Common Obstetrical and Gynecological Emergencies
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Transcript of Common Obstetrical and Gynecological Emergencies
Common
Obstetrical and Gynecological
Emergencies
Aboubakr Elnashar
Benha University Hospital, Egypt ABOUBAKR ELNASHAR
1. Abdominal pain in pregnancy
2. Bleeding in early pregnancy
3. Antepartum hge
4. Postpartum hge
5. Severe PET and eclampsia
6. Acute abdomen
ABOUBAKR ELNASHAR
1. ABDOMINAL PAIN IN PREGNANCY A. Conditions Incidental to Pregnancy
Acute appendicitis
Acute pancreatitis
Peptic ulcer
Gastroenteritis
Hepatitis
Bowel obstruction
Bowel Perforation
Herniation
Meckel’s Diverticulitis
Toxic megacolon
Pancreatic pseudocyst
Ovarian cyst rupture
Ureteral calculus
Rupture of renal pelvis
Ureteral obstruction
SMA syndrome
Thrombosis/infarction
Ruptured visceral artery aneurysm
Pneumonia
Pulmonary embolus
Intraperitoneal hemorrhage
Splenic rupture
Abdominal trauma
Acute intermittent porphyria
Diabetic ketoacidosis
Sickle Cell Disease
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B. Conditions Associated with
Pregnancy
Acute cholecystitis
Acute pyelonephritis
Acute cystitis
Rupture of rectus abdominus muscle
Constipation
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C. Conditions Due to Pregnancy
(Obstetrical causes)
First trimester
1. Miscarriage
2. Ectopic pregnancy
3. Rupture corpus luteal cyst
4. Acute salpingitis
5. Acute Retention of urine
6. Adenxal torsion
7. Stretching of round ligament
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1. Miscarriage Pain:
preceded by vaginal bleeding
in the middle
intermittent.
Cervix:
Closed (threatened abortion)
Open (inevitable)
U/S:
Gestational sac inside uterine cavity.
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2. Ectopic pregnancy Pain:
Before bleeding
limited initially to the affected side
Interperitoneal bleeding: generalized, shoulder tip and
rectal, diarrhea, shock
Investigations:
1. TVS
2. Serum quantitative HCG
No IU gestational sac at hCG >1500-2000 IU/L suggests an ectopic or nonviable IUP
3. Progesterone (nmol/L)
>60: viable IUP
<20: Failing PUL
ABOUBAKR ELNASHAR
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3. Rupture corpus luteal cyst functional ovarian cyst
Following a release of an ovum: corpus luteum.
Pregnancy: involute at the end of the 2nd T
Pain
Mild aching
Hemorrhage inside cyst: severe pain
Rupture: Sudden onset of pain
Signs of peritonism
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4. Acute Salpingitis up to the 10 w
{gonococcal infection or infection at attempted attempted abortion}
Pain:
in both iliac fossae
continuous
Associated:
Tenderness
Tachycardia
Elevated temperature
Culture of discharge: pathogens
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5. Acute retention of urine {usually due to enlargement of a cervical
fibroid in response to pregnancy}
Pain
Severe lower abdominal wall
Unable to pass urine
large tender bladder which may be mistaken for ov. Cyst
US
Catheterization:
immediate relief of pain
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6. Adenxal torsion
Pain:
Twisting
Lateral lower quadrant
sudden onset
Peritonism Fever ,leucocytosis,N/V US colour Doppler: no flow : Miscarriage PTL
Right adnexal torsion at
the utero-ovarian pedicle.
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7. Round ligament pain
Pain
Cramp like or stabbing
worse with movement
tenderness in the lower quadrant and groin
No constitutional symptoms.
Commonly towards the beginning and the end of
pregnancy
More in multips
{stretching of round ligaments}
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2nd trimester
1. Acute retention of urine {incarcerated RVF
gravid uterus}
2. Red degeneration in a fibromyoma
3. Rupture of rudimentary horn containing
pregnancy
4. Miscarriage
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1. Red degeneration of fibromyoma
Pain
mild to severe
over the fibroid.
tenderness over the fibroid.
