Emergency Gynaecology
Table of Contents
1. Intra-abdominal haemorrhage
A. Ruptured follicular or corpus luteal cyst
B. Ectopic pregnancy
2. Per vaginal bleeding
A. Pregnancy related
B. Non Pregnancy related
3. Injuries in genital region
A. Uterine perforation
B. Injuries caused by intercourse
C. Rape / assault
D. Injuries caused by accidents - Falling on fence, astride a bicycle, furniture,
post or similar objects, traffic accidents
E. Foreign body within vagina
4. Conditions presenting with acute pain
A. Pregnancy related
B. Non-pregnancy related
1. Intra-abdominal haemorrhage
A. Ruptured follicular or corpus luteal cyst
 Usually occurs in the second half of the regular menstrual cycle.
 Clinical symptoms and physical findings are:
 Increasing pain over lower abdomen, initially unilateral. Pain can be
acute in onset
 Shoulder pain (not necessarily)
 Nausea, +/- vomit
 Anaemia, maybe in shock
 Tenderness in lower abdomen, initially unilateral
 Fullness of Pouch of Douglas (not necessarily)
 Investigations
 Need to exclude pregnancy – perform urgent urine pregnancy test
 Ultrasound scan of the pelvis (preferably transvaginal) – maybe able to
see a follicular or corpus luteal cyst, with or without fluid collections in
the pelvis. Tenderness in the Pouch of Douglas is usually present
during the vaginal examination.
 Full blood count – may have anaemia if the bleeding is significant.
 Treatment
 Immediate hospitalization if in severe pain
 In those with initial or profound shock – start infusion with Haemacel.
Send blood for cross-match and may need blood transfusion if
bleeding is significant (with presence of anaemia). In such instances,
immediate surgery is required and best performed via laparoscopy if
feasible.
 If the patient’s condition is stable (with minimal clinical findings and no
anaemia), treatment can be conservative with analgesics such as
mefenamic acid or diclofenac. Admit for observation if necessary. If
managed as outpatient, follow-up appointment should be given and
analgesics prescribed. The patient should be advised to come back if
pain persist or increased in severity. The pain should resolve within a
few days.
B. Ectopic pregnancy
 Definition - Pregnancy occurring in sites other than the endometrium of the
uterus
 Clinical presentation
 Most common symptoms: amenorrhoea, lower abdominal pain (localized
or generalized), vaginal bleeding.
 Others: Shoulder tip pain (referred pain due to irritation of the diaphragm),
dizziness and fainting spells (due to anaemia and hypotension), passage
of tissue (decidual cast), pregnancy symptoms.
 Pallor, lower abdominal tenderness, guarding or rebound tenderness, pervaginal bleeding, adnexal mass and/or tenderness.
 May present in shock with hypotension and abdominal distension.
 Diagnosis
 Usually based on the history and clinical examination in a woman with a
positive urine pregnancy test (UPT) and an empty uterus. If diagnosis is
obvious, there is no need to perform bimanual examination to elicit for
cervical tenderness and adnexal mass. This may cause more bleeding.
 In ectopic pregnancy, the entire decidual layer in the uterus may be shed,
thus may mimic a passage of fetus or placental tissue that occurs in
miscarriage. It may be seen as a pseudo-sac on ultrasound, and can be
mistaken as early gestational sac. Therefore, if the histology of these
tissue (either passed out spontaneously or from curettage specimen) do
not show any chorionic villi, an ectopic pregnancy must be excluded.
Patients must be re-evaluated again in case the diagnosis is missed.
 Investigations
 Urine pregnancy test (UPT) or serum ßhCG.
 Ultrasonography - to locate the pregnancy. May be able to see fluid
collection in the pelvis (blood) and adnexal mass (tubal pregnancy). High
resolution tranvaginal scan is preferred. Consider ectopic pregnancy if:
- unable to see intra-uterine gestational sac (IUGS) by TAS if serum
ßhCG is more than 6500 mIU/ml.
- unable to see IUGS by TVS if serum ßhCG is more than 1500 mIU/ml
(some centers use a cut-off of 2000 mIU/ml).
 If the ultrasound is indeterminate and the patient is clinically stable, the
patient should return for follow up with OB-GYN specialist in 48 hours for a
repeat ßhCG and be cautioned to return immediately to the hospital if she
develops any signs suggestive of ectopic pregnancy
 Serial serum ßhCG which show either a rise of less than 66%, plateau or
falling level over 48 hours suggest an abnormal pregnancy (either ectopic
or a miscarriage).
