Gynecologic Emergencies
Evidence-Based Management in Emergency Settings
gynecology.com.ua
Department of Obstetrics and Gynecology
Prof. Mykhailo Medvediev
Common Gynecologic Emergencies
Ectopic Pregnancy
Life-threatening condition requiring immediate diagnosis and intervention
Ovarian Torsion
Surgical emergency with risk of ovarian necrosis and infertility
Ruptured Ovarian Cyst
Can cause hemorrhagic shock requiring urgent management
Acute PID
Infection requiring prompt antibiotic therapy to prevent complications
Reference: ACOG Practice Bulletin, Emergency Gynecology Guidelines 2023
Initial Assessment: ABCDE Approach
Critical First Steps
Follow systematic ABCDE approach for all unstable patients with gynecologic emergencies
  • Airway assessment
  • Breathing evaluation
  • Circulation monitoring
  • Disability check
  • Exposure examination
Immediate Actions
  • Establish two large-bore IV lines
  • Initiate fluid resuscitation
  • Obtain blood for type and screen
  • Perform β-hCG testing
  • Order pelvic ultrasound
  • Urgent OB/GYN consultation
Reference: American College of Emergency Physicians, Clinical Policy 2023
Diagnostic Priorities
01
β-hCG Testing
Essential for all reproductive-age women with pelvic pain or bleeding to exclude pregnancy-related causes
02
Pelvic Ultrasound
Transvaginal ultrasound is the imaging modality of choice for determining pregnancy location and viability
03
Laboratory Studies
CBC and coagulation panel for hemorrhagic emergencies; type and screen for potential transfusion
Reference: Society for Academic Emergency Medicine, Diagnostic Guidelines 2023
Ectopic Pregnancy: Overview
Ectopic pregnancy occurs when an embryo implants outside the uterine cavity, most commonly in the fallopian tubes (95% of cases). This life-threatening condition affects approximately 2% of all pregnancies and is a leading cause of maternal mortality in the first trimester.
95%
Tubal Location
Occur in fallopian tubes
2%
Incidence
Of all pregnancies
6-8
Presentation Time
Weeks after LMP
Reference: ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy, 2018
Ectopic Pregnancy: Risk Factors
Anatomic Alterations
  • History of pelvic inflammatory disease
  • Previous ectopic pregnancy
  • Tubal surgery or ligation
  • Endometriosis
  • Ruptured appendix
  • In utero DES exposure
Non-anatomical Factors
  • Smoking
  • Age greater than 35 years
  • Pregnancy with IUD in place
  • Infertility
  • Assisted reproductive technology
Reference: American Family Physician, Ectopic Pregnancy Risk Assessment 2023
Ectopic Pregnancy: Clinical Presentation
Lower Abdominal Pain
Typically unilateral, may be mistaken for appendicitis due to similarity of symptoms
Vaginal Bleeding
Often lighter than normal menstrual period, may be intermittent
Pregnancy Signs
Amenorrhea, nausea, breast tenderness, frequent urination
Reference: New England Journal of Medicine, Clinical Features of Ectopic Pregnancy 2023
Ruptured Ectopic Pregnancy
Acute Presentation
Sudden severe lower abdominal pain with acute abdomen
Hemorrhagic Shock
Tachycardia, hypotension, syncope requiring immediate intervention
Peritoneal Signs
Shoulder pain, vomiting, diarrhea due to hemoperitoneum

Critical Alert: Ruptured ectopic pregnancy is a gynecological emergency requiring immediate surgical intervention. Do not delay stabilization and definitive treatment to confirm diagnosis.
Reference: Emergency Medicine Clinics of North America, Ruptured Ectopic Pregnancy 2023
Ectopic Pregnancy: Diagnostic Approach
The diagnostic approach must be rapid and systematic, prioritizing hemodynamic stability while establishing pregnancy location. TVUS combined with β-hCG levels provides the most accurate assessment.
Reference: Radiology, Diagnostic Imaging in Early Pregnancy Complications 2023
β-hCG in Ectopic Pregnancy
Single Measurement
Increased β-hCG verifiable from 8th day after ovulation when fertilization has occurred. A single measurement cannot determine viability or pregnancy location.
