The lecture contains practical aspects of management of gynaecological emergencies for FY1 and FY2 doctors

1. Gynaecological
Emergencies
Indunil Piyadigama
Whipps Cross University Hospital

2. Common presentations to
AnE
• Lower abdominal pain
• Bleeding
• Vaginal discharge
• Passage of products

4. DD
Pregnant
Non- Pregnant
Non gynaecological
Miscarriage
Ectopic pregnancy
Fibroid degeneration
Corpus luteal cyst rupture
OHSS
Dysmenorrhoea
Ovarian cyst accidents
• Torsion
• Haemorrage
• Rupture
Tubo-ovarian abscess
Midcycle pain
Musculoskeletal
GI
Urinary tract

5. Miscarriage
• Spontaneous loss of pregnancy prior viability
• Overall 30% will have pain or bleeding during the 1st half of the
pregnancy

6. Threatened
Incomplete
Missed
Complete

7. OS closed – threated
Os open - Inevitable
GS + yolk sac
+/- fetal pole and heart
Incomplete Products (mixed echogenic)
Complete Products < 15mm
Regularity and vascularity are probably more important
Missed mc USS –
Mean GS diameter >/= 25mm – No Yolk sac
CRL >/=7mm – No fetal heart

8. Clinical assessment
• History
Pain
Bleeding/ discharge
Passage of products
Pregnancy symptoms
• Examination
Abdominal - Palpable masses, Tenderness, Guarding, rigidity
VE -
Bleeding, products
Cervix - consistency, dilatation
Size of uterus, adnexal tenderness or masses

9. Expectant Medical Surgical
Overall 85% will be successful in 3
weeks
98% success for incomplete , 30%
success for missed
Success rate 95% incomplete, 90%
missed
95% success
Increased bleeding and blood tx 0.5% risk of perforation
Repeat evacuation in 5%
No increase risk of pain Less bleeding
Same – patient satisfaction and risk of Infections

10. Decision making
• Stability
• Type of miscarriage
• Patient characteristics
• Patient preferences

11. Ectopic pregnancy
Implantation in a site other than the uterine cavity

12. Clinical features
• Pain before bleeding
• Bright red bleeding
• SOB/ Shoulder tip pain/ Peritonitis features
• Atypical presentations
• Examination
Haemodynamics
Abdomen - Features of heamoperitoneum
VE - Cx firm, excitation, normal to slightly enlarged uterus, adnexal
tenderness

13. Management
• Acute
Monitoring
Cannula
FBC, G+S
Anaesthetist/ Theatre
• B HCG
• USS

14. Severe pain/ haemo-dynamically
unstable
Yes No
Surgery Medical/ Conservative

16. PUL

17. • A 24 year old woman attends to AnE with vaginal
bleeding, sudden onset abdominal pain and vomiting.
Symptoms going on for 7hrs. She is not pregnant.

19. Ovarian torsion

22. • Unlikely to occur in a normal ovary
• Common with dermoid cysts
• Never with endometriosis

23. Management
• Laparoscopic de-torsion
• Cystectomy

28. If not responding
• Consider removing IUCD
• Admit
• IV antibiotics
• Drainage

29. OHSS

33. Thank you