 Full blood count (FBC) - look at the haemoglobin and total white count (if
differential diagnosis is infection ).
 Laparoscopy - gold standard in diagnosis and can be for therapeutic as
well. There is still a 5% false positive rate and 3 – 4% false negative rate.
Management
 General
- Resuscitation – two i.v access (large bore if haemodynamically
unstable)
- Group and cross match blood.
- Check blood group and rhesus. Give anti-D immunoglobulin if rhesus
negative at a dose of 250 iu (50 microgrammes).
 Surgical treatment - laparoscopy is the method of choice. Laparotomy may
be needed in patient with large haemoperitoneum, clinically unstable or
has dense pelvic adhesions.
 Medical therapy or expectant management should only be managed by an
experienced gynaecologist, preferably in a tertiary hospital, with easy
access to urgent surgery if the need arises.
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2. Per vaginal bleeding
A. Pregnancy related
I.
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Miscarriage
Definition - loss of pregnancy before the 22nd completed weeks of pregnancy
or expulsion of fetus or embryo weighing 500 grams or less (World Health
Organization).
Approximately 80% will occur in the first trimester
Clinical presentation - patients present with vaginal bleeding, ranging from
scant bleeding to large clots, often with associated lower abdominal pain and
cramping. Patients with a septic abortion will also have a fever and peritoneal
signs. In threatened miscarriage, the clinical examination is usually
unremarkable.
Investigations
 Urine pregnancy test (UPT).
 Ultrasound scan - to look for intrauterine gestational sac, the presence of
fetal heart activity and the measurement of the gestational age (crown
lump length).
 Trans-abdominal ultrasound scan (TAS) - able to see fetal heart activity
from 7 weeks.
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 Trans-vaginal ultrasound scan (TVS) - able to see fetal heart activity at 6
weeks.
 Full blood count - mainly to assess the haemoglobin and platelet count.
 Blood group and rhesus - if Rhesus negative and non-sensitised, anti-D
immuno-globulin should be given if
 Ectopic pregnancy
 All miscarriages over 12 weeks (including threatened)
 All miscarriages requiring surgical evacuation
 Heavy bleeding or has pain in threatened miscarriage below 12
weeks.
 Serial serum hCG – 85% of normal intrauterine pregnancies has a rise of
66% in samples taken 48 hours apart. Abnormal rise or decreasing values
may suggest a failing intrauterine pregnancy or an ectopic pregnancy.
Serum hCG value of  150 IU/l at day 14 following embryo transfer is
associated with a high chance of successful pregnancy.
 Screening for Chlamydia infection (if available) in women undergoing
surgical evacuation.
Treatment – it will be based on the exact diagnosis.
Threatened miscarriage: follow-up scan should be arranged in 1-2 weeks. Subsequent
scans or follow-up depend on the bleeding pattern.
Incomplete miscarriage
 Definition: Incomplete expulsion of the product of conception and is retained in
the uterine cavity. This usually needs to be removed surgically.
 Ultrasound scan can identify residual tissue in the uterus.
 The cervix is usually open and there may be continued bleeding and pelvic pain.
Presence of the products of conception (POC) at the cervical os may be
associated with excessive bleeding which can lead to hypovolaemic shock. A
quick speculum examination and removal of this product of conception from
within the os with the sponge forcep will often stop the bleeding.
 Refer for Gynecology consult if products are not removed easily or bleeding
continues. Tissue should be sent to pathological examination.
 Bleeding can be controlled with either ergometrine 0.25mg to 0.50 mg (given i.v
or i.m) or syntometrine 1 ml given i.m while waiting to arrange for surgical
evacuation under i.v sedation or general anaesthesia.
 In cases where there may be small amounts of product of conception retained
despite repeated surgical evacuation, conservative management may be
appropriate if ectopic pregnancy has been ruled out. Patient should be followed
up closely with serial hCG, ultrasound of the uterus and to look out for early
clinical signs of infection. Prophylactic oral antibiotics (a broad spectrum plus
metronidazole) may be prescribed.
Inevitable miscarriage
 Definition: onset of the miscarriage process and will end as either complete,
incomplete or septic miscarriage.
 Presents with pain and vaginal bleeding. The bleeding may be excessive and the
cervix is open.
 Presence of the products of conception (POC) at the cervical os may be
associated with excessive bleeding which can lead to hypovolaemic shock. A
quick speculum examination and removal of this product of conception from
within the os with the sponge forcep will often stop the bleeding.
