GYNECOLOGIC EMERGENCIES

Ectopic pregnancy

DEFINITION Ectopic pregnancy- implantation outside of

the uterine cavity The most common reason of

peritoneal signs in gynecology

Frequency of ectopic pregnancy in Europe

1-2: 100

Types of ectopic pregnancy by location

• Ampullary 78% • Isthmic 12% 95% „tubal pregnancy”• Fimbrial 5%• Interstitial 2-3% • Ovarian 1% (3% after ART)• Abdominal 1-2% (high mortality)• Cervical 0,5%

Risk factors for ectopic pregnancy

• (30-50%) Salpingitis; PID (Chlamydia trachomatis!!!)

damage for such infection may retard the passage of the fertilized ovum through the tube to the endometrial cavity

• Operations a) surgery of fallopian tubesb) plastic reconstruction of fallopian tubes

• ART– ovarian stimulation – embryo transfer reflux

• Previous ectopic pregnancy• Age 35-45

Risk factors for ectopic pregnancy

• Contraception ??? • Endometriosis• Congenital defects of fallopian tubes • Psychical spasm of fallopian tubes • Smoking • Multiparous women • Black and Hispanic women

• Idiopatic

Symptoms of unrupted ectopic pregnancy

Very different - depends of location and development of ectopic pregnancy

• Abdominal/pelvic pain- unilateral or bilateral; intermittent or constant

• Amenorrhea • Pregnancy symptoms • Vaginal bleeding • Pregnancy test or HCG

Gynecological examination

• Adnexal tenderness• Cervical motion tenderness• Adnexal mass • Uterus- normal size (70%) or enlarged

(30%) • Hemoperitoneum; convexity of cul-de-sac

Ectopic pregnancyDiagnosis

1.Pregnancy test - detects level of HCG (Human Chorionic Gonadotropin)

a) 5 days after conception – serum assaysb) 14 days after conception – urinary tests

HCG < 10 mIU/ml – no pregnancy HCG > 25 mIU/ml – pregnancy 4-5 Hbd HCG > 750 mIU/ml (or 1000 mIU/ml) and visible in USG

Early pregnancy- up to 6 weeks • Increasing of HCG > 66% in 48 hours • Increasing of HCG > 114% in 72 hours • Increasing of HCG > 175% in 96 hours

Ectopic pregnancyDiagnosis

2. USG:

• 4-5 weeks of pregnancy- visible in USG

• Enlarged size of fallopian tube

• Empty uterine cavity

• Large endometrium

Ectopic pregnancyDiagnosis

3. Progesterone (always with HCG and USG)

• > 25ng/ml - normal pregnancy

• < 5 ng/ml - ectopic pregnancy or obsolete pregnancy

4. high concentration of:

Estradiol; Il 6; Il 8; TNFα; creatine kinase

The most common symptom of ruptured ectopic pregnancy

Hemoperitoneum

Symptoms of ruptured ectopic pregnancy

• Hypovolemic shock- a decrease in blood pressure and an increase in pulse

• Syncope• Acute abdominal pain • Temperature > 37º C • Urge to defecate or urinary urge • Vomiting • Peritoneal signs- hemoperitoneum • Irritation of the diaphragm- shoulder pain

Differential Diagnosis of Ectopic Pregnancy

• any woman of reproductive age with- acute pelvic or lower abdominal pain - abnormal bleeding - amenorrhea

• complications of intrauterine pregnancy (complited or incomplited abortion)

• acute or chronic salpingitis

Differential Diagnosis of Ectopic Pregnancy

• Follicular or corpus luteum cyst rupture

• Endometriosis

• Adnexal torsion

• Gastroenteritis

• Appendecitis

Combined pregnancy (heterotopic pregnancy)

• intrauterine and extrauterine gestations

1: 30 000• after ART

1: 100

approximately 1 in 3 of the intrauterine pregnancies are reproted as surviving

Managment of Ectopic Pregnancy

• expectant treatment

• pharmacotheraphy (Methotrexate)

• surgery

Managment of Ectopic Pregnancy

„ expectant treatment”

Indications

• low HCG level

• ectopic gestation < 4 cm in diameter

• ampullary localization

• no bleeding

• no symptoms of rupture

Managment of Ectopic Pregnancy

Pharmacotheraphy

Methotrexate (folinic acid antagonist)

Indications HCG level < 10 000 mIU/ml• ectopic gestation < 4cm in diameter• cervix, ovarium, intramural localization

for 20% of women 1 dose is enough

Managment of Ectopic Pregnancy„surgery”

• Unruptured

- Laparoscopy

- salpingtomy

- salpingectomy

- Laparotomy- surgical techniques

• Ruptured- Laparoscopy - Laparotomy- surgical techniques

- salpingectomy

Ectopic Pregnancy

• Rh- negative mothers with ectopic pregnancy should recieve Rh immune globulin to prevent Rh sensitisation

• risk of Rh sensitisation < 1%

Pelvic Inflammatory Disease

PID is a polymicrobal infection involving endogenous aerobes and anaerobes as well as sexually transmitted pathogens.

