1. Gynaecological Emergencies

2. OUTLINE
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INTRODUCTION
CAUSES
CLINICAL FEATURES
INVESTIGATION
TREATMENT
CONCLUSION

3. INTRODUCTION
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Spectrum of gynaecological diseases that
causes an acute symptoms, necessitating
urgent and prompt management.
Presentation of gynaecologic
emergencies
Acute pelvic pain
Abnormal vaginal bleeding
Abnormal vaginal discharge
Acute pelvic swelling

4. Anatomy of uterus

5. Relationship of ureter to uterus

6. Common Presentations
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Pelvic Pain
Infections
Vaginal Discharge
Vaginal Bleeding
Contraceptive Problems

7. Gynaecological Emergencies
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Diagnostic challenges
Overlapping and similar symptoms
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Must rule out
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Pregnancy (esp. ectopic)
Non-gynaecological causes

8. Gynaecological Problems – General
Approach
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Hx and Ex require attention to
privacy and confidentiality
Obtain full menstrual, contraceptive
and sexual hx
Interview without other family
members present
Wear gloves, examine in unhurried
manner and use chaperone
Digital and speculum vaginal
examination except certain
circumstances (eg. children, painful
vulval ulcers)
Consider pregnancy

9. Pelvic Pain - Gynaecologic
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Pregnancy
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Pain related to menstrual cycle
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Ectopic, uterine, miscarriage
Physiological dysmenorrhoea
Endometriosis
Rupture of corpus luteum cyst
Mittelschmerz
Pain not related to menstrual cycle
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Uterine: fibroids, polyps, rupture
Ovarian: torsion, bleeding
Infection: PID, STD

14. Pelvic Pain – Non gynaecologic
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GIT:
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Appendicitis, diverticulitis, gastroenteritis, obstruction, hernia
Urinary:
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Pyelonephritis, cystitis, renal stones
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Abdominal wall pain
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Thoracic:
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Pneumonia, PE
Misc:
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Porphyria, Sickle Cell, DKA, Uraemia

15. Approach to Pelvic Pain
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Does it need emergent treatment?
What is the most serious diagnosis?
Can an accurate diagnosis be made?
Does the patient need to be admitted?
What follow up arrangements need to be made?

16. Does it need emergent treatment?
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Acute abdomen
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Stabilise – ABCs
Surgical consultation  Theatre
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17. History
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Characteristics of pain
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Pelvic fullness, bleed, discharge
Associated symptoms
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LMP, previous ectopics, TA, previous PID, STDs, hx of ovarian
cysts, partners
Contraception
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Urinary, GIT, pyrexia
Obstetrical and Gynaecological History
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Dyspareunia
IUCD, OCP, Barrier
Surgical History

18. Physical Exam
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General
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CVS
Chest
Abdominal
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Looks unwell, dehydrated, colour
Distension, bowel sounds, hernia, tenderness, mass
Back

19. Pelvic Examination
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Empty bladder!
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Vaginal
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Size, shape, regularity,
tenderness, position, mobility
Adnexa
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Chandelier sign, os
open/closed
Uterus
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Lesions, discharge
Cervix
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Wash hands, gloves, warm
vaginal speculum with warm
water, obtain specimens as
needed (Pap smear, cultures)
Masses, tenderness, ovaries
Rectal
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Mass, tenderness, blood

20. Investigations
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Blood
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Microbiology
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Urinalysis, beta HCG
Radiology
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Blood cultures, Triple swab, urine C+S
Urine
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FBC, U+E, Creatinine, Glucose, LFT, beta-HCG, CRP
KUB, abdominal
USS
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Abdominal, pelvic

21. Management
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Depends on cause
Ovarian cysts
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Very common cause of adnexal enlargement with
pelvic pain
Important points:
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Ovarian torsion
Ovarian neoplasm - older women

22. Ovarian cysts - Types
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Functional
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Multiple
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PCO
Endometriosis
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Follicular
Corpus luteum
Corpus haemorrhagicum
Chocolate cysts
Neoplasm
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Benign – serous/mucinous cystadenomas, dermoid (teratoma)
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Malignant

23. Ovarian cysts - Management
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Medical
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Expectant management 4-8 weeks
Self contained haemorrhagic cysts resorb
NSAIDs
Follow up with gynaecologist
OCP – prevent gonadotrophin ovarian stimulation
Surgical
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Very large cysts
Persistent cysts
Haemorrhagic cysts rupture with decreasing Hb
Complex adnexal mass
Acute abdomen – dermoid cyst; adnexal torsion

