GYNECOLOGIC EMERGENCIES

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GYNECOLOGIC EMERGENCIES
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Ectopic pregnancy
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DEFINITION Ectopic pregnancy- implantation
outside of the uterine cavity

• The most common reason of peritoneal signs in
  gynecology

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Frequency of ectopic pregnancy in Europe 1-2
100
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Types of ectopic pregnancy by location

• Ampullary 78
• Isthmic 12 95 tubal
  pregnancy
• Fimbrial 5
• Interstitial 2-3
• Ovarian 1 (3 after ART)
• Abdominal 1-2 (high mortality)
• Cervical 0,5

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Risk factors for ectopic pregnancy

• (30-50) Salpingitis PID
• (Chlamydia trachomatis!!!)
• damage for such infection may retard the passage
  of the fertilized ovum through the tube to the
  endometrial cavity
• Operations
• surgery of fallopian tubes
• plastic reconstruction of fallopian tubes
• ART
• ovarian stimulation
• embryo transfer reflux
• Previous ectopic pregnancy
• Age 35-45

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Risk factors for ectopic pregnancy

• Contraception ???
• Endometriosis
• Congenital defects of fallopian tubes
• Psychical spasm of fallopian tubes
• Smoking
• Multiparous women
• Black and Hispanic women
• Idiopatic

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Symptoms of unrupted ectopic pregnancy

• Very different - depends of location and
  development of ectopic pregnancy
• Abdominal/pelvic pain- unilateral or bilateral
  intermittent or constant
• Amenorrhea
• Pregnancy symptoms
• Vaginal bleeding
• Pregnancy test or ? HCG

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Gynecological examination

• Adnexal tenderness
• Cervical motion tenderness
• Adnexal mass
• Uterus- normal size (70) or enlarged (30)
• Hemoperitoneum convexity of cul-de-sac

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Ectopic pregnancyDiagnosis

• Pregnancy test - detects level of ? HCG
• (Human Chorionic Gonadotropin)
• a) 5 days after conception serum assays
• b) 14 days after conception urinary tests
• ? HCG lt 10 mIU/ml no pregnancy
• ? HCG gt 25 mIU/ml pregnancy
• 4-5 Hbd ? HCG gt 750 mIU/ml (or 1000 mIU/ml) and
  visible in USG
• Early pregnancy- up to 6 weeks
• Increasing of ? HCG gt 66 in 48 hours
• Increasing of ? HCG gt 114 in 72 hours
• Increasing of ? HCG gt 175 in 96 hours

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Ectopic pregnancyDiagnosis

• 2. USG
• 4-5 weeks of pregnancy- visible in USG
• Enlarged size of fallopian tube
• Empty uterine cavity
• Large endometrium

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Ectopic pregnancyDiagnosis

• 3. Progesterone (always with HCG and USG)
• gt 25ng/ml - normal pregnancy
• lt 5 ng/ml - ectopic pregnancy or obsolete
  pregnancy
• 4. high concentration of
• Estradiol Il 6 Il 8 TNFa creatine kinase

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The most common symptom of ruptured ectopic
pregnancy Hemoperitoneum
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Symptoms of ruptured ectopic pregnancy

• Hypovolemic shock- a decrease in blood pressure
  and an increase in pulse
• Syncope
• Acute abdominal pain
• Temperature gt 37º C
• Urge to defecate or urinary urge
• Vomiting
• Peritoneal signs- hemoperitoneum
• Irritation of the diaphragm- shoulder pain

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Differential Diagnosis of Ectopic Pregnancy

• any woman of reproductive age with
• acute pelvic or lower abdominal pain
• abnormal bleeding
• amenorrhea
• complications of intrauterine pregnancy
  (complited or incomplited abortion)
• acute or chronic salpingitis

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Differential Diagnosis of Ectopic Pregnancy

• Follicular or corpus luteum cyst rupture
• Endometriosis
• Adnexal torsion
• Gastroenteritis
• Appendecitis

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Combined pregnancy (heterotopic pregnancy)

• intrauterine and extrauterine gestations
• 1 30 000
• after ART
• 1 100
• approximately 1 in 3 of the intrauterine
  pregnancies are reproted as surviving

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Managment of Ectopic Pregnancy

• expectant treatment
• pharmacotheraphy (Methotrexate)
• surgery

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Managment of Ectopic Pregnancy

• expectant treatment
• Indications
• low ? HCG level
• ectopic gestation lt 4 cm in diameter
• ampullary localization
• no bleeding
• no symptoms of rupture

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Managment of Ectopic Pregnancy

• Pharmacotheraphy
• Methotrexate (folinic acid antagonist)
• Indications
• ? HCG level lt 10 000 mIU/ml
• ectopic gestation lt 4cm in diameter
• cervix, ovarium, intramural localization
• for 20 of women 1 dose is enough

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Managment of Ectopic Pregnancysurgery

• Unruptured
• Laparoscopy
• salpingtomy
• salpingectomy
• Laparotomy- surgical techniques

• Ruptured
• - Laparoscopy
• - Laparotomy- surgical techniques
• - salpingectomy

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Ectopic Pregnancy

• Rh- negative mothers with ectopic pregnancy
  should recieve Rh immune globulin to prevent Rh
  sensitisation
• risk of Rh sensitisation lt 1

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Pelvic Inflammatory Disease

• PID is a polymicrobal infection involving
  endogenous aerobes and anaerobes as well as
  sexually transmitted pathogens.