PID

Variables that increase the incidence of PID:

• teenage years• multiple sexual partners• previous PID• intrauterine device (two months after insertion

only)• uterine instrumentation

PID- etiology

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Escherichia colli, Proteus, Klebsiella, Streptococcus- endogenous aerobes

• Bacteroides, Peptostreptococcus, Peptococcus- endogenne anaerobes

• Actinomyces israeli- IUCD

Chlamydia trachomatis(intracellular parasite)

Infection rates• 20-40% of sexually active women have

antibodies to Chlamydia• five times higher in women with three or more

partners• four times higher in women using no

contraception or nonbarrier methods• up to 20% has asymptomatic cervical infection

Chlamydia trachomatis(intracellular parasite)

Symptoms• subtle and nonspecific physical findings• mucopurulent cervicitis• acute urethritis• salpingitis• PID• Fitz-Hugh-Curtis syndrome (perihepatitis)

– localized fibrosis with scarring of the liver and adjacent peritoneum

Chlamydia trachomatis(intracellular parasite)

Infertility and ectopic pregnancy

• mild form of salpingitis with insidious symptoms

• established infection remain active for many months

• increasing tubal damage

Chlamydia trachomatis(intracellular parasite)

• infection is suspected on clinical grounds

• culture results (obtained after 48-72 h) confirms the diagnosis– ELISA performed on cervical secretions

95% specificity

– monoclonal fluorescent antibody test carried out on dried specimens

90% sensitivity; 95% specificity;

Neisseria gonorrhoeae(Gram-negative intracellular diploccocus)

• Easy acquired – single encounter with infected partner leads to infection 80-90% of the time

• First signs or symptoms of infection:– 3-5 days after exposure, often mild– malodorous purulent discharge from the urethra, Skene`s

duct, cervix, vagina or anus– „mucopus” – greenish or yellow discharge from the cervix– infection of the Bartholin`s gland

• Fitz-Hugh-Curtis syndrome• 15% of women with N. gonorrhoeae develop

acute pelvic infection (PID)

Neisseria gonorrhoeae(Gram-negative intracellular diploccocus)

Laboratory diagnosis:

• cultures obtained from the cervix, uretra, anus, pharynx

• Thayer-Martin agar plates kept in

CO2-rich environment – 80-90% sensitivity

PID

Hager’s criteria for diagnosing acute PID:

• history of lower abdominal pain or tenderness

• cervical motion tenderness and adnexal tenderness

(all necessary for diagnosis !)

PIDHager’s criteria for diagnosing acute PID:• fever > 38°C• leukocytosis > 10 000 WBC/mm3

• culdocentesis fluid containing WBCs or bacteria

• inflammatory mass on pelvic examination or USG

• evidence of gonococcus or Chlamydia on cervical Gram’s stain

(one or more of the objective findings necessary for diagnosis !)

PID

Clinical diagnosis of PID is often imprecise

• white cell count above 10 000 > 50% of patients • positive chlamydia cultures ~ 30% of patients • positive gonorrhea cultures ~ 25% of patients

PID

Correct diagnosis in cases of misdiagnosis of PID• acute appendicitis 28% of cases• endometriosis 17% of cases• corpus luteum bleeding 12% of cases• ectopic pregnancy 11% of cases• adhesions 7% of cases• „other” 28% of cases

PIDIndications for hospitalization

• presence of tuboovarian complex or abscess (TOA)

• uncertain diagnosis• significant gastrointestinal symptoms• nulliparity• pregnancy

PID

Recommendations for hospitalized patients(no pelvic mass, IUD, recent history of pelvic instrumentation)

• cefoxitin 2g IV q6h

• cefotetan 2g IV q12h + doxycycline 100 mg q12h

regimen continued for at least 48 hours after the patient clinically improves

PID

Recommendations for hospitalized patients(pelvic mass, IUD, recent history of pelvic instrumentation)

• clindamycin 900 mg IV q8h + gentamycin 2 mg/kg IV,

followed by gentamycin 1,5 mg/kg IV q8h

regimen continued for at least 48 hours after the patient clinically improves

PID

Tests that should be also obtain:

• Trichomonas vaginalis screening (wet preparat)

• serology syphilis screening

• HIV screening

PID

If outpatient treatment is used, the patient must be reexamined after 48 to 72 hours.

If the response for the treatment is suboptimal, the patient need to be hospitalized and intravenous antibiotics initiated.

