Reproductive and Sexual Health Handbook

Gynaecological emergencies may present with acute severe pelvic pain or heavy vaginal bleeding, and may be associated with hypovolaemic or septic shock. Causes can include ectopic pregnancy, miscarriage, acute pelvic inflammatory disease (PID), tubo-ovarian abscess, post-partum sepsis or haemorrhage, or post-operative infection or haemorrhage.⁽¹⁾ The key points in management are to ensure hemodynamic stability, instituting emergency resuscitation measures where indicated and to rapidly distinguish between pregnancy-related causes, gynaecological disorders and non-reproductive tract causes. It is important to remember that early pregnancy complications and loss not only represent potential medical emergencies but may also be very distressing for a patient and their partner.

KEY POINT

All women of reproductive age presenting with pelvic pain and/or vaginal bleeding should be assumed to be pregnant until proven otherwise.

Causes of acute pain in the context of a positive pregnancy test may include:

ectopic pregnancy pregnancy of unknown location miscarriage red degeneration of fibroid (where a fibroid outgrows its blood supply and undergoes necrosis)

Causes unrelated to pregnancy include:

pelvic inflammatory disease haemorrhage, torsion or rupture of ovarian lesion rupture of acute degeneration of uterine fibroid dysmenorrhoea endometriosis ovarian hyperstimulation in a woman undergoing fertility treatment

Non-reproductive tract causes include:

urinary tract infection pyelonephritis renal calculi diverticulitis appendicitis^{(2, 3)}

Table 14.1 Common causes of low abdominal (pelvic) pain in women of reproductive age

DIFFERENTIAL DIAGNOSIS TYPICAL PRESENTATION FINDINGS THAT SUPPORT THE DIAGNOSIS  DEFINITIVE DIAGNOSTIC FINDINGS MEDICAL EMERGENCIES  Ectopic Pregnancy  Pelvic pain and/or bleeding in the first trimester (typically 6 to 8 weeks) Pain may localise to one side  Positive pregnancy test  Empty uterus on ultrasound  Ectopic pregnancy identified on imaging and/or laparoscopy  Appendicitis Acute onset (hours to days) Migration of pain from peri umbilicus to RIF Systemic symptoms present: anorexia, nausea, vomiting Migration of pain from umbilicus to right iliac fossa Onset of pain not associated with menses McBurney’s point site of maximal tenderness Appendicitis confirmed on imaging, laparoscopic and/or histological findings Ovarian cyst complications (rupture/

torsion) Sudden onset of unilateral pelvic pain, more common in the right iliac fossa  May be associated with vaginal bleeding Adnexal mass felt on bimanual examination  Ruptured ovarian cyst identified on imaging and/or laparoscopy  OTHER CAUSES PID¹  Typical pain: 

Onset days to weeks and Appendicitis: usually presents with right iliac fossa pain and systemic features which may include fever, anorexia and vomiting. Pain may commence at the umbilicus before migrating to the right iliac fossa.⁽³⁾ Adnexal tenderness may be present on pelvic examination.⁽¹⁵⁾ Computed tomography (CT) scan has a higher sensitivity and specificity than ultrasound in the diagnosis of acute appendicitis.⁽¹⁵⁾ Definitive diagnosis is made at the time of surgery. Prompt referral to hospital is recommended if appendicitis is suspected. Diverticulitis: an important differential, especially in patients aged over 40, and typically presents with left sided pain with or without associated rectal bleeding. CT scan may show changes associated with diverticular disease.⁽¹⁵⁾ In some cases, abscess formation and bowel perforation can occur. Urinary tract pathology including infection or renal calculi.

Acute gynaecological emergencies may present with bleeding and subsequent hypovolaemic shock. Severe bleeding and shock require management and resuscitation in an emergency setting. Treatment primarily involves identification of the source and control of bleeding, reversal of possible coagulopathy, and administration of adequate fluids and blood products to maintain normal tissue perfusion.⁽¹⁸⁾

Prompt physical examination including assessment of vital signs, vaginal and pelvic examination and rapid bedside ultrasound in the emergency setting are important management tools. A pregnancy test should be performed in all patients of reproductive age presenting with bleeding.

