of 75–98% in preventing pregnancy. Anti-emetics should always be given, and a spare dose of hormone tablets, should vomiting occur. Advice given with emergency contraception should include risk of failure and appropriate follow-up, and counselling regarding contraceptive use.

DRUGS IN PREGNANCY

Drugs should be prescribed in pregnancy only if the expected benefit to the mother is thought to be greater than the risk to the fetus, and all drugs should be avoided if possible during the first trimester. Drugs that have been extensively used in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs; and the smallest effective dose should be used.

Few drugs have been shown conclusively to be teratogenic in humans but no drug is safe beyond all doubt in early pregnancy. For information regarding specific drugs, MIMS should be consulted.

ANTI-D PROPHYLAXIS

RhD immunoglobulin (anti-D) is administered for prophylaxis against haemolytic disease of the newborn. Current indications and doses include potentially sensitising events, e.g. miscarriage, ectopic pregnancy during the first trimester (250 IU RhD immunoglobulin); potentially sensitising events during the second and third trimester (625 IU RhD immunoglobulin, plus additional doses as indicated from the assessment of the extent of feto-maternal haemorrhage).

RECOMMENDED READING

Cameron P., Jelinek G., Kelly A., et al. Textbook of adult emergency medicine, 3rd edn. Edinburgh: Churchill Livingstone; 2009.

D’Amours S.K., Sugrue M., Russell R., et al. Handbook of trauma care. The Liverpool Hospital trauma manual, 6th edn. Sydney: Trauma Department, Liverpool Hospital; 2002.

Mein K.J.J.K., Palmer C.M., Shand M.C., et al. Management of acute adult sexual assault. Med J Aust. 2003;178(5):226-230.

National Health and Medical Research Council. Guidelines on the prophylactic use of RhD immunoglobulin (anti-D) in obstetrics. Canberra: AGPS; 1999.

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