PID

Recomendation for outpatient therapy

• cefoxitin 2g IM + probenecid 1g PO• ceftriaxon 250 mg IM + doxycycline 100 mg

PO q12h for 10 - 14 days• tetracycline 500 mg PO q6h for 10 - 14 days• erythromycin 500 mg PO q6h for 10 - 14

days

PID

Laparoscopy

- diagnosis of PID is in doubt

- the patient does not respond to medical therapy

PID

Laparoscopic criteria for acute PID

minimum criteria

• erythema of fallopian tubes

• edema and swelling of fallopian tube

• exudate from fimbria or on serosa of fallopian tube

PID

Scoring

• mild: minimum criteria, tubes freely movable and patent

• moderate: more marked , tubes not freely movable, patency uncertain

• severe: inflammatory mass

PID

Complications of PID• formation of tuboovarian abscess (TOA)• ectopic pregnancy (rate seven to ten times

normal)

• infertility (rate increase proportional to the number of episodes of acute PID)

• chronic pelvic pain (approximately 20%)

• recurrent PID (approximately 25%)

PID

Surgical treatment of PID (extirpation)

• Ruptured TOAs,

• TOAs that do not respond to medical therapy within 4 to 5 days

• TOAs that results in chronic pain

teenangermultiple sexual partnersprevious PIDIUDuterin instrumentationpainpelvic tendernessfevermassvaginal discharge

PID

WBCChlamydial culture or antigen detection testGonorrhea cultureSyphilis wet prep., serologyHIVUSG

Outpatient treatment

Hospitalization

Antibiotic

Response

No response

Discharge onantibiotic

Laparoscopy

Complications

Tuboovarianabscess

Operative drainage

Ectopicpregnancy

Infertility

Chronicpain

Recurent PID

PID

Therapy of the symptomatic as well as asymptomatic male partners is an integral part of treatment PID.

PID

Variables that decreases the incidence of PID

• use of mechanical contraceptives

• use of oral contraceptives

Other causes of bleeding into the abdominal cavity

• Rupture of follicular cyst

• Corpus hemorrhagicum

• Rupture of ovarian tumor

• Postoperation bleeding

Adnexal torsion (10%)

DEFINITION:

partial or complete rotation of the ovary, fallopian tube or both, on its vascular pedicle.

Adnexal torsion

Etiology

• 50-60% - ovarian and/or adnexal mass

• increased weight of the ovary

• reduced venous return from the ovary

Adnexal torsion

All ages, usually:

• women in their mid 20s

• postmenopausal women

• 20% of cases of torsion occur during prgnancy

Adnexal torsionSymptoms – variable and nonspecific

- acute abdominal pain- nausea, vomiting- anorexia,- peritoneal signs- diarrhea- hypovolemic shock

½ of the patients have had a similar episode in the pastapproximately ½ of the patients have a palpable mass

Adnexal torsion1. Sonography

• multiple peripheral cysts in an enlarged ovary – relatively specific

• free pelvic fluid• adnexal cysts and tumors

2. Colour Doppler• shows whether the vascular flow is impaired:• absence of vascular flow is not specific for torsion• presence of vascular flow does not rule out torsion (flow may be seconadry to the dual blood supply of the ovary or from venous thrombosis

which causes symptoms before the loss of arterial flow)

3. CT, MRI

Adnexal torsiondifferental diagnosis

Based on clinical presentation:

• appendicitis

• intussusception

• gastroenteritis

• pyelonephritis

• salpingititis

• inflammatory bowel disease

Based on sonography:

• hemorrhagic ovarian cyst

• ovarian mass or neoplasm

• parovarian cyst

• pelvic inflammatory disease

• abscess

Adnexal torsionmanagement

• surgery• oophoropexy (if the ovary is thougt to be viable

during surgery)

– preserves the ovary, reduces the incidence of reccurent torsion

– also for contralateral ovary to prevent its subsequent torsion

Rupture of ovarian cyst (3%)

• Bleeding into abdominal cavity

• Symptoms

- acute abdominal pain

- peritoneal signs

- hypovolemic shock

Diagnosis

• General examination

• Gynecological examination

• USG

• Abdominal X- ray

• Laboratory tests

Vaginal bleeding

• Injury- sexual intercorses • Abortion • Carcinoma Cervical carcinoma

– Endometrial carcinoma – Vaginal carcinoma – Myomas

• Functional bleeding

Gynecological iatrogenic emergencies

• Laparotomy

• Laparoscopy

• Other (D&C; HSG)

Laparoscopy, laparotomy – iatrogenic complications

• Anesthesial complications

• Postoperation bleeding

• Mechanical obstruction

• Paralytical obstruction

• Peritonitis

Sepitic Pelvic Thrombophlebitis

• Multiple bacteria infection• Septic thrombosis in vessels• Subseqent microembolisation in lungs or other

organs by way of the inferior vena cava is possible• Symptoms: residual fever and tachycardia • Antibiotics and anticoagulation therapy is

recommended for at least 7 and up to 30 days

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