Causes of severe vaginal bleeding may include:

miscarriage or threatened miscarriage gestational trophoblastic disease ectopic pregnancy complication of termination of pregnancy anovulatory bleeding vaginal trauma uterine fibroids gynaecological malignancy antepartum or postpartum haemorrhage

Bradycardia and hypotension resulting from cervical stimulation or instrumentation is referred to as “cervical shock”. It may result from the presence of products of conception in the cervix during miscarriage, which should be removed if present. More commonly, in primary care settings, cervical shock can occur during insertion of an intrauterine device (IUD). It is thought to be due to stimulation of the vagal nerve. Whilst uncommon, it can rapidly cause a woman to become unwell with circulatory compromise.⁽¹⁹⁾ The UK Faculty of Sexual and Reproductive Healthcare (FSRH) states that the availability of appropriate emergency medication, including atropine, during IUD insertion is essential, and this is a service standard for resuscitation in sexual health services in the UK.⁽²⁰⁾

For a patient with symptomatic bradycardia secondary to cervical shock, cease manipulation of the cervix and remove all instruments. Call for help. Assess the patient with the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).⁽²⁰⁾ Assess vital signs and provide oxygen, if required. Ensure the patient is supine and elevate the legs to improve venous return. If these are insufficient to improve the patient’s haemodynamic status, 500-600mcg IV atropine is recommended followed by a saline flush

There are several acute gynaecological emergencies which can present with sepsis. Prompt recognition and treatment of the source is essential.

PID and tubo-ovarian abscess – severe PID may involve peritonitis, tubo-ovarian abscess and sepsis. Tubo-ovarian abscess may occur in up to one-third of patients admitted with PID.⁽²³⁾ Pelvic ultrasound has high sensitivity and specificity for diagnosis of tubo-ovarian abscess.⁽²³⁾ These appear as multiloculated complex masses with internal debris, septations, irregular thick walls and increased vascularity. They are often bilateral and tender to probe pressure.⁽¹⁵⁾ It is thought that 60-80 per cent of tubo-ovarian abscesses can be managed conservatively with analgesia, intravenous fluids and parenteral antibiotics, however those with abscess rupture, peritonitis and sepsis require urgent surgical management and delay can be fatal.⁽²³⁾ Septic abortion – refers to an abortion or miscarriage accompanied by an intrauterine infection. Septic abortion is less common in women with spontaneous miscarriage compared with termination of pregnancy. Whilst rare, it can be severe and life threatening. Management includes assessment for haemodynamic stability, administration of broad-spectrum intravenous antibiotics and surgical evacuation of any retained products of conception.⁽²⁴⁾ Bartholins abscess – this is a perineal abscess that

Patients who have recently undergone gynaecological procedures including laparoscopy and laparotomy are at risk of presenting with an acute post-operative complication which may present as an emergency. Prompt recognition and management is essential. Post-operative complications with the potential to present as an emergency include:

Wound infection Wound dehiscence may indicate infection and require return to theatre Pelvic collection – requires imaging if suspected and may warrant return to theatre Ureteric/bladder injury – the incidence of urinary tract injury ranges from 0.05 per cent to 8.3 per cent for laparoscopy. Bladder injury is more common than ureteric injury, with the latter more commonly missed at the time of surgery.⁽²⁸⁾ Post-operative urinary symptoms require urgent review. Bladder or ureteric injury requires urgent surgical management. Post-instrumentation PID – any instrumentation of the uterus (e.g. IUD insertion, hysteroscopy, dilatation and curettage) may result in post instrumentation PID within 4-6 weeks of the procedure. Intestinal injury – only 30-50 per cent of intestinal injuries are recognised at the time of surgery; the remainder may take up to 30 days after surgery to present depending on the site and type of injury. Symptoms may be subtle and include abdominal distension, low grade fever, diarrhoea with few peritoneal signs. Others may

Family Planning NSW factsheet:

Pelvic Inflammatory Disease

New South Wales STI Program Unit

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