Common Obstetrical and Gynecological Emergencies

1. Common
Obstetrical and Gynecological
Emergencies
Aboubakr Elnashar
Benha University Hospital, EgyptABOUBAKR ELNASHAR

2. 1. Abdominal pain in pregnancy
2. Bleeding in early pregnancy
3. Antepartum hge
4. Postpartum hge
5. Severe PET and eclampsia
6. Acute abdomen
ABOUBAKR ELNASHAR

3. 1. ABDOMINAL PAIN IN PREGNANCY
A. Conditions Incidental to Pregnancy
 Acute appendicitis
 Acute pancreatitis
 Peptic ulcer
 Gastroenteritis
 Hepatitis
 Bowel obstruction
 Bowel Perforation
 Herniation
 Meckel’s Diverticulitis
 Toxic megacolon
 Pancreatic pseudocyst
 Ovarian cyst rupture
 Ureteral calculus
 Rupture of renal pelvis
 Ureteral obstruction
 SMA syndrome
 Thrombosis/infarction
 Ruptured visceral artery
aneurysm
 Pneumonia
 Pulmonary embolus
 Intraperitoneal hemorrhage
 Splenic rupture
 Abdominal trauma
 Acute intermittent porphyria
 Diabetic ketoacidosis
 Sickle Cell Disease
ABOUBAKR ELNASHAR

4. B. Conditions Associated with
Pregnancy
 Acute cholecystitis
 Acute pyelonephritis
 Acute cystitis
 Rupture of rectus abdominus muscle
 Constipation
ABOUBAKR ELNASHAR

5. C. Conditions Due to Pregnancy
(Obstetrical causes)
First trimester
1. Miscarriage
2. Ectopic pregnancy
3. Rupture corpus luteal cyst
4. Acute salpingitis
5. Acute Retention of urine
6. Adenxal torsion
7. Stretching of round ligament
ABOUBAKR ELNASHAR

6. 1. Miscarriage
 Pain:
preceded by vaginal bleeding
in the middle
intermittent.
 Cervix:
Closed (threatened abortion)
Open (inevitable)
U/S:
Gestational sac inside uterine cavity.
ABOUBAKR ELNASHAR

7. 2. Ectopic pregnancy
 Pain:
Before bleeding
limited initially to the affected side
Interperitoneal bleeding: generalized, shoulder tip and
rectal, diarrhea, shock
 Investigations:
1. TVS
2. Serum quantitative HCG
No IU gestational sac at hCG >1500-2000 IU/L suggests an
ectopic or nonviable IUP
3. Progesterone (nmol/L)
>60: viable IUP
<20: Failing PUL
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8. ABOUBAKR ELNASHAR

9. 3. Rupture corpus luteal cyst
functional ovarian cyst
Following a release of an ovum: corpus luteum.
Pregnancy: involute at the end of the 2nd T
 Pain
Mild aching
Hemorrhage inside cyst: severe pain
Rupture: Sudden onset of pain
Signs of peritonism
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10. 4. Acute Salpingitis
 up to the 10 w
 {gonococcal infection or infection at attempted
attempted abortion}
 Pain:
in both iliac fossae
continuous
 Associated:
Tenderness
Tachycardia
Elevated temperature
Culture of discharge: pathogens
ABOUBAKR ELNASHAR

11. 5. Acute retention of urine
 {usually due to enlargement of a cervical
fibroid in response to pregnancy}
 Pain
Severe lower abdominal wall
Unable to pass urine
large tender bladder which may be mistaken
for ov. Cyst
US
 Catheterization:
immediate relief of pain
ABOUBAKR ELNASHAR

12. 6. Adenxal torsion
Pain:
Twisting
Lateral lower quadrant
sudden onset
Peritonism
Fever ,leucocytosis,N/V
US colour Doppler: no flow
: Miscarriage
PTL
Right adnexal torsion at
the utero-ovarian pedicle.
ABOUBAKR ELNASHAR

13. 7. Round ligament pain
 Pain
Cramp like or stabbing
worse with movement
tenderness in the lower quadrant and groin
 No constitutional symptoms.
 Commonly towards the beginning and the end of
pregnancy
 More in multips
 {stretching of round ligaments}
ABOUBAKR ELNASHAR