History
Menorrhagia before pregnancy
U/S:
Fibroid
Degenerative cystic changes
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2. Pregnancy in rudimentary horn
Pain
resemble that of ectopic: usually the condition
discovered during laparotomy
Rupture:
usually in the 2nd T
: sudden onset with collapse
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3rd trimester
1. Placental abruption
2. Severe preeclampsia
3. Red degeneration of fibromyoma
4. Uterine rupture
5. Contractions of labour
6. Acute fatty liver
7. Stretching of round ligament
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1. Placental abruption
0.5- 1 % of all pregnancies
Pain:
acute onset
Severe
considerable shock and collapse.
Abdominal ms: Tense
Uterus: larger than expected, hard tender with
difficulty in palpating fetal parts
Fetal heart: usually absent
May be:
Vagina bleeding
Hypertension
Coagulopathy
ABOUBAKR ELNASHAR
2. Severe PET
Pain
Epigastric, Rt upper quadrant
Signs of PET:
hypertension, proteinuria, oedema
Uterus: not tender
Fetal parts: palpable
FHR: usually present
Investigation: PET
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HELLP Syndrome Hemolysis – Elevated Liver Enzymes – Low Platelets
Timing: 28-36 w Labs: Plts, AST/ALT, indirect bili, haptoglobin, schistocytes on peripheral Smear
Sign/Sx Frequency
Proteinuria 87
HTN (>140/90) 85
RUQ/Epigastric
pain
40-90
Nausea/Vomitin
g
29-84
Headache 33-60
Visual changes 10-20
Jaundice 5
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3. Uterine rupture
Think
Grand multiparous ┼
Scarred uterus
{CS, myomectomy, perforation}
Pain:
Sudden onset, constant:
shock & collapse.
Vaginal bleeding: common.
Fetal parts: easily felt
FHR: absent
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4. Labour pains
prematurely or at term
intermittent & gradually become stronger and
more frequent.
Show
Cervix: taken up and perhaps dilated
CTG
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5. Acute fatty liver of pregnancy
Incidence: Rare
Timing: 2nd half (usually 3rd T)
Pain:
Epigastric (50%), Rt upper quadrant
N/V (75%), anorexia, jaundice +/- signs of PET
Investigations
1. All PET investigation: PT, PTT +/- Plts Cr
2. AST/ALT,, glucose, +/- WBC,
3. US/CT or MRI liver
Early diagnosis essential
Cannot be predicted
LFT in a pt presenting with abdominal pain ABOUBAKR ELNASHAR
6. Chorioamnionitis
Usually precede by PROM
Tender uterus
Offensive discharge
Systemic signs of sepsis
Investigations
1. Blood culture
2. Inflammatory markers
3. Speculum ex
4. CTG
ABOUBAKR ELNASHAR
7. Rectus sheath hematoma
Rare, usually in multiparous
{Rupture of inferior epigastric artery
May follow a bout of coughing or abdominal
trauma}
Pain
Sudden onset
Large unilateral painful swelling
Superficial location
Confused with abruption
ABOUBAKR ELNASHAR
2. BLEEDING IN EARLY PREGNANCY
1. Threatened miscarriage (50 % )
2. Missed miscarriage (25 %)
3. Blighted ovum (20 %)
4. Incomplete miscarriage (3 %)
5. Ectopic pregnancy (2 %)
6. Hydatiform mole (< 1 %)
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3. ANTE PARTUM HGE
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4. POSTPARTUM HGE
Causes: four Ts:
tone: 90%
tissue,
trauma,
thrombin
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5. SEVERE PET AND ECLAMPSIA
ECLAMPSIA (E)
convulsions superimposed on PET.