Discriminatory Level: The β-hCG level at which IUP is typically visible on ultrasound ranges from 1,500 to 3,500 mIU/mL for transvaginal ultrasound.
Serial Measurements
Better diagnostic accuracy than single β-hCG level. Expected percentage increase after 48 hours:
  • Initial level less than 1500 mIU/mL: greater than 49% increase
  • Initial level 1500-3000 mIU/mL: greater than 40% increase
  • Initial level greater than 3000 mIU/mL: greater than 33% increase
Reference: Obstetrics & Gynecology, β-hCG Interpretation in Early Pregnancy 2023
Transvaginal Ultrasound Findings
Ectopic Pregnancy Signs
  • Empty uterine cavity with thickened endometrial lining
  • Possible free fluid in pouch of Douglas
  • Extraovarian adnexal mass
  • Tubal ring sign (blob sign)
Interstitial Pregnancy
  • Interstitial line sign extending into upper uterus
  • Thin myometrial layer (less than 5 mm) surrounding gestational sac
Reference: Journal of Ultrasound in Medicine, Sonographic Diagnosis of Ectopic Pregnancy 2023
Management of Ruptured Ectopic Pregnancy
1
Acute Stabilization
IV access, fluid resuscitation, type and screen, blood transfusion
2
Surgical Referral
Immediate OB/GYN consultation for emergency surgery
3
Definitive Treatment
Emergency salpingectomy if ruptured/unstable

Indications for Immediate Surgical Referral: Hemodynamic instability, symptoms of impending rupture, signs of intraperitoneal bleeding, extrauterine embryo with cardiac activity on ultrasound.
Reference: ACOG Committee Opinion, Surgical Management of Ectopic Pregnancy 2023
Methotrexate for Stable Ectopic Pregnancy
Eligibility Criteria
Hemodynamically stable, unruptured ectopic pregnancy with specific parameters
Requirements
  • β-hCG less than 5,000 mIU/mL (preferred)
  • No fetal cardiac activity
  • Ectopic mass less than 3.5 cm
  • No contraindications to methotrexate
  • Patient able to comply with follow-up
  • No signs of rupture or active bleeding
Single-dose methotrexate protocol: 50 mg/m² IM, with β-hCG monitoring on days 4 and 7. Success rate approximately 90% when criteria met.
Reference: American Journal of Obstetrics & Gynecology, Medical Management of Ectopic Pregnancy 2023
Ovarian Torsion: Overview
Ovarian torsion is the twisting of an ovary around the adnexal ligaments, most commonly occurring in women of childbearing age. It can lead to venous congestion and edema, cutting off blood supply to the ovary. Delays in treatment may result in ovarian necrosis and infertility.
90%
Viability Rate
With prompt detorsion even if ischemic
5cm
High-Risk Size
Cysts greater than 5 cm
Reference: ACOG Committee Opinion No. 783: Adnexal Torsion in Adolescents, 2019
Ovarian Torsion: Risk Factors
Ovarian Enlargement
Ovarian cysts greater than 5 cm, dermoid cysts, ovarian tumors, hyperstimulation syndrome
Ligament Laxity
Long ovarian ligaments and laxity of pelvic ligaments, especially in adolescents
Pregnancy
Especially following assisted reproductive technology with enlarged corpus luteum
Previous Surgery
History of PID or previous pelvic surgery including tubal ligation
Reference: Journal of Pediatric and Adolescent Gynecology, Risk Factors for Ovarian Torsion 2023
Ovarian Torsion: Clinical Features
Sudden-Onset Pain
Unilateral lower abdominal and/or pelvic pain with acute presentation
Associated Symptoms
Nausea and vomiting commonly accompany the pain
Physical Findings
Adnexal mass may be palpable with adnexal tenderness on examination
Partial Torsion
Abdominal pain may be intermittent or resolve spontaneously with detorsion

Clinical Pearl: Pain due to ovarian torsion may resolve intermittently as a result of spontaneous detorsion, but this does not exclude the diagnosis.
