Gynaecological Emergencies Flashcards
3 Main symptoms in Gynaecological emergencies
- Bleeding
- Pain
- Fever
- Others
History taking of Gynaecological emergencies
- Bleeding
- Pregnant?
- Sexually active?
- Contraception?
- Menstrual-related?
- Trauma?
- Haematological disorder? - Fever
- Pregnant? (Pelvic infection uncommon in pregnancy) (Need to bring down temperature asap otherwise “cook” the baby)
- Sexually active?
- Surgical condition?
- Medical condition? - Pain
- OPQRST
- Pregnant?
- Sexually active?
- **Menstrual-related? (e.g. Dysmenorrhoea)
- **Trauma?
- **Surgical condition? (e.g. Appendicitis / Ruptured ovarian cyst)
- **Medical condition? - Other history
- **Urinary, Bowel symptoms
- **Past obstetric history (e.g. history of ectopic pregnancy)
- Predisposing risk factors
- Social history
P/E of Gynaecological emergencies
- General condition
- Abdominal exam
- IPPA - Pelvic exam
- Speculum, Bimanual exam
- Rectal exam
***Gynaecological emergencies
Pregnancy-related:
1. **Miscarriage / Abortion (Threatened / Incomplete / Complete / Inevitable / Silent / Septic)
2. **Ectopic pregnancy (Triad: Missed period, Vaginal bleeding, Abdominal pain)
3. Postpartum haemorrhage (PPH)
Non-pregnancy-related:
1. Acute bleeding in Menstrual disorders
2. Dysmenorrhoea
3. **Ovarian cyst complications
4. **Pelvic inflammatory disease (PID)
Others:
1. Post-treatment complications
2. Incarcerated uterine prolapse
3. Urinary retention
4. Surgical conditions
5. Medical conditions
- Miscarriage: ***Diagnosis of Silent miscarriage
Transvaginal USG:
- CRL (Crown-rump length) <7mm + No visible heartbeat —> Rescan >=7 days later
- CRL >=7mm + No visible heartbeat —> 2nd opinion / Rescan >=7 days later
- Intrauterine gestational sac with MSD (mean sac diameter) <25mm + No visible fetal pole —> Rescan >=7 days later
- Intrauterine gestational sac with MSD >=25 mm + No visible fetal pole —> 2nd opinion / Rescan >=7 days later
(Fetal pole: normally can be seen at 5-6 weeks (Web))
Transabdominal USG:
- Rescan >=14 days later
Rescan: ***No interval change —> can make diagnosis of Silent miscarriage
NB:
- Private scans with reports done by radiologists / gynaecologists can be accepted as 2nd opinion
- Where there is any doubt about diagnosis / a woman request a repeat scan —> should be performed at an interval of >=1 week from initial scan before treatment
Management of Miscarriage
1st line: **Expectant management for **7-14 days
—> Resolution of bleeding + pain (i.e. Complete miscarriage)
—> **Pregnancy tests after **3 weeks
—> If negative —> No further action
—> If positive —> USG to guide further management
—> No resolution —> Repeat USG scan
AND
—> ***Repeat USG scan —> Incomplete —> Discuss all treatment options (Continued expectant management, medical / surgical management)
- Advise on pain relief, when to get help in emergency, other treatment options
- Most cost-effective + negates risk of intervening + accidentally terminating a viable pregnancy
- Explore management options if:
—> Increased risk of haemorrhage (e.g. late 1st trimester)
—> Previous adverse / traumatic experience associated with pregnancy (e.g. stillbirth, miscarriage, antepartum haemorrhage)
—> Increased risk from effects of haemorrhage (e.g. coagulopathies / unable to have blood transfusion)
—> Evidence of infection
2nd line: **Medical management (next most cost-effective)
- **Vaginal Misoprostol single dose 800mcg
- 8am —> come back next day at 8am for 2nd dose if bleeding not started
—> **Pregnancy test after **3 weeks (1 week if 2nd dose given)
—> If negative —> No further action
—> If positive —> ***USG to look for molar / ectopic pregnancy + guide further management
AND
—> **Repeat USG scan after **3 weeks —> Gestational sac present / Incomplete —> Discuss treatment options
- specimen bottle for patient to collect any tissue mass passed —> confirm product of gestation + exclude gestational trophoblastic disease
- expect cramping abdominal pain + vaginal bleeding (2-3 weeks) (paracetamol 1g QID for pain, A/E if heavy bleeding / severe pain)
3rd line:
- Surgical management
