Gynecologic emergency procedures

⚠️ When Things Go Wrong

• Hemorrhage: Assess stability (ABCs). Manage with pressure, uterotonics (oxytocin, misoprostol), vessel ligation (uterine a.), or emergency hysterectomy.
• Organ Injury:
  • Ureter: High risk during uterine artery ligation. Diagnose with IV dye (indigo carmine) or CT urogram.
  • Bladder: Common in hysterectomy. Intra-op cystoscopy with dye confirms integrity.
  • Bowel: Risk with adhesions. Requires immediate surgical repair.
• Infection: Post-op fever, pelvic abscess. Treat with broad-spectrum antibiotics & drainage.

⭐ 📌 "Water under the bridge": The Ureter (water) runs under the Uterine Artery (bridge), a critical landmark.

🚩 Clinical Manifestations: Reading the Red Flags

• Hemodynamic Instability:
  • Hypotension (SBP < 90 mmHg), orthostasis
  • Tachycardia (> 100 bpm)
  • Syncope, dizziness, pallor (signs of hypovolemic shock)
• Severe, Acute Abdominopelvic Pain:
  • Sudden, sharp, unilateral onset suggests torsion or ruptured ectopic.
  • ⚠️ Peritoneal signs (rebound tenderness, guarding) indicate intra-abdominal catastrophe (e.g., rupture, peritonitis).
• Abnormal Vaginal Bleeding:
  • Heavy flow: soaking >1 pad/hour.
  • Bleeding in postmenopausal or pregnant patients requires immediate evaluation.
• Systemic Signs of Infection (Sepsis):
  • Fever (>38°C), chills, altered mental status.
  • Purulent cervical discharge, cervical motion tenderness.

⭐ Classic Triad for Ectopic Pregnancy: Amenorrhea, unilateral pelvic pain, and vaginal spotting/bleeding. Always suspect in any woman of reproductive age presenting with these symptoms.

🕵️‍♀️ Diagnosis: The Detective Work

• Initial Assessment: ABCs first! Assess hemodynamic stability (BP, HR).
• Core Labs: STAT urine/serum β-hCG is paramount. Also, CBC (anemia, leukocytosis) and Type & Screen.
• Focused Exam: Check for peritoneal signs (rebound, guarding). Pelvic exam for cervical motion tenderness (CMT), adnexal masses, or bleeding.

⭐ Discriminatory Zone: If serum β-hCG is >2,000 mIU/mL, an intrauterine pregnancy (IUP) should be visible on TVUS. Its absence is highly suspicious for an ectopic pregnancy.

🚑 Management - The Rescue Mission

Immediate goal: Stabilize the patient (ABCs, 2 large-bore IVs, labs: β-hCG, CBC, type & cross) and proceed to definitive surgical management.

• Ruptured Ectopic Pregnancy:

  • Unstable: Emergency laparotomy.
  • Stable: Laparoscopy.
  • Procedure: Salpingectomy (tube removal) is standard for rupture. Salpingostomy (incision) is an option for stable patients desiring fertility.

• Ovarian Torsion:

  • Procedure: Laparoscopic detorsion to restore blood flow.
  • Assess ovarian viability; oophorectomy only if necrotic/malignant.
  • Consider oophoropexy to prevent recurrence.

• Ruptured Tubo-Ovarian Abscess (TOA):

  • Procedure: Urgent drainage (IR-guided or surgical) + broad-spectrum IV antibiotics.

• Acute Hemorrhage (AUB/Postpartum):

  • Stepwise approach: D&C → Intrauterine balloon tamponade (e.g., Bakri) → Uterine Artery Embolization (UAE) → Hysterectomy as a last resort.

⭐ In ovarian torsion, always attempt detorsion first, even if the ovary appears dusky or black. Oophorectomy is reserved for non-viable tissue or suspected malignancy, as many ovaries regain function.

⚡ Biggest Takeaways

• Ruptured ectopic pregnancy: Suspect with hypotension, adnexal mass, and positive hCG. Requires immediate surgical intervention, typically laparoscopic salpingectomy.
• Ovarian torsion: Presents as sudden, severe unilateral pelvic pain. Ultrasound with Doppler is key. Treatment is urgent laparoscopic detorsion to preserve ovarian function.
• Tubo-ovarian abscess (TOA): A severe PID complication. If unresponsive to broad-spectrum IV antibiotics, requires percutaneous or surgical drainage.
• Ruptured hemorrhagic cyst: Causes hemoperitoneum. Unstable patients require surgical exploration to control bleeding.
• Uterine perforation: A risk of instrumentation. Laparoscopy is indicated for instability or suspected bowel injury.