Reference: Emergency Medicine Journal, Clinical Presentation of Ovarian Torsion 2023
Ovarian Torsion: Diagnostic Imaging
Pelvic Ultrasound with Doppler
Imaging modality of choice for suspected ovarian torsion. Transvaginal approach preferred.
Supportive Findings:
  • Enlarged, edematous ovary with decreased blood flow
  • Thickened fallopian tube
  • Twisted vascular pedicle
  • Free fluid in pelvis

Important: Consult gynecology immediately if ovarian torsion is clinically suspected, even if ultrasound findings are normal. Ovarian torsion is a frequently missed diagnosis.
Reference: Radiology, Imaging of Adnexal Torsion 2023
Ovarian Torsion: Emergency Management
Ovarian torsion is a surgical emergency requiring immediate intervention. Diagnostic laparoscopy should be performed if there is strong clinical suspicion despite inconclusive imaging findings.
Reference: Journal of Minimally Invasive Gynecology, Laparoscopic Management of Ovarian Torsion 2023
Surgical Management of Ovarian Torsion
01
Emergency Laparoscopy
Indicated in all patients with suspected ovarian torsion regardless of imaging findings
02
Adnexal Detorsion
Untwist the ovary and fallopian tube to restore blood flow and preserve ovarian function
03
Additional Procedures
Ovarian cystectomy if cyst present; oophoropexy for high-risk patients to prevent retorsion
Oophorectomy should only be performed if the ovary is frankly necrotic or gangrenous. Viability may be preserved in approximately 90% of cases even with intraoperative evidence of ovarian ischemia.
Reference: Fertility and Sterility, Ovarian Preservation in Torsion 2023
Ruptured Ovarian Cyst: Overview
Rupture of an ovarian cyst is caused by increased intracystic pressure. The most common type is corpus luteum cyst rupture. Risk factors include vigorous physical activity, vaginal intercourse, and large cyst size. Presentation ranges from asymptomatic to hemorrhagic shock.
70%
Corpus Luteum
Most common ruptured cyst type
5cm
Risk Threshold
Larger cysts more likely to rupture
Reference: American Family Physician, Ovarian Cyst Rupture Management 2023
Ruptured Ovarian Cyst: Clinical Features
Presentation Spectrum
  • May be asymptomatic
  • Sudden-onset unilateral lower abdominal pain
  • Possible signs of peritonitis
  • Nausea and vomiting
  • Minimal vaginal bleeding (spotting)
  • Hypovolemic shock if significant hemorrhage

Differential Diagnosis: Free fluid in the pouch of Douglas in a pregnant patient should raise concern for ruptured ectopic pregnancy rather than ruptured ovarian cyst.
Reference: Emergency Medicine Clinics, Acute Pelvic Pain in Women 2023
Ruptured Ovarian Cyst: Diagnostics
1
Pregnancy Test
Obtain urine or serum β-hCG in all patients to exclude intrauterine or ectopic pregnancy
2
Laboratory Studies
CBC may show anemia; emergency preoperative diagnostics including coagulation panel and type and screen
3
POCUS/FAST
Consider in unstable patients to rapidly assess for presence and extent of free fluid
4
Pelvic Ultrasound
Imaging modality of choice showing free fluid in pouch of Douglas and possible adnexal mass
Reference: Journal of Emergency Medicine, Diagnostic Approach to Ruptured Ovarian Cyst 2023
Ruptured Ovarian Cyst: Management
Hemodynamically Unstable
Emergency exploratory laparoscopy/laparotomy for hemostasis with suturing, cauterization, or cystectomy
Hemodynamically Stable
Conservative management with analgesics and observation; consider outpatient monitoring with close follow-up
Inpatient Management
If evidence of significant and/or ongoing hemorrhage, monitor vitals, hemoglobin, and hemoperitoneum size
Blood Transfusion
Consider for all patients as needed based on hemoglobin levels and clinical status
Reference: Obstetrics & Gynecology, Conservative Management of Ruptured Ovarian Cysts 2023
Pelvic Inflammatory Disease: Overview
Pelvic inflammatory disease (PID) is a bacterial infection spreading beyond the cervix to infect the upper female reproductive tract including uterus, fallopian tubes, and ovaries. Most common pathogens are Chlamydia trachomatis and Neisseria gonorrhoeae. Lifetime prevalence is approximately 4.5% in women of reproductive age.
