Gynecologic and Obstetric Emergencies PDF

Gynecologic and Obstetric Emergencies ZIYA KALEM,MD ISTINYE UNIVERSITY FACULTY OF MEDICINE  LEARNING OBJECTIVES SYMPTOMS AND SIGNS OF GYNOCOLOGIC EMERGENCIES DIAGNOSTIC APPROACHES TO GYNOCOLOGIC EMERGENCIES DIFFERANTIAL DIAGNOSIS SURGYCAL DISEASE THAT CAUSE GYNOCOLOGIC ACUTE ABDOMEN SY...

Gynecologic and Obstetric Emergencies ZIYA KALEM,MD ISTINYE UNIVERSITY FACULTY OF MEDICINE  LEARNING OBJECTIVES SYMPTOMS AND SIGNS OF GYNOCOLOGIC EMERGENCIES DIAGNOSTIC APPROACHES TO GYNOCOLOGIC EMERGENCIES DIFFERANTIAL DIAGNOSIS SURGYCAL DISEASE THAT CAUSE GYNOCOLOGIC ACUTE ABDOMEN SYMPTOMS AND SIGNS OF OBSTETRIC EMERGENCIES MANAGEMENT OF DIC  ectopic pregnancies  adnexal torsion  tubo-ovarian abscess  hemorrhagic ovarian cysts  gynecologic hemorrhage (specifically abnormal uterine bleeding)  vulvar and vaginal trauma Ectopic pregnancies Differential diagnosis  appendicitis  ruptured hemorrhagic ovarian tumors  adnexal torsion  endometriosis. Etiology  The most common cause of ectopic pregnancy is salpingitis  Almost 50% of patients who underwent a salpingectomy for an ectopic pregnancy had a clinical history or histopathologic findings consistent with acute salpingitis  Altered ciliary motility within the oviduct from hormonal imbalances or tobacco abuse  Pelvic masses, tubal adhesions from prior surgeries, and abnormal embryonic development. Signs and symptoms  abdominal pain  amenorrhea  irregular vaginal bleeding  adnexal tenderness  Abdominal tenderness  adnexal mass. Diagnosis Physical examination Laboratory assessment Transvaginal ultrasound If acute bleeding is occurring, there may not be an initial drop in the patient’s hemoglobin; therefore clinical suspicion in a hemodynamically unstable patient may warrant surgical diagnosis.  If the patient is clinically stable, then it is appropriate to follow her with serial laboratory tests and physical examinations until diagnosis is confirmed. Complete blood count (CBC), Quantitative beta -human chorionic gonadotropin (beta –hCG) Blood type Quantitative b –hCG levels should be drawn on initial examination, and repeated in 48 hours if the patient is stable or if the diagnosis remains unclear. 85% of normal pregnancies have a b -hCG increase of 66% or more within 48 hours only 13% of ectopic pregnancies demonstrate increases exceeding 66%. Transvaginal ultrasound has proved invaluable in assessing early pregnancy complaints, including vaginal bleeding and pelvic pain. The cutoff quantitative b -hCG value at which an intrauterine pregnancy should be visualized on transvaginal ultrasound ranges between 1500 and 2000 mIU/mL tvusg Pseudosacs adnexal mass pelvic fluid intra-abdominal hemorrhage Treatment Historically, almost all identified ectopic pregnancies were treated surgically. The advent of a methotrexate regimen has offered a medical alternative for patients. Laparotomy Laparoscopy (not appropriate for hemodynamically unstable patients) Surgical options for tubal ectopic pregnancies salpingostomy? salpingectomy? Many physician perform a salpingostomy in hopes of preserving the fallopian tube Methotrexate has had great success in treating ectopic pregnancies while preserving the tubular architecture Indications and contraindications for methotrexate use Adnexal torsion Patients who have adnexal torsion often present with intermittent acute abdominal pain Differential diagnosis  Ruptured corpus luteum  Adnexal abscess  Acute appendicitis  Ectopic pregnancy  Bowel obstruction Etiology Adnexal torsion is almost always associated with an enlarged ovarian mass. There is an increased incidence in adnexal torsion in patients undergoing in vitro fertilization as the ovarian follicles become hyperstimulated Pregnancy may also predispose a patient to adnexal torsion Ovarian tumors account for 50% to 60% of torsion cases, and of these, mature cystic teratomas (dermoid tumors) are most frequently involved. Signs and symptoms Acute, intermittent, unilateral pelvic pain. Pain may be exacerbated by positional shifts. 70% of patients have associated gastrointestinal complaints to include nausea and vomiting On physical examination, a tender, unilateral adnexal mass is found in roughly 70% of patients Many women develop a fever once necrosis start Diagnosis Diagnosis is often made by ruling out other causes and by having a strong clinical suspicion A pregnancy test can help exclude an ectopic pregnancy A GC/chlamydia culture may help rule out pelvic inflammatory disease (PID) An elevated white count will be seen The diagnosis and treatment of adnexal torsion are made on surgical evaluation. Treatment The treatment of adnexal torsion is surgical reduction. More recently, studies have evaluated a more conservative surgical approach to patients who have adnexal torsion. Instead of performing a salpingo-oophorectomy, a laparoscopic evaluation with a gentle untwisting of the ovary and an oophoropexy can be performed In the setting of severe vascular compromise, unilateral salpingo-oophorectomy should be performed Tubo-ovarian abscess Differential diagnosis PID can result in significant morbidity, not only in the initial presentation but also, more importantly, concerning the long-term sequelae Patients who have infections of the upper genital tract may present in a similar fashion as those who have an ectopic pregnancy, hemorrhagic corpus luteal cyst, appendicitis, or endometriosis/endometrioma. Criteria for diagnosis of pelvic inflammatory disease PID may be treated on an outpatient basis There are some indications for hospitalization of patients who have an acute PID picture. Patient who has an adnexal mass and an acute abdomen in a setting of PID, a tubo-ovarian abscess should be considered Indications for hospitalization of patients who have pelvic inflammatory disease Etiology The organisms responsible are polymicrobial organisms, The two most