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Gynecological Emergencies

Gynecological Emergencies. Prepared by Shane Barclay MD. Objectives. This will cover the gynecological causes of acute, emergency pelvic pain and bleeding in non pregnant women in the ER.

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Gynecological Emergencies

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  1. Gynecological Emergencies Prepared by Shane Barclay MD

  2. Objectives This will cover the gynecological causes of acute, emergency pelvic pain and bleeding in non pregnant women in the ER. This will not cover obstetrical emergencies. That is covered in the Remstarbc link http://remstarbc.ca/obstetrical-emergencies.php

  3. Overview Two different gynecological emergencies exit: - pelvic pain - abnormal uterine/vaginal bleeding Abdominal and pelvic pain can be a difficult diagnostic dilemmas to confront. Differential categories for pelvic pain include: GI: MSK: Urological: Vascular: Neurological: Gynecological:

  4. Overview Gynecological ‘Emergencies’ should mean conditions that compromise the patient from a hemostatic perspective or require urgent surgical referral. As such, in non-pregnant women, ‘gynecological emergencies’ really only consist of: - ovarian torsion - severe menorrhagia (abnormal uterine bleeding) However, this presentation will also cover causes of pelvic pain in women that are not ‘true’ emergencies.

  5. General Approach to Pelvic Pain The first priority is to establish if the patient is in shock or compromise. This necessitates plans for immediate steps at resuscitation and transfer from your rural site along with attempts at diagnosis: First step – pregnancy test. If Negative:Is there vaginal discharge or bleeding? Consider: - PID/STI, abnormal uterine bleeding. No bleeding/discharge – Consider: - torsion, endometriosis, ovarian cyst, leiomyoma. - plus GI, urologic, MSK, vascular causes.

  6. General Approach Pregnancy Test Positive Negative See Obs. emerg Pelvic bleeding? No Yes Torsion Menorrhagia (AUB) Endometritis PID/STI Endometriosis Dysmenorrhea Ruptured ovarian cyst Leiomyoma/Adenomyosis

  7. Anatomy Review

  8. Anatomy Review

  9. Topics This will cover first, the 2 conditions that can be gynecological emergencies – surgical or hemodynamic emergencies. Ovarian/fallopian tube torsion Severe abnormal uterine bleeding – AUB Then other acute conditions seen in the ER will be briefly reviewed.

  10. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  11. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  12. Ovarian Torsion

  13. Ovarian Torsion Tubo-ovarian torsion compromises blood supply to the ovary and thus is a surgical emergency. Can be associated with internal hemorrhage or peritonitis.

  14. Ovarian Torsion - Usually rotates on the ovarian and suspensory ligament. • Usually associated with cysts or neoplasms of the ovary. • Peak age onset is 20s to late 30s. Rare postmenopausal. • Increased risk during pregnancy. • Can be associated with prior physical exertion/exercise. • In premenarchal girls is not associated with cysts or tumors. • More common on the right (ligament is longer).

  15. Ovarian Torsion Clinical Presentation: • Acute onset of pelvic pain. • Nausea +/- vomiting may occur. • Usually in association with a pelvic mass. • Fever and Vaginal bleeding are rare.

  16. Ovarian Torsion Management: • Pregnancy test, CBC, lytes • IV, analgesics. • Pelvic ultrasound (accuracy similar to CT/MRI). • Ob-Gyne referral.

  17. Topics Ovarian/fallopian tube torsionAbnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  18. Abnormal Uterine Bleeding Has been called ‘menorrhagia, menometrorrhagia and oligomenorrhea in the past.

  19. Abnormal Uterine Bleeding Current terminology and differential diagnosis for causes of AUB is known as: PALM-COEIN Polyp Adenomyosis Leiomyoma Malignancy/Hyperplasia Coagulopathy Ovulatory Dysfunction Endometrial Iatrogenic Not yet classified

  20. Abnormal Uterine Bleeding Evaluation: • Pregnant? • Source of the bleeding – upper genital tract, uterus, cervix, vagina. • Causes – long list of differentials.

  21. Abnormal Uterine Bleeding Management of heavy menstrual bleeding requiring resuscitation: • IVs and fluids. • Labs: CBC, X-M, hCG, Prothrombin time, aPTT. • Complete pelvic exam. • Consult gynecology.

  22. Abnormal Uterine Bleeding Management of heavy menstrual bleeding requiring resuscitation: 5. If determined uterine etiology consider OCP 50 mcg ethinyl estradiol q 4-6 hrs or IV conjugated estrogen 25 mg q 4-6 hrs. both usually require antiemetics. 6. Consider use of Tranexamic acid 1300 mg po TID.

  23. Topics The remaining topics are brief reviews of other causes of pelvic pain and/or pelvic bleeding. They are not topics that usually require ‘resuscitation’ in the ER but are common presenting complaints.

  24. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB)Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  25. Dysmenorrhea Dysmenorrhea is ‘painful periods’. Occurs on average in 70% of women. Cause is from prostaglandins from endometrium at the start of menses causing uterine contractions. Pain usually starts 1-2 days prior to menses and can last for a few days after the stoppage of the period. Can also be accompanied by nausea, fatigue and headache.