24. Infections
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Symptomatic vs. Asymptomatic
Lower Genital Infections (STD/Non-STD):
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Chlamydia, Gonorrhoea, Herpes, Trichomoniasis, Candidiasis,
Bacterial vaginosis, Condyloma
Vulval ulcers – consider SCC, Behcets syndrome, TB, Crohn’s
Painful lumps – Bartholin’s abscess, infected sebaceous cysts,
urethral carbuncle
Upper Genital Infections:
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Pelvic Inflammatory Disease (PID)
Tubo-Ovarian abscess (TOA)

25. Herpes Simplex Virus Infection

26. Acute Pelvic Inflammatory Disease
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Infection of uterus, Fallopian tubes, adjacent pelvic
structures not associated with surgery or pregnancy
Symptoms:
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Low abdominal pain, pyrexia, N+V
Vaginal discharge, intermenstrual bleeding
Previous hx of GUM attendance
Clinical Features:
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Abdominal tenderness, peritonism right sub-costal in Fitz-HughCurtis syndrome, cervical discharge, cervicitis, cervical
excitation tenderness, adnexal tenderness

27. Acute Pelvic Inflammatory Disease
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Aetiology
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Differential diagnosis
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Chlamydia trachomatis, N. Gonococcus, Mycoplasmas,
Ureaplasmas, streptococci often mixed with gram-negatives and
anaerobes
Uncommon : TB PID and actinomycosis
Secondary to appendicitis, diverticulitis, pregnancy terminations,
D+C, following IUCD insertion
Appendicitis, diverticulitis, ovarian cyst accident, ectopic
pregnancy, fallopian tube torsion, endometriosis
Risks
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Septicaemia, abscess, infertility, chronic PID, adhesion
formation and recurrent pelvic pain

28. Acute Pelvic Inflammatory Disease
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Investigations:
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Triple swabs, FBC, ESR, CRP, Beta HCG, urinalysis, consider
general surgical opinion
Management:
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Refer
Resuscitate – ABCs and with IV fluids if shocked
Remove IUCD after consultation with seniors and send to
microbiology
Antibiotics (doxycyline, metronidazole and ceftriaxone or oflaxacin
if allergy hx)
Analgesia and anti-emetics
4 hourly observations (temp, pulse, RR)
Consider laparoscopy if no improvement in pain/pyrexia in 24hrs
Follow up in GUM clinic. Treat partner.

29. Acute Pelvic Inflammatory Disease
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Indications for hospitalization
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Diagnosis uncertain
Possible surgical emergency cannot be excluded
Suspect pelvic abscess
Pregnant patient
HIV +ve
Adolescent
Unable to follow or tolerate out-patient Rx
Did not respond to outpatient Rx
Unable to arrange follow up in 48-72 hours

30. Vaginal discharge
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Physiological
Atrophic vaginitis
Thrush – check for glycosuria
Other infections
Neoplasm – cervical and endometrial
Fistulae
Foreign Bodies – tampons, condoms, plus ???
Toxic Shock Syndrome – remove tampon, resuscitate,
antibiotics and refer ICU

31. Toxic Shock Syndrome

32. Vaginal Bleeding
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Pregnancy related:
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Non-gynaecological:
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Spontaneous abortion, ectopic pregnancy, trophoblastic
GI – rectal bleeding
Urinary – urethral
Systemic disease – hypothyrodism, endocrinopathy, liver
disease, renal failure, blood dyscrasias and coagulopathies
Iatrogenic – Hormonal (OCP or menopausal), glucocortcoids,
anti-coagulants, psychoactive drugs, digitalis
Gynaecological

33. Abnormal vaginal bleeding
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Normal blood loss 35cc/cycle
>80cc = menorrhagia
Primary goals:
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Control the bleeding
Determine the cause
Prevent recurrence
Preserve fertility (if desired)

35. That hormone thing aka Menstrual Cycle
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Normal 21-35 days. Flow 3-7
days
Precise sequence of events
with appropriate amounts of
progesterone and oestrogen
2 phases – Follicular and Luteal
Follicular – oestrogen
stimulates endometrial growth
Ovulation – surge of LH and
FSH causes release of oocyte
Luteal – CL produces
progesterone which matures
endometrium
Without HCG from embryo, CL
regresses. Drop in Prog & Oest
Spiral arteries supplying
endometrium restricted and
release vasoactive substances

36. History
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How much bleeding?
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Obstetrical and gynaecological hx
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Miscarriage, endometriosis, STD exposure
Medications
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Clots, pad count, LMP, symptomatic, duration, menses,
regular/irregular
Contraception, hormones, anti-coagulants, psychotropics
Smoking
Stress
Other illnesses
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Hypothyroidism, liver disease, coagulopathy

37. Examination
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Haemodynamic status – hypovolaemia?
Stigmata of liver disease, hypothyroidism, Cushing’s,
Polycystic ovaries
Abdominal exam –mass, tenderness
Pelvic exam – trauma, laceration, infection, polyps,
tenderness
Cervix – os open/closed, tissue, clots