14. 2nd trimester
1. Acute retention of urine {incarcerated RVF
gravid uterus}
2. Red degeneration in a fibromyoma
3. Rupture of rudimentary horn containing
pregnancy
4. Miscarriage
ABOUBAKR ELNASHAR

15. 1. Red degeneration of fibromyoma
 Pain
mild to severe
over the fibroid.
tenderness over the fibroid.
 History
Menorrhagia before pregnancy
 U/S:
Fibroid
Degenerative cystic changes
ABOUBAKR ELNASHAR

16. 2. Pregnancy in rudimentary horn
 Pain
resemble that of ectopic: usually the condition
discovered during laparotomy
 Rupture:
usually in the 2nd T
: sudden onset with collapse
ABOUBAKR ELNASHAR

17. 3rd trimester
1. Placental abruption
2. Severe preeclampsia
3. Red degeneration of fibromyoma
4. Uterine rupture
5. Contractions of labour
6. Acute fatty liver
7. Stretching of round ligament
ABOUBAKR ELNASHAR

18. 1. Placental abruption
 0.5- 1 % of all pregnancies
 Pain:
acute onset
Severe
considerable shock and collapse.
 Abdominal ms: Tense
Uterus: larger than expected, hard tender with
difficulty in palpating fetal parts
Fetal heart: usually absent
 May be:
Vagina bleeding
Hypertension
Coagulopathy ABOUBAKR ELNASHAR

19. 2. Severe PET
 Pain
Epigastric, Rt upper quadrant
 Signs of PET:
hypertension, proteinuria, oedema
 Uterus: not tender
Fetal parts: palpable
FHR: usually present
 Investigation: PET
ABOUBAKR ELNASHAR

20. HELLP Syndrome
Hemolysis – Elevated Liver Enzymes – Low
Platelets
 Timing: 28-36 w
 Labs:
Plts,
AST/ALT,
indirect bili,
haptoglobin,
schistocytes on peripheral
Smear
Sign/Sx Frequency
Proteinuria 87
HTN (>140/90) 85
RUQ/Epigastric
pain
40-90
Nausea/Vomitin
g
29-84
Headache 33-60
Visual changes 10-20
Jaundice 5
ABOUBAKR ELNASHAR

21. 3. Uterine rupture
 Think
Grand multiparous ┼
Scarred uterus
{CS, myomectomy, perforation}
 Pain:
Sudden onset, constant:
shock & collapse.
 Vaginal bleeding: common.
 Fetal parts: easily felt
 FHR: absent
ABOUBAKR ELNASHAR

22. 4. Labour pains
 prematurely or at term
 intermittent & gradually become stronger and
more frequent.
 Show
 Cervix: taken up and perhaps dilated
 CTG
ABOUBAKR ELNASHAR

23. 5. Acute fatty liver of pregnancy
Incidence: Rare
 Timing: 2nd half (usually 3rd T)
 Pain:
Epigastric (50%), Rt upper quadrant
N/V (75%), anorexia, jaundice +/- signs of PET
 Investigations
1. All PET investigation: PT, PTT +/- Plts Cr
2. AST/ALT,, glucose, +/- WBC,
3. US/CT or MRI liver
 Early diagnosis essential
Cannot be predicted
LFT in a pt presenting with abdominal pain
ABOUBAKR ELNASHAR

24. 6. Chorioamnionitis
 Usually precede by PROM
 Tender uterus
Offensive discharge
Systemic signs of sepsis
 Investigations
1. Blood culture
2. Inflammatory markers
3. Speculum ex
4. CTG
ABOUBAKR ELNASHAR

25. 7. Rectus sheath hematoma
 Rare, usually in multiparous
 {Rupture of inferior epigastric artery
May follow a bout of coughing or abdominal
trauma}
 Pain
Sudden onset
Large unilateral painful swelling
Superficial location
 Confused with abruption
ABOUBAKR ELNASHAR