Early embryonic or fetal demise (Missed miscarriage/abortion, blighted ovum, delayed
miscarriage, anembryonic pregnancy)
 Definition: where there is pregnancy failure before the expulsion of the product of
conception. The fetus may be visualized and no fetal heart activity is seen.
 Diagnosis: via scan (see flow chart). If there is doubt about the gestation or the
fetal viability, a repeat scan should be done in 1 or 2 weeks.
 The uterus is usually smaller than dates and the cervical os is closed. There is
usually a reduction or cessation of pregnancy symptoms.
 If left alone, spontaneous expulsion of the product of conception will occur, which
may lead to either complete or incomplete miscarriage. The risk of disseminated
intra-vascular coagulation (DIVC) is very rare in first trimester miscarriages.
 The standard treatment is surgical evacuation under general or regional
anaesthesia. Cervical softening agents (such as vaginal gemeprost 1 mg, oral or
vaginal misoprostol) can be given 2 - 3 hours before the procedure especially in
a primigravida. This will make it easier to dilate the cervix, thus minimizes trauma
to the cervix and perforation of the uterus.
 Medical evacuation and expectant management are accepted alternative
techniques for incomplete miscarriage or cases of early embryonic or fetal
demise (uterine size less than or equal to 12 weeks), although they have not
replaced surgical evacuation. Misoprostol is commonly used but the best
regimen is yet to be defined. One example of misoprostol regimen that can be
use is: 600 mcg given orally as a single dose for incomplete miscarriage and 800
mcg given vaginally as a single dose for early embryonic or fetal demise. A
repeat dosing may be necessary and may increase efficacy (e.g on day 3).
Surgical evacuation is considered only after 7 days if she fails to respond.
Efficacy rates vary widely from 60 to 100%. This should be offered only in units
where patients have access to 24-hour telephone advice and immediate
admission can be arranged. Side effects are: cramping pain, nausea and
vomiting, diarrhoea, heavy bleeding. Anti-emetic and analgesics may be given to
minimize some of these side effects.
Miscarriage with infection (Septic miscarriage)
 Definition: due to ascending bacterial infection secondary to incomplete
miscarriage or termination of pregnancy.
 Infection may be localized to the uterine cavity or present as septicaemia.
Common organisms are E. coli and other gram negatives, Bacteroides,
streptococci, Clostridium welchii.
 Symptoms: feeling unwell, fever, lower abdominal pain, foul smelling vaginal
discharge.
 Physical signs: spiking temperature, lower abdominal and pelvic tenderness,
abdominal guarding, may be in a state of septic shock.
 Ultrasound scan of the uterus may show presence of POC within the uterine
cavity
 Management
- admit for further management.
- take full blood count (FBC), blood for culture and sensitivity (C&S), swab
from endocervix for culture and sensitivity, serum electrolytes, +/- liver
function test (LFT).
- i.v hydration.
- i.v antibiotic (either double or triple regimens and must be effective for the
gram positive, gram negative and anaerobic organisms ).
 i.v ampicillin 2 gm stat, then 1 gm q.i.d + i.m gentamicin 80 mg t.d.s
+ i.v metronidazole 500 mg t.d.s. OR
 i.m ceftriaxone 250 mg once daily + oral or i.v doxycycline 100mg
b.d + i.v metronidazole 500 mg t.d.s. OR
 i.v clindamycin 900 mg t.d.s + i.v gentamicin 1.5mg/kg body weight
t.d.s
(For all regimens, therapy should be continued for at least 2 days
after the patient is fever free – the usual duration is 7 – 10 days)
- arrange for surgical evacuation after 12 - 24 hours of commencing the i.v
antibiotics if there is presence of products of conception in the uterine
cavity.
II.
Molar pregnancy
Hydatidiform Mole (Molar Pregnancy)
Consist of two entities:
1. Complete moles:
2. Partial moles
A complete mole is defined as a 46,XX karyotype, both of paternal origin with no fetal
tissues.
A partial mole is defined as a 69,XXY karyotype (triploidy,dispermy), and may have a
viable fetus.
Complete Moles
 Incidence - North America: 0.6-1.1 per 1,000 pregnancies, Malaysia: 2.8 per
1,000 deliveries
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Aetiology - Unknown. A molar pregnancy is typically benign, but has the potential
to transform into malignant choriocarcinoma.
Risk Factors
 Age below 20 and above 40.
 Previous molar pregnancy.
 COCs use.
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Clinical History
 Commonly present with vaginal bleeding (84%), usually between 6th and
16th weeks.