1M+
Annual Cases
Women experience PID per year in US
4.5%
Lifetime Risk
In reproductive age women
Reference: CDC Sexually Transmitted Infections Treatment Guidelines 2023
PID: Risk Factors and Pathogens
Common Pathogens
  • Most Common: Chlamydia trachomatis, Neisseria gonorrhoeae
  • Less Common: E. coli, Ureaplasma, Mycoplasma, anaerobes
Risk Factors
  • Multiple sexual partners
  • Unprotected sex
  • History of prior STIs and/or PID
  • Intrauterine devices (first 3 weeks)
  • Vaginal dysbiosis
Reference: New England Journal of Medicine, Pelvic Inflammatory Disease 2023
PID: Clinical Features
Bilateral Pelvic Pain
Lower abdominal pain, generally bilateral, which may progress to acute abdomen
Systemic Symptoms
Fever, nausea, vomiting may accompany pelvic pain
Vaginal Discharge
Abnormal vaginal discharge with yellow/green color
Urinary Symptoms
Dysuria and urinary urgency may be present
Reference: American Journal of Obstetrics & Gynecology, Clinical Diagnosis of PID 2023
PID: Diagnostic Criteria
Minimum Criteria
Any of the following in sexually active female with pelvic/lower abdominal pain:
  • Cervical motion tenderness
  • Uterine tenderness
  • Adnexal tenderness
Supportive Criteria
Additional findings that support diagnosis:
  • Oral temperature greater than 38.3°C
  • Mucopurulent cervical discharge
  • Cervical friability
  • Abundant WBCs on microscopy
  • Elevated ESR and/or CRP
  • Confirmed cervical infection with N. gonorrhoeae or C. trachomatis
Reference: CDC STI Treatment Guidelines, PID Diagnostic Criteria 2023
PID: Initial Evaluation
PID is a clinical diagnosis. Maintain a low threshold for assessing PID in young, sexually active women with lower abdominal pain. Start antibiotic therapy as soon as diagnosis is suspected.
Reference: ACOG Practice Bulletin, Pelvic Inflammatory Disease 2023
PID: Empiric Antibiotic Therapy
Outpatient Regimen
Single dose IM ceftriaxone 500 mg followed by 14 days oral doxycycline 100 mg twice daily plus metronidazole 500 mg twice daily
Inpatient Regimen
Cefotetan or cefoxitin IV plus doxycycline; switch to oral after 24-48 hours of improvement
Coverage Required
Must cover N. gonorrhoeae, C. trachomatis, and anaerobes for adequate treatment

Important: Complete treatment even if infectious testing comes back negative. Undertreating or missing PID can result in long-term infertility.
Reference: CDC STI Treatment Guidelines, PID Antibiotic Regimens 2023
PID: Indications for Hospitalization
Admit for Inpatient Care
Several clinical scenarios require hospital admission for IV antibiotics and monitoring
Hospitalization Criteria
  • Concern for surgical emergency
  • Tubo-ovarian abscess
  • Severe illness with nausea, vomiting, fever greater than 38.5°C
  • Pregnancy
  • Unable to tolerate or adhere to oral regimen
  • No clinical response to outpatient therapy
Reference: Journal of Emergency Medicine, Inpatient Management of PID 2023
Tubo-Ovarian Abscess
Tubo-ovarian abscess is an infectious inflammatory mass of the fallopian tubes and/or ovary that may spread to adjacent organs. It represents a severe complication of PID requiring aggressive management.