26. 2. BLEEDING IN EARLY PREGNANCY
1. Threatened miscarriage (50 % )
2. Missed miscarriage (25 %)
3. Blighted ovum (20 %)
4. Incomplete miscarriage (3 %)
5. Ectopic pregnancy (2 %)
6. Hydatiform mole (< 1 %)
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30. 3. ANTE PARTUM HGE
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34. 4. POSTPARTUM HGE
Causes: four Ts:
 tone: 90%
 tissue,
 trauma,
 thrombin
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39. 5. SEVERE PET AND ECLAMPSIA
ECLAMPSIA (E)
convulsions superimposed on PET.
Preeclampsia (PET)
PIH in association with proteinuria (> 0.3 g/24 h) ±
oedema
Severe PET
DBP ≥ 110 mmHg on 2 occasions or
SBP ≥ 170 mmHg on 2 occasions and that, together
with significant proteinuria (1 g/litre)
DBP ≥ 100 mmHg on 2 occasions & significant
proteinuria with at least 2 S or S of imminent E.
ABOUBAKR ELNASHAR

40. I. Control BP
Antihypertensive treatment
Indications:
1. SBP> 160 mmHg or
DBP>110 mmHg.
2. SBP <160 plus
severe disease
heavy proteinuria or
disordered liver or haematological test)
{alarming rises in BP may be anticipated}.
ABOUBAKR ELNASHAR

41. Drugs:
•Acute, severe:
Nifedipine: oral not sublingually
IR cap:10 mg initial; repeat after 30 m if necessary
IR cap: 10-30 mg tid; not to exceed 120-180 mg/d
Hydralazine
IV: 5 mg over 5 min, repeat /20 min until DBP 95 mmHg, No
more than 4 doses. If not give Labetalol or Nifidipine.
Maintenance: 10 mg/h
Add 2ml NS to reconstitute 20 mg hydralazine. Withdraw 0.5 ml
hydralazine solution and add 9.5 ml NS to give total 10 ml
solution.
ABOUBAKR ELNASHAR

42. II. Prevention of seizures
Indications:
Severe PET:
 Once a delivery decision has been made and in
the immediate postpartum period.
 When conservative management of a woman with
severe hypertension and a premature fetus is
made it would be reasonable not to treat until the
decision to deliver has been made.
ABOUBAKR ELNASHAR

43. If Mg So is given:
1. It should be continued for 24 h following delivery or
24 h after the last seizure, whichever is the later,
unless there is a clinical reason to continue.
2. Regular assessment of:
a. Urine output,
b. Maternal reflexes,
c. Respiratory rate
d. Oxygen saturation .
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44. III. Control of seizures
I.
1. Do not leave the patient alone.
2. Prevent maternal injury during the convulsion.
3. Call for help and place a code blue call- Medical
Emergency call.
4. Initiate resuscitation.
5. Turn the patient into left lateral position when able
to do so.
6. Inform the consultant obstetrician and anesthetist
on call.
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45. II. AIRWAY
1. Assess and maintain patency, using oral suction if
necessary.
2. Insert a plastic oral airway if possible
3. Administer oxygen therapy via face mask.
III. BREATHING
1. Assess respiratory rate and ambubag using facial
mask/laryngeal mask or endotracheal tube if
necessary.
ABOUBAKR ELNASHAR

46. IV. CIRCULATION
1. Evaluate Pulse and B P. If absent, initiate CPR.
2. Secure IV access as soon as possible
with main line infusion,
with three-way tap attached
Hartmann's Solution
very slow rate, as fluid intake will be restricted to
1 ml/kg/h
3. Pulse oximetry is helpful.
ABOUBAKR ELNASHAR

47. V. Mg SO4
Therapy of choice to control seizures.
Loading dose:
4 g
infusion pump over 5–10 min
Maintainance:
1 g/h for 24 h after the last seizure.
Recurrent seizures
Further bolus of 2 g Mg SO4 or
an increase in the infusion rate
to 1.5 g or 2.0 g/h.
ABOUBAKR ELNASHAR

48. Prepare loading dose
Add 4g (8ml) of 50% MgS04 to 12ml of NS.
Administer slowly IV over 10 m.
 Prepare Maintenance dose
Add 50g (100 ml) of 50% MgS04 to 400ml of NS
(withdraw 100mls from 500ml bag of NS, prior to
adding MgS04).
Administer IV via volumetric pump at 10ml/h
=1g/hour.
ABOUBAKR ELNASHAR

