O&G: Gynaecological Emergencies

Question 1

Ectopic pregnancy

Answer 1

Consider this Dx in ***any woman of reproductive age who complains of:
1. Abdominal pain
2. Fainting attack secondary to hypovolaemic shock

Clinical presentation often ***not classical:
1. Abdominal pain
2. Fainting attack secondary to hypovolaemic shock
3. Prominent GI symptoms: Diarrhoea, Painful defaecation

Investigations:
1. **β-hCG
- considered in **any young woman with **unexplained abdominal pain whether she has **missed a period / ***abnormal vaginal bleeding

2. USG
   - ultrasonically ***“empty” uterus but presents with vaginal bleeding in pregnancy

Management:
1. Rapid referral + Assessment
- esp. women in haemorrhagic shock following rupture of ectopic pregnancy
2. ***Laparoscopic / Open surgery

Patients who died:
1. Socially deprived (e.g. recent immigrants)
2. Language barrier
3. Itinerant occupations
4. Previous substance abuse

Question 2

Miscarriage

Answer 2

Spontaneous vs Induced

Complications:
- **Septic abortion (ANY abortion (spontaneous or induced) complicated by uterine infection, including **endometritis)
—> Rapid clinical deterioration postoperatively
—> Direct + rapid involvement of senior obstetric staff + other relevant specialists e.g. ICU doctors

Management of septic abortion:
- **IV antibiotics
- **Evacuation of uterus (1 hour after IV antibiotics)

Question 3

Termination of Pregnancy

Answer 3

Before ToP:
- USG examination to establish:
—> Gestational age
—> Viability
—> Site

• USG intrauterine pregnancy but failure to obtain tissue at suction termination —> suggest abnormal site of implantation e.g. ***Cornual pregnancy
• ***Perforation of uterus during suction ToP
  —> Laparoscopy / Laparotomy essential
  —> ∵ risk of bowel damage + life-threatening sequelae

Dilatation + Evacuation:
- questionable in terminating 2nd trimester pregnancy
- ∵ effective ***medical alternatives exist

From CFB 23:
1st trimester abortion: **Mifepristone (Anti-progestogen) 200mg PO —> **Misoprostol PV / Sublingual 1-3 days later (applicable up to 9 weeks of gestation)
2nd trimester abortion: ***Misoprostol 400 mcg PV Q3H (up to 5 times / day)