common bacteria are Neisseria gonorrhoeae and Chlamydia trachomatis. Many times these bacteria coexist Signs and symptoms 90% of patients present with abdominal pain and 75% of patients have an elevated white blood cell count. Diagnosis Pelvic ultrasound CT scan MRI Treatment Patients who have a tubo-ovarian complex are admitted to the hospital and started on intravenous (IV) antibiotics for a period of 48 to 72 hours Commonly used regimen includes; clindamycin, gentamicin, and ampicillin Because an abscess has low oxygen, anaerobic bacteria are frequently found and have been cultured in greater than 60% of patients If the patient does not clinically improve on broad- spectrum antibiotics, drainage should be considered  Initial operative intervention may be considered in patients who have lifethreatening infections, ruptured tubo-ovarian abscesses, or for removal of persistent, symptomatic masses in women who have no further desire for future fertility. In most cases, laparotomy is necessary secondary to dense inflammatory pelvic adhesions. Hemorrhagic ovarian cysts Differential diagnosis Patients who have hemorrhagic ovarian cysts often present with an acute abdomen.  acute appendicitis  ectopic pregnancy  ruptured endometrioma  ovarian torsion Etiology Approximately 2 to 4 days after ovulation, the ovary becomes vascular, blood from the vascular theca zone often fills the cavity of the cyst Signs and symptoms History should include when the patient’s last menstrual period took place. Unilateral tenderness in the lower abdomen or pelvic region Diagnosis Transvaginal ultrasound often demonstrates an adnexal mass CBC should be taken to assess the current blood count. An abdominal/pelvic CT with contrast can further assist in evaluating other potential causes, including acute appendicitis.  Treatment Indications for immediate operative intervention include a large amount of peritoneal fluid found on a transvaginal ultrasound, hemodynamic instability, and severe pain. operative intervention include a large amount of peritoneal fluid found on a transvaginal ultrasound, hemodynamic instability, and severe pain Laparoscopic evaluation is usually feasible  Gynecologic hemorrhage, specifically abnormal uterine bleeding Differential diagnosis Gynecologic hemorrhage usually presents in two main cohorts: abnormal uterine bleeding (AUB) with an organic cause and those who have a cause based on ovulation, or more specifically, the anovulatory patterns of a patient’s menstrual cycle An endometrial biopsy should be performed on these patients Etiology AUB can occur as menorrhagia (bleeding greater than 7 days or 80 mL or metrorrhagia (uterine bleeding occurring at irregular intervals). Signs and symptoms Women who have menstrual blood loss greater than 80 mL during their cycle have significantly lower hemoglobin, hematocrit, and iron levels Diagnosis  CBC  coagulation panel  liver function tests  thyroid-stimulating hormone  pregnancy test.  pap smear,  gonorrhea/chlamydia culture, and an  endometrial biopsy  20% of adolescent females hospitalized for AUB were linked to coagulation defects. Any patient at risk for endometrial cancer should have endometrial sampling to rule out malignancy In a patient who is clinically unstable, medical supportive care includes blood product transfusion and high-dose estrogen for stabilization of the endometrial lining Vulvar and vaginal trauma Etiology Hematomas of the vulva and vagina are usually secondary to blunt trauma Sexual abuse should be strongly considered when the trauma includes hymenal or labial tearing in a pediatric or adolescent patient. Hematomas not involved with blunt trauma can also be seen with a rupture of a varicosity in the late antepartum period, Diagnosis Careful notation of the hematoma size and location should be Made Treatment Management of vulvar and vaginal hematomas is usually conservative unless the hematoma exceeds 10 cm in diameter or if it is rapidly expanding Most hematomas are venous in origin; however, a rapidly expanding hematoma could indicate an arterial injury and attempts should be made to identify this vessel for ligation Venous hematomas are typically self-limiting in nature and more difficult to control surgically than arterial hematomas. Most patients respond to ice packs and compression. In cases wherein the bleeding site cannot be identified, interventional radiology can perform embolization Complete resolution may take several weeks Premature separation of the placenta accounts for about 15% of all neonatal deaths. Approximately half of abruptions are grade 0 or 1 This is a small part of the placenta involved, symptoms are mild. Most babies and placentas can compensate for small abruption Grade 3 involves more than ½ of the placenta, and DIC will always happen then also.  INCIDENCE Abruption happens more often than we realize, about 1 in 120 deliveries. ( Frequency of abruption causing death is 1 in 1420). Abruptio placentae has become the leading known cause of fetal death. 1 in 8 recurrence rate Even if the infant survives, there may be adverse sequelae—14% are later found to have significant neurological deficits within the first year of life. The cord Can extend through the vaginal opening Can be felt at the cervical opening Can be occult or hidden Any obstetric condition that predisposes to poor application of the fetal presenting part to the cervix can result in prolapse of the umbilical cord. Cord prolapse is associated with prematurity (< 34 weeks' gestation), abnormal presentations (breech, brow, compound, face, transverse), occiput posterior positions of the head, pelvic tumors, multiparity, placenta previa, low-lying placenta, and cephalopelvic disproportion. In addition, cord prolapse is possible with polyhydramnios, multiple gestation, or premature rupture of the membranes occurring before engagement of the presenting part.