49. VI. Once stabilized
Plans should be made to deliver the woman
No particular hurry and a delay of several
hours to make sure the correct care is in
hand is acceptable, assuming that there is
no acute fetal concern such as a fetal
bradycardia.
The woman’s condition will always take
priority over the fetal condition.
ABOUBAKR ELNASHAR

50. VI. Fluid balance
1. Fluid restriction is advisable
{reduce the risk of fluid overload in the intrapartum
and postpartum periods}
Total fluids should be limited to 80 ml/h or 1 ml/kg/h
{a. pulmonary oedema has been a significant cause
of maternal death.
b. No evidence of the benefit of fluid expansion
c. fluid restriction regimen is associated with good
maternal outcome.
d. No evidence that maintenance of a specific urine
output is important to prevent renal failure, which is
rare.}
ABOUBAKR ELNASHAR

51. ABOUBAKR ELNASHAR

52. 6. GYNECOLOGICAL CAUSES OF
ACUTE ABDOMINAL PAIN
A. Women of reproductive age
I. Pregnancy related
Ectopic
Septic abortion
Endometritis: post-partum or post-abortion
II. Infection
PID
TOA
III. Complicated ovarian cyst
Torsion, rupture, hemorrhage, OHSS
IV. Complicated fibroid
Degenerating
Torsion ABOUBAKR ELNASHAR

53. B. Adolescents
Similar +
imperforate hymen and
transverse vaginal septum
C. Postmenopausal women
Similar –
ectopic pregnancy and
ovarian torsion
ABOUBAKR ELNASHAR

54. Most common causes of acute lower
abdominal pain
1. PID
2. Ruptured ovarian cysts
3. Appendicitis
ABOUBAKR ELNASHAR

55. CDC Criteria for Diagnosis of PID. (2006)
At least one of the following criteria:
1. Adnexal tenderness
2. Cervical motion tenderness
3. Uterine tenderness
Additional diagnostic criteria (enhances specificity if present):
1. Cervical or vaginal mucopurulent discharge
2. Elevated CRP
3. Elevated ESR
4. Lab documentation of cervical infection with N
gonorrhoeae or C trachomatis
5. Tem >38.3° C
6. Saline microscopy of vaginal secretions: abundant
numbers of WBC
ABOUBAKR ELNASHAR

56. Adenxal torsion
 Pain:
Twisting
Lateral lower quadrant
sudden onset
 Peritonism
 Fever, leucocytosis, N/V
US colour Doppler: no flow
Right adnexal torsion at the
utero-ovarian pedicle.
ABOUBAKR ELNASHAR

57. Endometriosis
Pain:
Acute Abdominal Pain
{Rupture of an endometrioma}
usually at menstruation
Most commonly between 30 and 45 y
Usually preceded by premenstrual lower abdominal
pain
Diagnosis: confirmed at laparoscopy
ABOUBAKR ELNASHAR

58. History, Examination, Pregnancy test
Pregnant
Yes: evaluate for ectopic: BHCG, TVSNo
Right lower quadrant pain or pain migrating from umbilicus to RT lower
quadrant
Yes: surgical consultation and laparotomy for appendicitis; if
diagnosis in doubt: US or CT with IV contrast
No
Cervical motion, uterine, or adenxal tenderness
Yes: Consider PID: TVS for TOANo
Pelvic mass on examination
Yes: consider complicated ovarian cyst , complicated fibroid or
endometriosis: TVS
No
Dysuria and WBC on urine analysis
Yes: Evaluate for UTI or PNP: urine cultureNo
Gross or microscopic hematuria
Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone
protocol CT
No
TVS to evaluate for other diagnosisABOUBAKR ELNASHAR

59. CONCLUSION
The most common urgent causes are
ectopic pregnancy, ruptured or torsion
ovarian cyst, PID
Early diagnosis is important to prevent
sequelae of delayed diagnosis
Most diagnosis can be made with
History examination , pregnancy test and
TVS
ABOUBAKR ELNASHAR

60. As the first priority, urgent life-
threatening conditions and fertility-
threatening conditions must be
considered.
A high index of suspicion should be
maintained for PID when other
etiologies are ruled out, because the
presentation is variable and the
prevalence is high.
ABOUBAKR ELNASHAR

61. Thank you
ABOUBAKR ELNASHAR