Gynaecological emergencies

Question 1

Ectopic pregnancy

Answer 1

An ectopic pregnancy is one that occurs anywhere outside of the uterus - commonly in fallopian tubes

Question 2

Most common location for ectopic pregnancy?

Answer 2

In one of the fallopian tubes.

Question 3

Presentation of ectopic pregnancy

Answer 3

Abdominal pain, pelvic pain, amenorrhoea, usually HCG positive and unilateral pain, shoulder tip pain

Question 4

Investigations for ectopic pregnancy

Answer 4

Urine hCG, serum hCG and abdominal ultrasound

Question 5

Risk factors for ectopic pregnancy

Answer 5

Previous ectopic
Tubal damage- infection, endometriosis, surgery, PID, 
Intrauterine contraceptive devices
Smoking
Infertility
Infertility treatment
Extremes of reproductive age

Question 6

Management of ectopic pregnancy

Answer 6

Medical management involves the administration of systemic methotrexate, with ongoing monitoring of serum hCG levels.

Surgical management involves the surgical removal of the ectopic pregnancy (most commonly a laparoscopic salpingectomy).

Question 7

Ovarian torsion

Answer 7

the rotation of the ovary at its pedicle to such a degree as to occlude the ovarian artery and/or vein.

Question 8

Ovarian torsion symptoms

Answer 8

Sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting.

HCG negative and unilateral

Question 9

Management of Ovarian torsion

Answer 9

~	Resuscitation
~	Laparoscopy – small incision and ideal
~	Laparotomy – large open incision
~	Detorsion
~	Cystectomy – operation to remove whole bladder
~	Oophorectomy

Question 10

Ovarian cyst

Answer 10

An ovarian cyst is a fluid-filled sac that forms on or inside an ovary. In some cases, the cyst can break open (rupture).

Question 11

Presentation of Ovarian cyst

Answer 11

Remember, presentation would be unilateral, HCG negative with signs of infection – like raised WBCs

Question 12

Pelvic inflammatory disease

Answer 12

An inflammatory condition (often secondary to infection), affecting any part of the higher female reproductive system, e.g; uterus, fallopian tubes, ovaries.

Typically results from an ascending infection from the cervix, and most commonly is a result of the sexually transmitted infections chlamydia, or less so, gonorrhoea.

Question 13

PID symptoms (lots)

Answer 13

Generalised Abdominal pain, HCG negative
Usually lower region
Can be bilateral or unilateral

If pain is severe, may be associated with nausea and vomiting. If nausea and vomiting are present, this suggests peritonitis.

Dyspareunia
Cervical / vaginal discharge, Often foul smelling
Irregular vaginal bleeding
Heavy blood loss suggests endometritis

Fever (About 1/3 of patients)

Cervicitis

Question 14

Dyspareunia

Answer 14

pain on sexual intercourse

Question 15

If nausea and vomiting are present in PID, what does this suggest?

Answer 15

Peritonitis

Question 16

Investigations in PID

Answer 16

~ FBC, CRP, ?LFT
~ Cervical motion tenderness
~ Genital swabs x2

Question 17

Management of PID

Answer 17

Some patients may be suitable for oral antibiotics and outpatient treatment

Typical regimen might be single IM dose of ceftriaxone with 14 days doxycycline + metronidazole

Question 18

Bartholin cyst/abscess

Answer 18

A build-up of mucus secretions can cause the duct of the gland to become blocked, from which a cyst can develop. The cyst itself can become infected, and if untreated, develop into an abscess.

Question 19

Where are the bartholin glands?

Answer 19

Greater vestibular glands - are located deep to the posterior aspect of the labia majora.

Question 20

Presentation of small bartholin cysts.

Answer 20

Small Bartholin’s cysts are often asymptomatic.

If they become large, they can cause vulvar pain.

Question 21

Presentation of bartholin cyst rupture.

Answer 21

The cyst can undergo spontaneous rupture – after which the patient typically experiences a sudden relief of pain.

Bartholin’s abscesses typically present with acute onset of pain, and/or difficulty passing urine.

Question 22

The morphology of bartholin cyst & abscess

Answer 22

Bartholin’s cyst – typically soft, fluctuant and non-tender

Bartholin’s abscess – typically tense and hard, with surrounding cellulitis

Question 23

Management of bartholin cyst & abscess

Answer 23

Conservative, Antibiotics- broad spectrum, Incision and drainage

Question 24

Investigations of bartholin cyst & abscess

Answer 24

Clinical - swabs