- Ectopic pregnancy
See CFB16: Complications of Early Pregnancy
Classic triad:
- **Missed period
- **Vaginal bleeding
- ***Abdominal pain
- Menstrual disorders
- “Extremes” of reproductive age: watch out Anovulatory bleeding
- Puberty DUB —> Hormonal treatment
- Perimenopausal DUB —> Endometrial sampling (exclude cancer) then Hormonal treatment
Organic causes:
1. Fibroid polyp
2. Fibroid
3. Adenomyosis
4. Endometrial polyp
5. Endometrial carcinoma
—> Treat accordingly
Control of acute bleeding in DUB
Medication:
1. Monophasic combined pills TDS for 1 week —> OD 3 weeks
2. Medroxyprogesterone acetate 20mg TDS for 1 week —> OD 3 weeks
3. IV Premarin (conjugated estrogen) 25mg suspended in 5ml NS and injected over 2 min —> 2nd dose if still bleeding after 3 hours —> 3rd dose if still bleeding after another 2 hours
Surgical:
4. Hysteroscopy + curettage (immediate stop bleeding, get tissue for diagnosis, but need GA)
- Dysmenorrhoea
Primary dysmenorrhoea:
- Young
- Analgesics, Hormonal therapy
Secondary dysmenorrhoea:
- Endometriosis
- Adenomyosis
- ?Chronic PID (difficult to define)
Indicators of Secondary dysmenorrhoea:
- In the first 6 months from start of menarche (first few periods should not be painful ∵ anovulatory)
- Appear after many years of painless menses
- Pelvic abnormality on examination
- Infertility, menorrhagia, irregular cycles
- Not responding to standard treatment
- Ovarian cyst complications
Complications:
1. Torsion
2. Rupture / Leak
3. Bleeding into / form cyst
4. Infection (rare, ∵ well hidden in abdomen, DDx: Tubo-ovarian abscess)
S/S:
1. Pain (vs also bleeding + missed period in Ectopic pregnancy)
Torsion of ovarian cyst
S/S:
1. Acute / Subacute pain
2. Sudden onset
3. Recurrent (∵ twist + untwist itself), intermittent, progressive
4. N+V, Fever (∵ ischaemia)
5. Acute abdomen
6. Pelvic mass
Uncertain diagnosis: USG, Laparoscopy
—> Early diagnosis + treatment essential to save ovary (~ testicular torsion)
Treatment:
1. Detorsion, Cystectomy
- incomplete torsion (<360o, some residual perfusion) with no evidence of tissue damage
- desire to preserve fertility
- benign looking cyst
- Salpingo-oophorectomy (Current: ?Detorsion + Cystectomy)
- complete torsion
- venous thrombosis
- ovarian infarction
- Pelvic inflammatory disease (PID)
S/S:
1. Fever
2. Bilateral lower abdominal tenderness
3. Abnormal vaginal / cervical discharge
4. Abnormal vaginal bleeding
5. Cervical motion tenderness
6. Adnexal tenderness
Diagnosis:
1. Culture (even if negative —> still treat the same way)
2. Laparoscopy (if uncertain)
DDx:
1. Ectopic pregnancy
2. Appendicitis
NB:
- Current male partners / Other recent sexual partners of PID women should be contacted + offered health advice + screening for Gonorrhoea and Chlamydia
—> Tracing of contacts within 6 month period of onset of symptoms
Management of PID
Low threshold of empirical treatment
- Lack of definitive clinical diagnostic criteria
- Many complications of PID if left untreated (e.g. subfertility, ectopic pregnancy, chronic abdominal pain)
***Broad spectrum antibiotic:
- covering Gonococcus, Chlamydia, Anaerobes, Gram -ve facultative bacteria, Streptococci
Outpatient treatment:
1. IM Ceftriaxone 500mg
—> Oral Doxycycline 100mg BD + Metronidazole 400mg BD for 14 days
(Oral Levofloxacin 500mg QDS + Oral Metronidazole 400mg BD for 14 days)
Inpatient indications:
1. Surgical emergency cannot be excluded
2. Clinically severe disease
3. Tubo-ovarian abscess
4. PID in pregnancy
5. Lack of response to oral therapy
6. Intolerance to oral therapy
Inpatient treatment:
1. IV Ceftriaxone 2g OD + Oral Doxycycline 100mg BD
—> Oral Doxycycline 100mg BD + Metronidazole 400mg BD for 14 days
- IV Clindamycin 900mg Q8H + Gentamicin 2mg/kg loading dose
—> 1.5mg/kg Q8H (or 7mg/kg everyday)
—> Oral Doxycycline 100mg BD + Metronidazole 400mg BD for 14 days / Oral Clindamycin 450mg QID for 14 days
- Other post-treatment complications
- Ovarian hyperstimulation syndrome
- Secondary haemorrhage following LEEP
- Wound complications (Infection, Hernia)
- Vault haematoma (after hysterectomy)
- Bowel / Urinary tract injuries