38. Investigations
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Bloods
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Beta HCG, FBC, Clotting screen, TFT, LFT
Pap smears and cultures
Endometrial biopsy
Ultrasound
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Polyps, fibroids

39. Treatment
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Depends on cause
If shocked, ABC (Oxygen, x-match, Rhesus status,
resuscitate IV fluids)

40. Dysfunctional Uterine Bleeding
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Diagnosis of exclusion
Abnormal bleeding not caused by recognised anatomical
or pathological abnormalities of the uterus
Extremes of age
Ovulatory vs. Anovulatory DUB:
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Ovulatory – abnormal progesterone secretion
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A) Regular cyclic bleeding with mid-cycle spotting (decreased
oestrogen levels at ovulation)
B) Polymenorrhoea – short secretory phase
C) Oligomenorrhoea – prolonged secretory phase
Anovulatory – absence of progesterone with unopposed
oestrogen with irregular cycles

41. Dysfunctional Uterine Bleeding - Treatment
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Medical:
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Hormonal treatment – oestrogen, progesterone, combination
hormones (OCP. Premarin)
NSAIDs – mefenamic acid, ibuprofen, meclofenamate, naproxen
Antifibrinolytics – aminocaproic acid, tranexamic acid
Danazol
GnRH analogs
Surgical:
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Dilatation and curettage (temporizing)
Hysteroscopy
Endometrial ablation (85% success rate)
Hysterectomy

42. Contraceptive Problems
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Post-coital contraception
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MAP stops pregnancy. Needs to be taken <72hrs
1) Levonelle one step (OTC) 2) Levonelle 500 (Prescription)
(Alternative – IUCD up to 5 days after sex)
Use
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Women after unprotected sex
Rape
Couples who have condom break during sex
Women lured into sex after drugs/drinks

43. Levonelle one step
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Take ASAP – ideally <12hrs
Ask about LMP
If vomit <3hrs after taking tablet, need to take another one
Does not protect against STD. Failure rate approx. 1-2%
Caution – Crohn’s disease, rare hereditary problems of galactose
intolerance, LAPP lactase deficiency
Avoid – Pregnancy, Unprotected sex >72hrs, Severe decreased liver
fxn, known allergy, porphyria
S/E – nausea, vomit (1 in 60), vaginal bleed, abdominal pain, fatigue,
early or delayed start to next period, headache, diarrhoea
Drug interactions with enzyme inducing drugs
Arrange follow up with GP in 3/52. Advise alternative contraception.
Warn risk of ectopic pregnancy and return if abdominal pain –
document advice.

44. Genital injury and assault
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Hx may be misleading. Have high index of suspicion and full
examination to exclude significant injury
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Blunt:
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Falls astride. Most vulval haematomas settle with rest and ice
packs. Very large haematomas may need surgical evacuation
Penetrating:
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Assault, FB insertion, migration/perforation of IUCD
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IVA, G+S, erect CXR, AXR, antibiotics and refer

45. CAUSES OF ACUTE ABDOMINAL
SWELLING
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Rupture ectopic
GTD/H MOLE
Neoplasm
Peritonitis-post abortal

46. Rape and sexual assualt
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Vulval penetration by penis without consent
Grossly under-reported
Privacy essential – should ideally have specialised equipped room
Ensure female member of staff present throughout
Legible and meticulous documentation
Treatment and resuscitation by ED staff; collection of forensic
evidence by police surgeon +/- gynaecologist
Sometimes women initially decline police involvement: full
assessment and documentation may prove useful if there is a
change of mind

47. Rape and sexual assualt
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First exclude life-threatening or serious injuries
History
 Establish type, date, time and place of assault. Obtain contraception
and sexual hx. Enquire about LMP/pregnancy
Examination
 Look for evidence of vaginal, oral or anal injury (+ take swabs). Record
any other injuries (photos useful – taken with consent by police)
Investigation
 Obtain written informed consent. Retain clothing, loose hairs, fingernail
clippings, and tampons for evidence. Take appropriate swabs (vaginal,
oral, anal). Perform pregnancy test. Take and store blood for future
DNA testing.
Treatment
 Resuscitate as necessary. Consider need for post-coital contraception.
Consider prophylaxis against Hep B, HIV and tetanus. Arrange FU to
exclude STD. Consider Abx prophylaxis against STD. Provide
counselling and ensure safe place to stay (social worker). Arrange
future counselling. Inform of independent local advice (eg. Rape Crisis
Centre)

48. Conclusion
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Gynaecological emergencies need a
good clinical acumen to differentiate the
gynecology from non- Gynaecological
causes.
Moreso, it prompt detection saves lives