  26. Dysmenorrhea Diagnosis is clinical. Differential Diagnosis PID Uterine adenomyosis Fibroids Management: Analgesics Gynecology referral NSAIDS

  27. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  28. Endometritis A benign condition consisting of endometrial tissue outside the uterine cavity and can occur anywhere in the pelvis or even abdominal cavity (even the chest cavity). Can cause chronic pain, dysmenorrhea and dyspareunia. Can occur in premenses all the way to postmenopausal women.

  29. Endometritis Clinical Presentation: • Pelvic pain – usually 1-2 days prior to menses. • Ovarian mass – occasionally . • Dyspareunia/dysmenorrhea. • Infertility. • Bowel or bladder dysfunction. • Lower back pain. Most common in women 25 - 35 years of age.

  30. Endometritis Imaging: Pelvic ultrasound often unlikely to reveal any abnormality other than possible ovarian mass. If large endometrial masses they are often hypoechoic and vascular.

  31. Endometritis Management: Analgesics Advise gynecological referral – surgery, Danazol

  32. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  33. Ruptured Ovarian Cyst • Can be physiologic (corpus luteal , follicular) or pathological (dermoid, cancer etc) • Dermoids tend to be the most painful. • Follicular cyst rupture mid cycle with ovulation. • Often occurs after intercourse or exercise. • More common on the right side (65%). • Pathological cysts can rupture anytime.

  34. Ruptured Ovarian Cyst • Dermoid cyst rupture often requires surgery. • Ultrasound may delineate other more serious ovarian cystic structures. • ER ultrasound may demonstrate excess fluid in the cul de sac. • Large amounts of free fluid necessitate close monitoring. • May not see a cyst as it may have collapsed with rupture. • Other causes of pelvic pain need to be ruled out.

  35. Ruptured Ovarian Cyst Management: • Assess for hemodynamic stability. • If large blood loss, need admission or transfer. • If stable, treat symptomatically.

  36. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cystUterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  37. Uterine Leiomyoma (Fibroids) • Are benign tumors of the smooth muscle of the myometrium. • Symptomatic fibroids usually related to menses (heavy, painful, prolonged) or due to size (fullness, pain or pressure in pelvis). • Rarely, very large fibroids can cause urinary frequency or even ureteric obstruction (hydronephrosis) and bowel constipation/obstipation.

  38. Uterine Leiomyoma (Fibroids) Causes of ER presentation related to fibroids is most commonly due to: • Fibroid degeneration: causes acute pain, fever, peritoneal signs • Can usually be treated conservatively.

  39. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  40. Adenomyosis • Are endometrial glands within the uterine musculature. • Can be microscopic to small nodules (adenomyomas) or result in diffuse enlargement of the uterus. • Can be confused with leiomyomas. • Clinically present with heavy/painful menses, chronic pelvic pain, AUB and diffusely enlarged uterus. • Diagnosis can be with ultrasound, MRI or often histologically.

  41. Adenomyosis ER Management: • Analgesia • Gynecological referral. (definitive treatment is hysterectomy)

  42. Topics Ovarian/fallopian tube torsion Abnormal Uterine Bleeding (AUB) Dysmenorrhea Endometritis Ruptured ovarian cyst Uterine leiomyoma Adenomyosis Pelvic inflammatory disease and abscess

  43. Pelvic Inflammatory Disease Is the acute infection of the female upper genital tract. • Can result in endometritis, salpingitis, peritonitis, abscess. • 80 – 90% caused by STIs. Remainder are enteric or even respiratory pathogens.

  44. Pelvic Inflammatory Disease Clinically: - usually presents with bilateral lower abdominal pain. • May be worse with coitus or activity. • Abnormal bleeding only occurs in a 1/3 of patients. • Patients usually have uterine tenderness along with cervical motion tenderness.

  45. Pelvic Inflammatory Disease Diagnosis: - Pregnancy test • Pelvic exam looking for tenderness. • Swabs for all STI, syphilis serology, HIV screen. • Urinalysis. • If hospitalized – CBC, CRP +/- blood cultures. • Pelvic ultrasound if suspected abscess.

  46. Pelvic Inflammatory Disease Treatment: Outpatient with no recent pelvic instrumentation/BV or Trichomonas - Ceftriaxone 250 mg IM single dose plus - Doxycycline 100 mg PO BID x 14 days

  47. Pelvic Inflammatory Disease Treatment: Outpatient with recent pelvic instrumentation/BV or Trichomonas - Ceftriaxone 250 mg IM single dose plus - Doxycycline 100 mg PO BID x 14 days plus - Metronidazole 500 mg PO BID x 14 days

  48. Pelvic Inflammatory Disease Treatment: In-patient - Cefoxitin 2 gm IV q 6 hours plus - Doxycycline 100 mg PO BID x 14 days plus/minus - Metronidazole 500 mg PO BID x 14 days

  49. The END

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