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

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

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

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

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

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

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

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)

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

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.