01
Clinical Recognition
Fever, lower abdominal pain, vaginal discharge, leukocytosis on laboratory studies
02
Imaging Confirmation
Ultrasound or CT showing complex adnexal mass with thick walls and internal debris
03
Initial Treatment
Admit for at least 24 hours of IV antibiotics with broad anaerobic coverage
04
Drainage if Needed
Surgical or image-guided drainage for abscess greater than 3 cm or lack of improvement after 24-48 hours
Reference: Obstetrics & Gynecology, Management of Tubo-Ovarian Abscess 2023
PID: Long-Term Complications
Tubal Infertility
Inflammation leads to tubal scarring and loss of ciliary function, resulting in infertility
Ectopic Pregnancy
Tubal damage increases risk of ectopic pregnancy in future pregnancies
Chronic Pelvic Pain
Adhesions and scarring can lead to persistent pelvic pain syndrome
PID is one of the most common causes of infertility. Early diagnosis and complete treatment are essential to prevent long-term complications.
Reference: Fertility and Sterility, Long-Term Sequelae of PID 2023
Abnormal Uterine Bleeding: Overview
Abnormal uterine bleeding (AUB) encompasses any bleeding that differs from normal menstruation in frequency, duration, regularity, or volume. It affects approximately 10-30% of women of reproductive age and requires systematic evaluation to identify the underlying cause.
10-30%
Prevalence
Of reproductive age women
150-250
Word Count
Words per section target
Reference: ACOG Practice Bulletin, Management of Abnormal Uterine Bleeding 2023
AUB: PALM-COEIN Classification
Structural Causes (PALM)
  • Polyp - Endometrial polyps
  • Adenomyosis - Endometrial tissue in myometrium
  • Leiomyoma - Uterine fibroids
  • Malignancy - Endometrial hyperplasia or cancer
Non-Structural Causes (COEIN)
  • Coagulopathy - Bleeding disorders
  • Ovulatory dysfunction - Hormonal imbalances
  • Endometrial - Primary endometrial disorders
  • Iatrogenic - Medications, IUD
  • Not yet classified
Reference: International Federation of Gynecology and Obstetrics, PALM-COEIN System 2023
AUB: Initial Assessment
Rule out pregnancy in any premenopausal patient who presents with vaginal bleeding. The diagnostic approach should be guided by the patient's age, bleeding pattern, and risk factors for malignancy.
Reference: American Family Physician, Evaluation of Abnormal Uterine Bleeding 2023
Acute Heavy Menstrual Bleeding
1
Hemodynamic Support
IV access, fluid resuscitation, blood transfusion if needed
2
Pharmacologic Treatment
High-dose IV estrogen and tranexamic acid if not contraindicated
3
Mechanical Control
Balloon tamponade for refractory bleeding
4
Surgical Intervention
D&C, uterine artery embolization, or hysterectomy if medical management fails

Emergency Management: Hemodynamically unstable patients require immediate hemodynamic support with urgent OB/GYN consultation for definitive management.
Reference: Obstetrics & Gynecology, Acute Management of Heavy Menstrual Bleeding 2023
Postmenopausal Bleeding: Approach
Postmenopausal bleeding is defined as bleeding occurring 12 months or more after the onset of permanent amenorrhea. Endometrial cancer must be ruled out in all postmenopausal individuals through comprehensive evaluation including endometrial sampling when indicated.
01
Risk Assessment
Evaluate for risk factors for endometrial cancer including obesity, diabetes, unopposed estrogen
02
Transvaginal Ultrasound
Measure endometrial thickness; thickness greater than 4 mm requires further evaluation
03
Endometrial Sampling
Perform if risk factors present, endometrial thickness greater than 4 mm, or persistent bleeding
Reference: ACOG Committee Opinion, Endometrial Cancer Screening 2023
Postcoital Bleeding: Evaluation
Common Causes
  • Cervical ectropion
  • Cervicitis
  • Cervical polyps
  • Cervical cancer (early stages)
  • Endometrial polyps
  • Vulvovaginal atrophy
  • Vaginal injuries
There is currently no standard diagnostic algorithm for postcoital bleeding. Evaluation should include pregnancy test, cervical cancer screening if not up-to-date, and assessment for cervical pathology. Rule out endometrial cancer in postmenopausal patients.