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PID

• Variables that increase the incidence of PID

• teenage years
• multiple sexual partners
• previous PID
• intrauterine device (two months after insertion
  only)
• uterine instrumentation

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PID- etiology

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Escherichia colli, Proteus, Klebsiella,
  Streptococcus- endogenous aerobes
• Bacteroides, Peptostreptococcus, Peptococcus-
  endogenne anaerobes
• Actinomyces israeli- IUCD

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Chlamydia trachomatis(intracellular parasite)

• Infection rates
• 20-40 of sexually active women have antibodies
  to Chlamydia
• five times higher in women with three or more
  partners
• four times higher in women using no contraception
  or nonbarrier methods
• up to 20 has asymptomatic cervical infection

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Chlamydia trachomatis(intracellular parasite)

• Symptoms
• subtle and nonspecific physical findings
• mucopurulent cervicitis
• acute urethritis
• salpingitis
• PID
• Fitz-Hugh-Curtis syndrome (perihepatitis)
• localized fibrosis with scarring of the liver and
  adjacent peritoneum

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Chlamydia trachomatis(intracellular parasite)

• Infertility and ectopic pregnancy
• mild form of salpingitis with insidious symptoms
• established infection remain active for many
  months
• increasing tubal damage

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Chlamydia trachomatis(intracellular parasite)

• infection is suspected on clinical grounds
• culture results (obtained after 48-72 h) confirms
  the diagnosis
• ELISA performed on cervical secretions
• 95 specificity
• monoclonal fluorescent antibody test carried out
  on dried specimens
• 90 sensitivity 95 specificity

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Neisseria gonorrhoeae(Gram-negative
intracellular diploccocus)

• Easy acquired single encounter with infected
  partner leads to infection 80-90 of the time
• First signs or symptoms of infection
• 3-5 days after exposure, often mild
• malodorous purulent discharge from the urethra,
  Skenes duct, cervix, vagina or anus
• mucopus greenish or yellow discharge from the
  cervix
• infection of the Bartholins gland
• Fitz-Hugh-Curtis syndrome
• 15 of women with N. gonorrhoeae develop acute
  pelvic infection (PID)

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Neisseria gonorrhoeae(Gram-negative
intracellular diploccocus)

• Laboratory diagnosis
• cultures obtained from the cervix, uretra, anus,
  pharynx
• Thayer-Martin agar plates kept in
• CO2-rich environment 80-90 sensitivity

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PID

• Hagers criteria for diagnosing acute PID
• history of lower abdominal pain or tenderness
• cervical motion tenderness and adnexal tenderness
• (all necessary for diagnosis !)

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PID

• Hagers criteria for diagnosing acute PID
• fever gt 38C
• leukocytosis gt 10 000 WBC/mm3
• culdocentesis fluid containing WBCs or bacteria
• inflammatory mass on pelvic examination or USG
• evidence of gonococcus or Chlamydia on cervical
  Grams stain
• (one or more of the objective findings necessary
  for diagnosis !)

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PID

• Clinical diagnosis of PID is often imprecise
• white cell count above 10 000 gt 50 of patients
• positive chlamydia cultures 30 of patients
• positive gonorrhea cultures 25 of patients

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PID

• Correct diagnosis in cases of misdiagnosis of PID
• acute appendicitis 28 of cases
• endometriosis 17 of cases
• corpus luteum bleeding 12 of cases
• ectopic pregnancy 11 of cases
• adhesions 7 of cases
• other 28 of cases

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PID

• Indications for hospitalization
• presence of tuboovarian complex or abscess (TOA)
• uncertain diagnosis
• significant gastrointestinal symptoms
• nulliparity
• pregnancy

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PID

• Recommendations for hospitalized patients
• (no pelvic mass, IUD, recent history of pelvic
  instrumentation)
• cefoxitin 2g IV q6h
• cefotetan 2g IV q12h doxycycline 100 mg q12h
• regimen continued for at least 48 hours after the
  patient clinically improves

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PID

• Recommendations for hospitalized patients
• (pelvic mass, IUD, recent history of pelvic
  instrumentation)
• clindamycin 900 mg IV q8h gentamycin 2 mg/kg
  IV,
• followed by gentamycin 1,5 mg/kg IV q8h
• regimen continued for at least 48 hours after the
  patient clinically improves

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PID

• Tests that should be also obtain
• Trichomonas vaginalis screening (wet preparat)
• serology syphilis screening
• HIV screening

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PID

• If outpatient treatment is used, the patient must
  be reexamined after 48 to 72 hours.
• If the response for the treatment is suboptimal,
  the patient need to be hospitalized and
  intravenous antibiotics initiated.