Preeclampsia (PET)
PIH in association with proteinuria (> 0.3 g/24 h) ±
oedema
Severe PET
DBP ≥ 110 mmHg on 2 occasions or
SBP ≥ 170 mmHg on 2 occasions and that, together
with significant proteinuria (1 g/litre)
DBP ≥ 100 mmHg on 2 occasions & significant
proteinuria with at least 2 S or S of imminent E.
ABOUBAKR ELNASHAR
I. Control BP
Antihypertensive treatment
Indications:
1. SBP> 160 mmHg or
DBP>110 mmHg.
2. SBP <160 plus
severe disease
heavy proteinuria or
disordered liver or haematological test)
{alarming rises in BP may be anticipated}.
ABOUBAKR ELNASHAR
Drugs:
•Acute, severe:
Nifedipine: oral not sublingually IR cap:10 mg initial; repeat after 30 m if necessary
IR cap: 10-30 mg tid; not to exceed 120-180 mg/d
Hydralazine IV: 5 mg over 5 min, repeat /20 min until DBP 95 mmHg, No
more than 4 doses. If not give Labetalol or Nifidipine.
Maintenance: 10 mg/h
Add 2ml NS to reconstitute 20 mg hydralazine. Withdraw 0.5 ml
hydralazine solution and add 9.5 ml NS to give total 10 ml
solution.
ABOUBAKR ELNASHAR
II. Prevention of seizures Indications:
Severe PET:
Once a delivery decision has been made and in
the immediate postpartum period.
When conservative management of a woman with
severe hypertension and a premature fetus is
made it would be reasonable not to treat until the
decision to deliver has been made.
ABOUBAKR ELNASHAR
If Mg So is given:
1. It should be continued for 24 h following delivery or
24 h after the last seizure, whichever is the later,
unless there is a clinical reason to continue.
2. Regular assessment of:
a. Urine output,
b. Maternal reflexes,
c. Respiratory rate
d. Oxygen saturation .
ABOUBAKR ELNASHAR
III. Control of seizures I.
1. Do not leave the patient alone.
2. Prevent maternal injury during the convulsion.
3. Call for help and place a code blue call- Medical
Emergency call.
4. Initiate resuscitation.
5. Turn the patient into left lateral position when able
to do so.
6. Inform the consultant obstetrician and anesthetist
on call.
ABOUBAKR ELNASHAR
II. AIRWAY
1. Assess and maintain patency, using oral suction if
necessary.
2. Insert a plastic oral airway if possible
3. Administer oxygen therapy via face mask.
III. BREATHING
1. Assess respiratory rate and ambubag using facial
mask/laryngeal mask or endotracheal tube if
necessary.
ABOUBAKR ELNASHAR
IV. CIRCULATION
1. Evaluate Pulse and B P. If absent, initiate CPR.
2. Secure IV access as soon as possible
with main line infusion,
with three-way tap attached
Hartmann's Solution
very slow rate, as fluid intake will be restricted to
1 ml/kg/h
3. Pulse oximetry is helpful.
ABOUBAKR ELNASHAR
V. Mg SO4
Therapy of choice to control seizures.
Loading dose:
4 g
infusion pump over 5–10 min
Maintainance:
1 g/h for 24 h after the last seizure.
Recurrent seizures
Further bolus of 2 g Mg SO4 or
an increase in the infusion rate
to 1.5 g or 2.0 g/h.
ABOUBAKR ELNASHAR
Prepare loading dose
Add 4g (8ml) of 50% MgS04 to 12ml of NS.
Administer slowly IV over 10 m.
Prepare Maintenance dose
Add 50g (100 ml) of 50% MgS04 to 400ml of NS
(withdraw 100mls from 500ml bag of NS, prior to
adding MgS04).
Administer IV via volumetric pump at 10ml/h
=1g/hour.
ABOUBAKR ELNASHAR
VI. Once stabilized
Plans should be made to deliver the woman
No particular hurry and a delay of several
hours to make sure the correct care is in
hand is acceptable, assuming that there is
no acute fetal concern such as a fetal
bradycardia.