Reference: British Medical Journal, Postcoital Bleeding Evaluation 2023
Pregnancy Loss: Types and Definitions
1
Threatened Abortion
Vaginal bleeding with closed cervix and fetal cardiac activity present
2
Inevitable Abortion
Vaginal bleeding with dilated cervix and visible/palpable products of conception
3
Missed Abortion
No bleeding, no fetal cardiac activity, closed cervix, no expulsion of POC
4
Incomplete Abortion
Vaginal bleeding with dilated cervix and POC within cervical canal or uterus
5
Complete Abortion
Vaginal bleeding with closed cervix and POC completely outside uterus
Reference: ACOG Practice Bulletin, Early Pregnancy Loss 2023
Spontaneous Abortion: Etiology
Fetal Causes
Chromosomal abnormalities account for up to half of all spontaneous abortions, particularly in first trimester losses.
  • Aneuploidy (most common)
  • Congenital anomalies
  • Anembryonic pregnancy
Maternal Causes
  • Uterine abnormalities (septate uterus, fibroids)
  • Cervical incompetence
  • Systemic diseases (diabetes, thyroid disorders)
  • Infections
  • Hypercoagulability
Reference: Fertility and Sterility, Etiology of Recurrent Pregnancy Loss 2023
Spontaneous Abortion: Clinical Features
Vaginal Bleeding
Ranging from light spotting to heavy bleeding with clots
Abdominal Pain
Cramping or pain in lower abdomen, may be severe
Loss of Symptoms
Disappearance of pregnancy symptoms such as breast tenderness and nausea
Ultrasound Findings
Absence of fetal cardiac activity or empty uterus on imaging
Reference: American Journal of Obstetrics & Gynecology, Clinical Presentation of Miscarriage 2023
Spontaneous Abortion: Diagnostic Approach
Diagnostic confirmation of fetal death prior to treatment is essential to avoid compromising a viable pregnancy. Ectopic pregnancy must be excluded in all cases.
Reference: Radiology, Ultrasound Diagnosis of Early Pregnancy Failure 2023
Ultrasound Findings in Pregnancy Loss
Definitive Pregnancy Failure
Absence of fetal cardiac activity when crown-rump length is 7 mm or greater
Empty Gestational Sac
Gestational sac 25 mm or greater without an embryo
Previously Visualized IUP
Previously documented intrauterine pregnancy no longer observed (empty uterus)

Important: Perform pelvic ultrasound on pregnant patients who present with abdominal pain or vaginal bleeding, regardless of β-hCG levels.
Reference: Journal of Ultrasound in Medicine, Sonographic Criteria for Pregnancy Failure 2023
Management of Threatened Abortion
Expectant Management
Conservative approach with close monitoring for stable patients
Management Steps
  • Advise patient to avoid strenuous physical activity
  • Prescribe as-needed oral analgesics (acetaminophen)
  • Educate on what to expect if tissue expulsion occurs
  • Provide detailed return precautions
  • Repeat pelvic ultrasound in one week
  • Rule out treatable causes of vaginal bleeding
Anti-D immunoglobulin should be considered for Rh(D)-negative women with threatened abortion.
Reference: ACOG Practice Bulletin, Management of Threatened Abortion 2023
Management Options for Pregnancy Loss
Expectant Management
Watchful waiting for spontaneous expulsion; option for women 12 weeks gestation or less
Medical Evacuation
Misoprostol with or without mifepristone pretreatment to induce expulsion
Surgical Evacuation
Vacuum aspiration or D&C; indicated for septic abortion, heavy bleeding, or patient preference
Management depends mostly on patient preference for uncomplicated spontaneous abortions. All options have similar long-term outcomes.
Reference: Cochrane Database, Management of Miscarriage 2023
Medical Evacuation Protocol
Medication Regimen
Misoprostol is used to induce cervical ripening and expulsion of products of conception. When available, pretreatment with mifepristone 24 hours prior is recommended.
Typical Protocol:
  • Mifepristone 200 mg orally (if available)
  • Followed 24 hours later by misoprostol 800 mcg vaginally or buccally
  • Repeat misoprostol dose if needed
Prescribe as-needed oral analgesics (NSAIDs preferred). Instruct patient on what to expect when tissue expulsion occurs and provide detailed return precautions.