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PID

• Recomendation for outpatient therapy
• cefoxitin 2g IM probenecid 1g PO
• ceftriaxon 250 mg IM doxycycline 100 mg PO q12h
  for 10 - 14 days
• tetracycline 500 mg PO q6h for 10 - 14 days
• erythromycin 500 mg PO q6h for 10 - 14 days

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PID

• Laparoscopy
• - diagnosis of PID is in doubt
• - the patient does not respond to medical
  therapy

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PID

• Laparoscopic criteria for acute PID
• minimum criteria
• erythema of fallopian tubes
• edema and swelling of fallopian tube
• exudate from fimbria or on serosa of fallopian
  tube

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PID

• Scoring
• mild minimum criteria, tubes freely movable and
  patent
• moderate more marked , tubes not freely movable,
  patency uncertain
• severe inflammatory mass

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PID

• Complications of PID
• formation of tuboovarian abscess (TOA)
• ectopic pregnancy (rate seven to ten times
  normal)
• infertility (rate increase proportional to the
  number of episodes of acute PID)
• chronic pelvic pain (approximately 20)
• recurrent PID (approximately 25)

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PID

• Surgical treatment of PID (extirpation)
• Ruptured TOAs,
• TOAs that do not respond to medical therapy
  within 4 to 5 days
• TOAs that results in chronic pain

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teenanger multiple sexual partners previous
PID IUD uterin instrumentation pain pelvic
tenderness fever mass vaginal discharge
Ectopic pregnancy Infertility Chronic pain Recu
rent PID
Discharge on antibiotic
Response
Outpatient treatment
Complications
PID
Antibiotic
Hospitalization
No response
Tuboovarian abscess
WBC Chlamydial culture or antigen detection
test Gonorrhea culture Syphilis wet prep.,
serology HIV USG
Laparoscopy
Operative drainage
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PID

• Therapy of the symptomatic as well as
  asymptomatic male partners is an integral part of
  treatment PID.

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PID

• Variables that decreases the incidence of PID

• use of mechanical contraceptives
• use of oral contraceptives

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Other causes of bleeding into the abdominal
cavity

• Rupture of follicular cyst
• Corpus hemorrhagicum
• Rupture of ovarian tumor
• Postoperation bleeding

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Adnexal torsion (10)

• DEFINITION
• partial or complete rotation of the ovary,
  fallopian tube or both, on its vascular pedicle.

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Adnexal torsion

• Etiology
• 50-60 - ovarian and/or adnexal mass
• increased weight of the ovary
• reduced venous return from the ovary

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Adnexal torsion

• All ages, usually
• women in their mid 20s
• postmenopausal women
• 20 of cases of torsion occur during prgnancy

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Adnexal torsion

• Symptoms variable and nonspecific
• - acute abdominal pain
• nausea, vomiting
• anorexia,
• peritoneal signs
• diarrhea
• hypovolemic shock
• ½ of the patients have had a similar episode in
  the past
• approximately ½ of the patients have a palpable
  mass

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Adnexal torsion

• Sonography
• multiple peripheral cysts in an enlarged ovary
  relatively specific
• free pelvic fluid
• adnexal cysts and tumors
• Colour Doppler
• shows whether the vascular flow is impaired
• absence of vascular flow is not specific for
  torsion
• presence of vascular flow does not rule out
  torsion
• (flow may be seconadry to the dual blood supply
  of the ovary or from venous thrombosis which
  causes symptoms before the loss of arterial flow)
• CT, MRI

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Adnexal torsiondifferental diagnosis

• Based on clinical presentation
• appendicitis
• intussusception
• gastroenteritis
• pyelonephritis
• salpingititis
• inflammatory bowel disease

• Based on sonography
• hemorrhagic ovarian cyst
• ovarian mass or neoplasm
• parovarian cyst
• pelvic inflammatory disease
• abscess

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Adnexal torsionmanagement

• surgery
• oophoropexy (if the ovary is thougt to be viable
  during surgery)
• preserves the ovary, reduces the incidence of
  reccurent torsion
• also for contralateral ovary to prevent its
  subsequent torsion

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Rupture of ovarian cyst (3)

• Bleeding into abdominal cavity
• Symptoms
• acute abdominal pain
• peritoneal signs
• hypovolemic shock

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Diagnosis

• General examination
• Gynecological examination
• USG
• Abdominal X- ray
• Laboratory tests

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Vaginal bleeding

• Injury- sexual intercorses
• Abortion
• Carcinoma
• Cervical carcinoma
• Endometrial carcinoma
• Vaginal carcinoma
• Myomas
• Functional bleeding

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Gynecological iatrogenic emergencies

• Laparotomy
• Laparoscopy
• Other (DC HSG)

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Laparoscopy, laparotomy iatrogenic
complications

• Anesthesial complications
• Postoperation bleeding
• Mechanical obstruction
• Paralytical obstruction
• Peritonitis

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Sepitic Pelvic Thrombophlebitis

• Multiple bacteria infection
• Septic thrombosis in vessels
• Subseqent microembolisation in lungs or other
  organs by way of the inferior vena cava is
  possible
• Symptoms residual fever and tachycardia
• Antibiotics and anticoagulation therapy is
  recommended for at least 7 and up to 30 days

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