 Others may have hyperemesis gravidarum, hyperthyroidism or noted
presence of vesicles per vagina.
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Uterus larger than dates (50%).
 15-25% has bilateral ovarian enlargement (theca lutein cyst).
 Signs of hyperthyroidism, early onset pre-eclampsia (hypertension).
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Investigations
 Ultrasound examination of the uterus – the diagnosis of complete mole is
almost always made by positive urine pregnancy test (UPT) and with
characteristics ultrasound findings (multiple echoes seen within uterine
cavity or so-called “snow storm appearance”). Bilateral theca lutein cysts
may be present. The diagnosis of partial mole can be missed on scan.
 Serum ßhCG levels – the level is much higher than expected for
gestational age.
 Full blood count (FBC), coagulation screen (PT, PTT).
 Serum electrolytes, creatinine and liver function tests (+/- thyroid function
test).
 Blood group and rhesus status.
 Chest X-ray – metastasis may be seen as either discrete, multiple or a
large solitary lesions. There may be miliary pattern of spread, or presence
of pleural effusions.
 Imaging by MRI or CT scan is indicated only when ultrasound examination
is inconclusive or if suspect metastasis.
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Management
 GXM 2-4 pints of whole blood – as preparation for immediate suction and
curettage.
 Suction evacuation, followed by gentle blunt curettage should be
performed as soon as possible under anaesthesia. Start syntocinon
infusions (20 units in 500 ml saline) during the procedure and continue for
4-6 hours to prevent excessive bleeding and helps to minimise the risk of
uterine perforation during the procedure. Possible complications of the
procedure are:
- Haemorrhage.
- Uterine perforation.
- Trophoblastic tissue embolisation to the lung.
- Sepsis.
 Give anti-D immunoglobulin if rhesus negative within 72 hours of suction
curettage.
 Repeat ultrasound examination of the uterine cavity in one week. If molar
tissue is still present, consider repeat suction curettage.
 Follow up with serial serum ßhCG as outpatient. Serum ßhCG usually will
drop to normal within 8-12 weeks after evacuation of the molar pregnancy.
Outcome: 80% will have spontaneous regression, 3-5% develop
choriocarcinoma and 15% have persistent mole. The need for
chemotherapy following a complete mole is 15% to 20% and 0.5 % after a
partial mole.
Partial moles – clinical presentation is similar to the complete moles but less severe.
Often, it is misdiagnosed as missed abortion or incomplete miscarriage in majority
of the cases. In such instances, the diagnosis is confirmed histologically following
the evacuation of the uterine cavity. Partial moles can be potentially malignant and
requires follow up similar to complete moles.
B. Non Pregnancy related
I.
II.
III.
IV.
DUB
Non DUB – fibroids, malignancy, adenomyosis, IUCD
Trauma
Post-operative complications – depends on nature of the bleeding
such as following intrauterine surgery (ERPOC, operative
hysteroscopic procedures and endometrial ablation), hysterectomy,
myomectomy, vaginal repairs, cone biopsy/LLETZ
3. Injuries in genital region
A. Uterine perforation
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Cause – iatrogenic (curettage, hysteroscopy), cancers, trauma
Diagnosis – no resistance of uterine wall, instrument penetrates deeper
than the size (sound) of the uterus, part of intestinal content seen with
hysteroscope
Treatment
Simple perforation by probe/sound/small Hegar dilator – stop procedure,
give iv antibiotics and followed by oral, conservative, look out for
peritoneal irritation,
Perforation with a larger Hegar dilator, with medium sized currete or ovum
forceps – may need to do a diagnostic laparoscopy and repair
Suspicion of intraperitoneal injury – diagnostic laparoscopy
Bleeding from the perforation - diagnostic laparoscopy
B. Injuries caused by intercourse
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Usually in young girls but also in women who have given birth, as a result
of rape.
Diagnosis – bleeding, with tear seen
Site of lesion – Introitus (deeply ruptured hymen), area of clitoris,
Perineum, Posterior wall of vagina
Watch out for injury to bladder, rectum, opening into POD
Treatment – minor tear at external can be sutured under local anaethesia.
More deeper of extensive injuries need repair under GA
Transport – sterile sanitary napkin, do not pack vagina.
C. Rape / assault
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Need to record
time of examination
Time of incidence
General condition including mental status
General examination – look for haematoma, scratches, injuries, All injuries
recorded by sketches, or better photographs
Investigation – blood
Avoid making any comments to patient or accompanying person