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Gynaecological Emergencies - Coggle Diagram
Gynaecological Emergencies
Common Gynaecological Emergency Presentations
Acute Presentations General
Acute pelvic pain
Acute menstrual bleeding
Acute vulval pain / swelling
Procidentia-related problems
Fibroid related urinary retention
Emergency contraception request
Sexual assault
EP pelvic pain / bleeding
EP vomiting
TOP request
Accute Presentations Post-op / Post-procedure
OHSS (ovarian hyperstimulation syndrome)
Red Flag Presentations
Postmenopausal bleeding
Cervical mass
Abdominal distension / mass
Vulval itch / pain
Incidental General Emergencies
Emergency Care General Approach
Gynae emergencies cause
collapse
mainly through
hypovolaemic shock
or
sepsis
Recognise
that patient is unwell
Call for
help
Position pt
Give
O2
Secure
IV access
Take
bloods
FBC
U&E
LFTs
CRP
ABG: Lactate
Give
IV fluids
Blood / blood products
Insert
urinary catherter
Transfer to
HDU/ICU
Arrange further investigations
ECG
Imaging
Acute Pelvic Pain
Definition
Pain in the lower abdomen or pelvis that either 1) had a
sudden onset
or 2) is
severe
Causes
Pregnancy-Related
Ectopic pregnancy
Miscarriage
Gynaecological
Ovarian cyst accident - torsion, rupture, haemorrhage
Pelvic inflammatory disease
Exacerbation of chronic condition - Fibroid degeneration / endometriosis
GI
Appendicitis
Diverticulitis
Urinary
Urinary tract calculus
UTI
Ask
Pregnancy test
Unilateral / bilateral
Vomiting
Peritonism (acute abdomen)
Classic Presentations
Ovarian Torsion
Known ovarian cyst (particularly dermoid)
Unilateral / colicky waves of pain
Sudden onset
Vomiting
+/- Peritonism
+/- Palpable mass
Pelvic US:
Enlarged ovary
> 5cm but US cannot exclude
Ovarian Cyst Rupture / Haemorrhage
Natural menstrual cycles → function cysts usually
Unilateral / sharp stabbing pain
Sudden onset
Mid-cycle
+/ Peritonism
Pelvic Inflammatory Disease
Sexually active
Bilateral / gradual onset
Abnormal discharge and bleeding
Pyrexia
Peritonsim
Relatively
more adnexal tenderness
Appendicitis
Under 40
Colicky - poorly localised central abdominal pain
Then sharp - localised to right side
More gradual onset
Anorexia / Vomiting
Pyrexia
Peritonism
Relatively
less adnexal tendernes
Urinary Calculus
Unilateral loin to groin pain
Colicky waves of severe pain
Sudden onset
=/- Peritonism
Microscopic haematuria - if stone
Assessment of Acute Pelvic Pain
Pregnancy
If having periods - pregnancy test
Stability
Well/unwell
Shock
History
SR-C-OPD-SARA
Gynae
Bleeding / periods
Chronic gynae pain
DDCP
Contraception
Sexual history
GI
Anorexia
N/V
Bloating / distension
Bowels opened last
Urinary
Dysuria
Frequency
Haematuria
Examination
Vitals
Pyrexia
Abdomen
Peritonsim
Mass
Sepculum VE
Abnormal bleeding / discharge
Digital VE
Uterine tenderness / size
Adnexal tenderness / mass?
