Gynaecology Emergencies in Primary Care

Mr Philip KalooConsultant Gynaecologist and

Laparoscopic Surgeon

Symptoms

Bleeding

InfectionPain

Until proven otherwise -

• All vaginal bleeding is due to pregnancy• All pelvic pain is due to ectopic pregnancy• All pelvic pain + pyrexia = PID

Bleeding

28 year old comes into your practice complaining of heavy bleeding

ABCHistory – How much?

Menstrual, LMPMedical hx, Drug hx

Examination – ObservationsAbdominal Vaginal

Investigations – pregnancy test

Scenario

7/40 pregnant, heavy bleeding. Soaked 4 pads at home.

BP 90/40, pulse 50Looks pale, not happy

Diagnosis?What do you do?

Speculum and remove products, refer.

So – if Pregnant + bleeding

Ectopic – unlikelyThreatened miscarriageInevitable miscarriageComplete miscarriage

So – if not pregnant + bleeding

Uterine pathologyFibroids, adenomyosis, endometrial pathology (e.g. polyp)

Anovulatory bleeds PCO, perimenopause, perimenarche

Systemic diseaseThyroid disorders, hepatic diseases, renal diseases, adrenal hyperplasia and Cushing's disease

CoagulopathyVon Willebrands disease, thrombocytopenia

IatrogenicIUCD in situ, Anticoagulants, antipsychotics, corticosteroids, pop, SSRI’s, tamoxifen, thyroxine, herbal and other supplements such as ginseng, ginkgo and soy

Dysfunctional uterine bleedingDiagnosis of exclusion

Pain

33 year old, G3P0, IVF 6 weeks ago, PMH – Endometriosis, CIN 3Sx - pelvic pain, no pv bleeding.Hx and examination

What is your differential?1. Ectopic until proven otherwise2. Ovarian cyst incident / torsion3. OHSS4. ?Endometriosis

Pregnancy test

Ectopic till proven

otherwise

GYNAECOLOGICAL

Symptoms – PainAmenorrhoeaEpisodes of syncopeChange in bowel habit

Ovarian cyst incidentOvarian torsionOHSSPIDTubo-ovarian abscess

And ECTOPIC!

+ve -ve

Refer Refer

Ovarian torsion

Uncommon cause of gynae emergencies <4%. 80% in reproductive ageIncreased with pregnancy (14%), ovarian cysts,

previous abdominal surgery, right sided.

Presentation •Systemically unwell (↑ Temp,↑ Pulse, ↑ Resp rate)•Unilateral lumbar or abdominal pain•Pain duration >8 hours•Nausea / Vomiting

Infectiona) PIDb) Tubo-ovarian abscessc) Bartholins cyst/abscessd) Toxic-shock syndrome

PID Presentation:● bilateral lower abdominal tenderness (sometimes radiating to the legs)● abnormal vaginal or cervical discharge● fever (greater than 38°C)● abnormal vaginal bleeding (intermenstrual, postcoital or ‘breakthrough’)● deep dyspareunia● cervical motion tenderness on bimanual vaginal examination● adnexal tenderness on bimanual vaginal examination (with or without a palpable mass).

PID – when to refer in

• Surgical emergency cannot be excluded• Clinically severe disease• Tubo-ovarian abscess• PID in pregnancy• Lack of response to oral therapy• Intolerance to oral therapy.

Toxic Shock SyndromeRare 18 cases per year in UK. ½ related to menstruationAcute, noncontagious, toxin-mediated febrile illness caused by staphylococcal

infection

Presentation•pyrexia (>39°C)•hypotension•diarrhoea and vomiting•headache •muscle cramps and myalgias•rash (diffuse macular erythroderma or 'sunburn')•multi-organ dysfunction•shock, adult respiratory distress syndrome, disseminated intravascular coagulation and renal failure

Gynae scanning

Take home messages

Bleeding – Assume pregnantDon’t underestimate

Pain – Ectopic till proven otherwise A negative pregnancy test does not

exclude an ectopic Ovarian torsion if treated <48 hours =

viable ovaryInfection – Treat early , refer early