The woman’s condition will always take
priority over the fetal condition.
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VI. Fluid balance 1. Fluid restriction is advisable
{reduce the risk of fluid overload in the intrapartum
and postpartum periods}
Total fluids should be limited to 80 ml/h or 1 ml/kg/h
{a. pulmonary oedema has been a significant cause
of maternal death.
b. No evidence of the benefit of fluid expansion
c. fluid restriction regimen is associated with good
maternal outcome.
d. No evidence that maintenance of a specific urine
output is important to prevent renal failure, which is
rare.}
ABOUBAKR ELNASHAR
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6. GYNECOLOGICAL CAUSES OF
ACUTE ABDOMINAL PAIN A. Women of reproductive age
I. Pregnancy related
Ectopic
Septic abortion
Endometritis: post-partum or post-abortion
II. Infection
PID
TOA
III. Complicated ovarian cyst
Torsion, rupture, hemorrhage, OHSS
IV. Complicated fibroid
Degenerating
Torsion ABOUBAKR ELNASHAR
B. Adolescents
Similar +
imperforate hymen and
transverse vaginal septum C. Postmenopausal women
Similar –
ectopic pregnancy and
ovarian torsion
ABOUBAKR ELNASHAR
Most common causes of acute lower
abdominal pain
1. PID
2. Ruptured ovarian cysts
3. Appendicitis
ABOUBAKR ELNASHAR
CDC Criteria for Diagnosis of PID. (2006)
At least one of the following criteria: 1. Adnexal tenderness
2. Cervical motion tenderness
3. Uterine tenderness
Additional diagnostic criteria (enhances specificity if present):
1. Cervical or vaginal mucopurulent discharge
2. Elevated CRP
3. Elevated ESR
4. Lab documentation of cervical infection with N
gonorrhoeae or C trachomatis
5. Tem >38.3° C
6. Saline microscopy of vaginal secretions: abundant
numbers of WBC
ABOUBAKR ELNASHAR
Adenxal torsion
Pain:
Twisting
Lateral lower quadrant
sudden onset
Peritonism Fever, leucocytosis, N/V US colour Doppler: no flow
Right adnexal torsion at the
utero-ovarian pedicle.
ABOUBAKR ELNASHAR
Endometriosis Pain: Acute Abdominal Pain {Rupture of an endometrioma} usually at menstruation Most commonly between 30 and 45 y Usually preceded by premenstrual lower abdominal pain
Diagnosis: confirmed at laparoscopy
ABOUBAKR ELNASHAR
History, Examination, Pregnancy test
Pregnant
Yes: evaluate for ectopic: BHCG, TVS No
Right lower quadrant pain or pain migrating from umbilicus to RT lower
quadrant
Yes: surgical consultation and laparotomy for appendicitis; if
diagnosis in doubt: US or CT with IV contrast
No
Cervical motion, uterine, or adenxal tenderness
Yes: Consider PID: TVS for TOA No
Pelvic mass on examination
Yes: consider complicated ovarian cyst , complicated fibroid or
endometriosis: TVS
No
Dysuria and WBC on urine analysis
Yes: Evaluate for UTI or PNP: urine culture No
Gross or microscopic hematuria
Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone
protocol CT
No
TVS to evaluate for other diagnosis ABOUBAKR ELNASHAR
CONCLUSION The most common urgent causes are
ectopic pregnancy, ruptured or torsion
ovarian cyst, PID
Early diagnosis is important to prevent
sequelae of delayed diagnosis
Most diagnosis can be made with
History examination , pregnancy test and
TVS
ABOUBAKR ELNASHAR
As the first priority, urgent life-
threatening conditions and fertility-
threatening conditions must be
considered.
A high index of suspicion should be
maintained for PID when other
etiologies are ruled out, because the
presentation is variable and the
prevalence is high.
ABOUBAKR ELNASHAR
Thank you ABOUBAKR ELNASHAR