Common

Obstetrical and Gynecological

Emergencies

Aboubakr Elnashar

Benha University Hospital, Egypt ABOUBAKR ELNASHAR

1. Abdominal pain in pregnancy

2. Bleeding in early pregnancy

3. Antepartum hge

4. Postpartum hge

5. Severe PET and eclampsia

6. Acute abdomen

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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

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B. Conditions Associated with

Pregnancy

Acute cholecystitis

Acute pyelonephritis

Acute cystitis

Rupture of rectus abdominus muscle

Constipation

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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

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1. Miscarriage Pain:

preceded by vaginal bleeding

in the middle

intermittent.

Cervix:

Closed (threatened abortion)

Open (inevitable)

U/S:

Gestational sac inside uterine cavity.

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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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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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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

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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

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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.

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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}

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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

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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

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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

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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

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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

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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

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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

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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

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4. Labour pains

prematurely or at term

intermittent & gradually become stronger and

more frequent.

Show

Cervix: taken up and perhaps dilated

CTG

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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

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

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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

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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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3. ANTE PARTUM HGE

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4. POSTPARTUM HGE

Causes: four Ts:

tone: 90%

tissue,

trauma,

thrombin

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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.

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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}.

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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.

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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.

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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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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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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.

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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.

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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.

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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.

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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.

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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.}

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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

B. Adolescents

Similar +

imperforate hymen and

transverse vaginal septum C. Postmenopausal women

Similar –

ectopic pregnancy and

ovarian torsion

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Most common causes of acute lower

abdominal pain

1. PID

2. Ruptured ovarian cysts

3. Appendicitis

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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

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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.

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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

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History, Examination, Pregnancy test

Pregnant

Yes: evaluate for ectopic: BHCG, TVS No

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 TOA No

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 culture No

Gross or microscopic hematuria

Yes: may be 2ndry to vaginal bleeding: consider stone kidney: stone

protocol CT

No

TVS to evaluate for other diagnosis ABOUBAKR ELNASHAR

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

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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.

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Thank you ABOUBAKR ELNASHAR