Investigations
Besides
Pregnancy test
Urinalysis
MSU C&S
Swabs - HVS, NAAT, Culture
Bloods
FBC
CRP
Imaging
Pelvis USS
Ovarian cyst
Free fluid
Pregnancy if PT+
Treatment
Ectoptic / Miscarriage
Laparoscopy
ERPC
Ovarian torsion
De-torsion - younger pts
Oophorectomy older pts
Ovarian cyst rupture / haemorrhage
Conservative - usually resolves
Laparoscopic cystectomy if not settling
PID
Admit → IV Abx → Discharge 24-48hrs if well
Appendicitis
Gen surg
CT AP
Laparoscopic appendectomy
Urinary Calculus
Refer for urology opinion
CT KUB scan
No obvious cause
Admit
IV antibiotics
Await progress - discharge if settles
Laparoscopy if not settling
Assessment of the Acute Acbomen
Superficial Palpation
Tenderness
Pain on palpation
Local or general
Gaurding
Muscle contraction
Does it persist on distraction
Local or general
Rebound tenderness
Pain n withdrawal of palpation
Rigidity
Whole abdomen held rigid
Acute Menstrual Bleeding
Definition
An episode of
heavy mentrsual bleeding
that is of sufficient quantitiy to require
immdiate intervention
to prevent further blood loss
Assessment
Assess Stability
Assess hypovolaemia
FBC / Coag / G&S
Perform pelvic exam to assess / confirm bleeding
Assess Cause
US
Endometrial biopsy
Hysteroscopy
Consider PALM COEIN causes
Consider bleeding disorder if young
Provide treatment
Resus
Stop bleeding
Medical
Antifibrinolytic (tranexamic acid) 1QDS PO 7 days
Progesterone: Medroxyprogesterone acetate (Provera): 10–20 mgs BD PO for 7 days OR
Norethisterone (Primolut N): 10 mgs TDS PO for 7 days
Surgical
If not responding
Endometrial ablation
Uterine artery embolism
Hysterectomy
Consider long term management
Acute Vulval Pain / Swelling
DDx
Pain and swelling
Bartholin's abcess
Pain and Ulcer
Herpes simplex infx
Vulval cancer
Assessment
Assess stability
Usually systemically stable
May find mobilising difficult
Assess cause
Bartholins abcess
Inflamed (hot, red, swollen, tender)
Clinical diagnosis
Herpes SImplex infection
Multiple tender vesicles / ulcers
Swab to confirm
Syphilis
Non painful single ulcer
Vulval cancer
Ulcerating
Necrotic
Hard mass
Provide Treatment
Bartholin's abcess
Abx
Severe: Incise, drain and marsupialise / Word catherter
Herpes simplex infection
Aciclovir
Analgesia including LA
Catheterise
STI management
Vulval Cancer
Refer to gynae oncology
Procidentia-Related Problems
Definition
Prolapse of the whole uterus through the baginal introitus - severe prolapse
Complications
Vaginal ulceration
Urinary retention
Bowel problems
Sexual probelms
Diagnosis
Clinical
Prolaspse symptoms
Confirm on physical exam
Management
Acute
Replace prolapse manully
Ulcerated
Pack vagina
Apply oetrogen cream (oestrogen soaked pack)
Non-ulcerated
Insert pessary - often shelf (not ring)
Long term
Surgery
Pessery
Depends on QOL
Fallen out pessary
Reinsert - larger size / different type
Fibroid-Related Urinary Retention
Fibroid-Related Urinary Retension
Epidemiology
Rare
Management
Catheterise
Surgery
Myometry or hysterectomy depending on wishes / fertility
Complications
Acute menstrual bleeding
Large fibroid
Prolapsed submucous fibroid
Pain
Degeneration of intramural fibroid
Torsion of pedunculated fibroid
Urinary Retention
Large fibroid uterus
Rapid growth for malignant transformation
Pregnancy related
Sexual Assault
Management
Contact ocal SATU even if doesn't want to report Gardai
Forensic clincail assessment
Consider
Emergency contraception
STI prophylaxis
Hep B PEP and HIV PEP
Wound management
Tetanus immunization
Info regarding councelling - rape crisis entr
Ovarian Hyperstimulation Syndrome (OHSS)
Definition
Systemic disease resulting from hyperstimulated ovaries characterised by 1)
ovarian enlargement
2)
increased vascular permeability
and 3)
prothrombotic effect
Cause
Gonadotrophins
Particularly HCG used during fertility treatments
Pathophysiology
Hyperstimulation of ovaries → release of proinflammatory products (particularly cytokines)
Risk factors
Age <35
Previous OHSS
PCO
Complications
Ovarian torsion
Ovarian rupture
Deydration
ARDs
Ascites
Renal failure
Multi-organ failure
VTED
Death
Fluid shift
Intravascular → extravascular
Assessment
For complications
BMI
Examine heart / lung/ abdomen (girth) / pelvis / legs
Bloods
FBC
U&E
LFTs
Coag
D-dimers
US pelvic - ovarian size
Clinical Diagnosis
Managment
Supportive
Hospitalise in severe cases
MDT
CAREFUL monitoring of fluid replacement
Thromboprophylaxis
Analgesia - avoid NSAIDs
Amtiemetics
Monitor and correct electrolye and organ dysfunction
Postoperative Complications
Main complications
Haemorrhage
Infection
wound
Pelvis
Urine
Chest
Thrombosis
DVT / PE
Visceral injury
Bowel
Ureter
Bladder
Timeframe
0-24 hr
Haemorrhage
1-5 days
Infection
Thrombosis
Visceral injury - direct injury
7-14 days
Infection
Thrombosis - classically day 10
Visceral injury - indirect injury - avascular necrosis
Red Flag Presentations
Postmenopausal bleeding
Think of endometrial cancer
Cervical mass
Think cervical cancer
Abdominal mass / distension
Think Ovarian cancer / fibroid uterus if young
Vulval itch / pain
Think Vulval cancer