Reference: ACOG Practice Bulletin, Medical Management of First-Trimester Abortion 2023
Surgical Evacuation Procedures
01
First Trimester
Vacuum aspiration or dilation and curettage (D&C) under local or general anesthesia
02
Second Trimester
Dilation and evacuation (D&E) requiring more extensive cervical preparation
03
Emergency Indications
Septic abortion, heavy bleeding, hemodynamic instability, or maternal comorbidities
Complications include uterine perforation, hemorrhage, endometritis, and intrauterine adhesions. Overall complication rate is low with experienced providers.
Reference: Obstetrics & Gynecology, Surgical Management of Pregnancy Loss 2023
Septic Abortion
Clinical Features
Fever, abdominal/pelvic pain, purulent vaginal discharge, uterine tenderness, septic shock
Etiology
Infection of placenta and fetus; complication of missed, inevitable, or incomplete abortion
Management
Broad-spectrum antibiotics with anaerobic coverage plus surgical evacuation of uterine cavity

Emergency Management: Consider diagnosis of septic abortion in patients with clinical features of pregnancy loss and fever. Obtain blood cultures, start antibiotics immediately, and consult OB/GYN urgently.
Reference: Clinical Infectious Diseases, Management of Septic Abortion 2023
Rh Immunization Prevention
Anti-D Immunoglobulin
Rh(D)-negative patients require anti-D immunoglobulin (RhIG) to prevent alloimmunization and hemolytic disease in future pregnancies.
Indications:
  • Consider for all Rh(D)-negative patients with vaginal bleeding
  • Indicated after surgical evacuation
  • Administer within 72 hours of event
Standard dose is 50 mcg (or 120 mcg in some protocols) for pregnancy loss before 12 weeks gestation. Full dose of 300 mcg recommended for losses after 12 weeks.
Reference: ACOG Practice Bulletin, Prevention of Rh D Alloimmunization 2023
Stillbirth: Definition and Epidemiology
Stillbirth (intrauterine fetal demise) is defined as loss of pregnancy after 20 weeks gestation. It affects approximately 1 in 160 pregnancies in the United States. Causes include maternal disease, placental disorders, umbilical cord complications, and fetal congenital anomalies, though many cases remain unexplained.
1/160
Incidence
Pregnancies in United States
2
Typical Onset
Weeks for spontaneous labor
Reference: American Journal of Obstetrics & Gynecology, Stillbirth Epidemiology 2023
Stillbirth: Management Approach
Spontaneous labor usually begins within 2 weeks of intrauterine fetal death. Vaginal delivery is safer than cesarean delivery for stillbirth. Fetal autopsy should be offered to determine underlying cause.
Reference: Obstetrics & Gynecology, Management of Stillbirth 2023
Acute Abdomen in Gynecology
Acute abdomen refers to severe abdominal pain lasting hours to days that may require urgent surgical intervention. In gynecology, immediately life-threatening causes include ruptured ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, and septic abortion.
ABCDE Approach
Systematic assessment and stabilization of airway, breathing, circulation, disability, exposure
Immediate Actions
Large-bore IV access, fluid resuscitation, pregnancy test, pelvic ultrasound, urgent OB/GYN consult
Red Flags
Unstable vitals, sudden severe pain, peritoneal signs, hematemesis, absent bowel sounds
Reference: Emergency Medicine Clinics, Acute Abdomen in Women 2023
Differential Diagnosis by Location
Right Lower Quadrant
  • Acute appendicitis
  • Ectopic pregnancy
  • Ovarian torsion
  • Ruptured ovarian cyst
  • Pelvic inflammatory disease
  • Ureteric colic
Left Lower Quadrant
  • Diverticulitis
  • Ectopic pregnancy
  • Ovarian torsion
  • Ruptured ovarian cyst
  • Pelvic inflammatory disease
  • Colitis
Reference: American Family Physician, Differential Diagnosis of Acute Abdominal Pain 2023
Imaging in Gynecologic Emergencies
Transvaginal Ultrasound
First-line imaging for suspected ectopic pregnancy, ovarian torsion, and early pregnancy complications
CT Abdomen/Pelvis
For suspected appendicitis, diverticulitis, or when ultrasound is inconclusive in non-pregnant patients
POCUS/FAST
Rapid bedside assessment for free fluid in unstable patients with suspected hemorrhage
MRI Pelvis
Alternative to CT in pregnant patients when ultrasound is inconclusive
Reference: Radiology, Emergency Imaging in Gynecology 2023
Emergency Surgical Indications
1
Ruptured Ectopic
Hemodynamic instability with hemoperitoneum
2
Ovarian Torsion
Suspected torsion requires immediate laparoscopy
3
Septic Abortion
Infection with retained products requiring evacuation
4
Hemorrhagic Cyst
Ongoing bleeding with hemodynamic compromise
Do not delay surgical intervention in unstable patients with obvious signs of diffuse peritonitis or sepsis. Immediate surgical management may be required without further diagnostic imaging.
