As medicine evolves and becomes more specialized the level and standard of care also changes. This article looks at common gynaecological emergencies, it will also look at the pregnant and non pregnant woman to give an insight into how these are managed.
In an emergency setting, the advantages of having a stand-alone gynaecological emergency service are numerous. The benefits include a better care package, decreased waiting times in the A&E setting, cost savings and patients being able to see specialists at the point of first contact with no need for referrals.
Bleeding in the pregnant patient
Ectopic pregnancy: Potentially life threatening, this is when a pregnancy occurs outside of the uterus. It is more common in the fallopian tubes but can occur in the cervix, ovary and abdomen. As the foetus gets bigger, it erodes the surrounding structures and eventually bleeds. This can be acute or chronic resulting in major blood loss. Treatment is either medical or surgical by laparoscopy.
Threatened miscarriage: Occurs in the first trimester. There is no abdominal pain. The foetus is viable on ultrasound and there is a greater than 95 per cent chance the pregnancy can continue to term.
Inevitable miscarriage: Associated with lower abdominal pain, bleeding and the cervical os is open on speculum examination. Management is to await events.
Incomplete miscarriage: Some of the tissue of pregnancy is passed but some is left in the uterus. This can be managed conservatively, medically or surgically depending on how much tissue there is in the uterus and what the patient wants after appropriate counselling on an outpatient basis.
Complete miscarriage: All the tissue of pregnancy has passed; a pregnancy test is repeated in two weeks and should be negative.
Septic miscarriage: If there is fever associated with a miscarriage, this can be potentially life threatening as one can get blood poisoning. Treatment is by surgical evacuation of the uterus and intravenous antibiotic cover for at least 24 to 48 hours.
Other causes of bleeding: Cervical ectropion and trauma which will be ruled out on speculum examination.
Pregnant but no bleeding
Hyperemesis Gravidarium: Excessive vomiting in the first trimester of pregnancy resulting in electrolyte abnormalities, dehydration and resultant weight loss of more than five per cent. Treatment is by antiemetics and rapid rehydration. An ultrasound is also done for dating/viability.
Ovarian cysts and urinary tract infections are other causes that have to be ruled out by urine analysis and ultrasound scan.
Non-pregnant women and bleeding
Fibroids and dysfunctional uterine bleeding: This bleeding can range from light to extremely heavy bleeding which can be life threatening, resulting in blood transfusion and rarely hysterectomy.
Treatment is tailored to the cause and definitive management depends on if fertility is an issue and can range from medical management, myomectomy, endometrial ablation to hysterectomy but these are usually done on an elective basis. In the interim, hormones are used to control the bleeding until a definitive treatment can be done.
Ovarian cysts: ovarian cyst accidents like rupture, haemorrhage and torsion are associated with lower abdominal pain, likely to be one sided with sudden onset. Diagnosis is clinical but confirmed by trans-abdominal or trans-vaginal ultrasound. Treatment is usually conservative management initially but definitively by laparoscopic cystectomy or oophorectomy.
Endometriosis: This is another common cause of pain and can be severe and debilitating. This is diagnosed by laparoscopy. The initial ultrasound can be normal but can sometimes show an endometrioma. Treatment is by hormonal methods or by surgery on an elective basis.
Pelvic inflammatory disease: This an infection of the pelvic organs. It can be mild, moderate or severe. This is usually associated with lower abdominal pain, fever and vaginal discharge. Fever may not be present in mild cases, but an ultrasound may show a collection which will requires drainage in severe circumstances.
Treatment is by oral antibiotics in mild cases and a review in 24 to 48 hours. If no resolution, then hospital admission is required for intravenous administration of antibiotics and surgery if required.
It should be noted that other diagnoses must be ruled out like urinary tract infection, appendicitis, intestinal obstruction, gastroenteritis in assessing women with abdominal pain or bleeding.
(Dr John Barker, Bsc MBBS DFSRH MRCOG BSCCP(cert), Dip (Risk Management). Consultant Obstetrician/Gynaecologist at JRB Medical Centre, 7th Avenue Belleville.
His special interests include gynaecological oncology, emergency gynaecology, alternatives to hysterectomy, out-patient hysteroscopy, high risk obstetrics.)