Reference: Journal of Emergency Medicine, Emergency Gynecologic Surgery 2023
Supportive Care in Gynecologic Emergencies
General Measures
Comprehensive supportive care while establishing diagnosis and definitive treatment
Key Interventions
  • Establish NPO status for potential surgery
  • Parenteral analgesics (opioids preferred perioperatively)
  • Antiemetics as needed for nausea and vomiting
  • NG tube placement if bowel obstruction suspected
  • Urinary catheter for monitoring and bladder decompression
  • Empiric antibiotics for suspected infection
Reference: Critical Care Medicine, Supportive Care in Gynecologic Emergencies 2023
Disposition and Follow-Up
01
Hemodynamically Unstable
Direct transfer to OR for emergency surgery or ICU admission for stabilization
02
Surgical Pathology
Inpatient admission for underlying surgical condition or intractable symptoms
03
Stable with Inconclusive Workup
Extended ED observation with serial abdominal examination or discharge with close follow-up
04
Discharge Criteria
Resolution of pain, ability to tolerate oral intake, reassuring exam, ability to adhere to instructions
Reference: Annals of Emergency Medicine, Disposition in Gynecologic Emergencies 2023
Patient Education and Counseling
Return Precautions
Instruct patients to seek immediate medical attention for:
  • Heavy vaginal bleeding (soaking more than 2 pads per hour)
  • Severe abdominal pain
  • Fever greater than 38°C (100.4°F)
  • Dizziness or syncope
  • Foul-smelling vaginal discharge
Follow-Up Care
  • Schedule follow-up appointment within 1-2 weeks
  • Provide written discharge instructions
  • Arrange for pregnancy loss counseling if indicated
  • Discuss contraception options
  • Ensure understanding of medication regimens
Reference: Patient Education and Counseling, Gynecologic Emergency Discharge Planning 2023
Key Takeaways
Early Recognition
Maintain high index of suspicion for life-threatening gynecologic emergencies in reproductive-age women
Systematic Approach
Follow ABCDE approach, obtain pregnancy test, perform pelvic ultrasound, and consult OB/GYN early
Timely Intervention
Do not delay stabilization and definitive treatment in unstable patients with suspected emergencies
Evidence-Based Care
Follow international guidelines and evidence-based protocols for optimal patient outcomes
Reference: Multiple International Guidelines, Evidence-Based Emergency Gynecology 2023
Summary and Resources
Gynecologic emergencies require prompt recognition, systematic evaluation, and timely intervention to prevent serious complications including infertility, hemorrhagic shock, and death. Key principles include maintaining high clinical suspicion, performing focused diagnostic workup, and consulting OB/GYN early for definitive management.
Essential Skills
  • ABCDE approach and hemodynamic stabilization
  • Pregnancy testing and pelvic ultrasound interpretation
  • Recognition of surgical emergencies
  • Appropriate use of antibiotics and analgesics
Additional Resources
  • ACOG Practice Bulletins and Committee Opinions
  • CDC STI Treatment Guidelines
  • Emergency Medicine and Radiology Guidelines
  • International Federation of Gynecology and Obstetrics
Department of Obstetrics and Gynecology
Prof. Mykhailo Medvediev
References: Based on ACOG Practice Bulletins, CDC Guidelines, WHO Recommendations, and peer-reviewed literature from major medical journals including NEJM, Obstetrics & Gynecology, and Emergency Medicine Clinics of North America, 2023.