JUST FOR WOMEN
| PELVIC PAIN AND GYNECOLOGIC EMERGENCIES —Lisa K. Everson, MD, Associate Clinical Professor of Obstetrics
and Gynecology, University of California, San Francisco, School of Medicine
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Ectopic Pregnancy
| Background: ususally presents as abnormal bleeding, abdominal pain, and spotting; incidence increasing, mortality decreasing;
leading cause of pregnancy-related death in first trimester
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| Ultrasonography (US): generally better than computed tomography (CT) for evaluating gynecologic organs; accuracy
operator-dependent; small amount of cul-de-sac and abdominal fluid normal; absence of adnexal mass on US does not
rule out ectopic pregnancy
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| Quantitative human chorionic gonadotropin (hCG): urine test for pregnancy best screening modality; patient
does not have ectopic pregnancy if urine pregnancy test negative; discriminatory zone (DZ)—level of hCG above which
gestational sac seen on US in viable intrauterine pregnancy (IUP); generally, DZ level 1500 to 2000 mIU/mL (machine-
and operator-dependent); hCG level below DZ does not mean US unhelpful; ectopic pregnancies have wide range of
hCG levels, many below DZ; if hCG >2000 mIU/mL and no IUP seen on US, pregnancy abnormal
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| Differential diagnosis: missed abortion—nonviable pregnancy in uterus not seen as gestational sac; evacuate uterus
using manual aspirator; analyze uterine tissue for presence of villi (float tissue in water; fronds of villi float in characteristic
pattern); if villi not seen but missed abortion still suspected, recheck hCG later (immediate significant decrease indicates
trophoblast evacuated); miscarriage—established on basis of history and hCG level
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| Diagnostic dilemmas: if hCG level below DZ, pregnancy possible; consider patient’s wishes, reliability, and circumstances
when deciding course of action; rely on clinical assessment to decide how to proceed; consider following patient
if patient reliable, in minimal pain, and stable; hCG should double or increase by ≥66% in 48 hr; have patient return in 48
hr; ≥66% increase in hCG consistent with normal IUP but does not rule out ectopic pregnancy; if increase in hCG <66%
and US reveals adnexal mass without cardiac activity, and uterine stripe thin, patient has ectopic pregnancy; consider
missed abortion in patient without adnexal mass and hCG level <66%; consider surgery or methotrexate in patient with
ectopic pregnancy; evacuation of uterus recommended prior to therapy with methotrexate (MTX)
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| Methotrexate: contraindicated if ectopic pregnancy ruptured; requires reliable, motivated, and compliant patient; in general,
lower the hCG level, greater the likelihood of success with MTX; successful MTX therapy—defined as good response
to single dose; high failure rate associated with hCG level >10 000 mIU/mL, and high success rate associated with
hCG level <2000 mIU/mL; fetal cardiac activity contraindication to MTX; obtain laboratory studies to make sure electrolytes,
liver, and renal function normal; dosage and follow-up—treat with 50 mg/m2 intramuscular (IM) injection to 100-
mg maximum; check hCG on days 4 and 7 and weekly thereafter; hCG level should rise until day 4, then drop ≥15% between
days 4 and 7 and weekly thereafter; redose with MTX or operate if <15% drop (≈20% of women require further intervention);
mean time for hCG to become nondetectable 35 days; ongoing spotting and abdominal pain during treatment
common; spontaneous tubal rupture can occur, even if hCG level declining; pain—50% of women experience pain and
≈35% experience significant increase in abdominal pain during first 2 to 10 days of treatment; abdominal pain caused by
tubal abortion, hematoma and tubal stretch, or tubal rupture; rupture—indicated by intra-abdominal bleeding; check vital
signs and hematocrit for evidence of blood loss; look for peritoneal signs; use US to assess amount of free fluid in pelvis
and abdomen; tubal rupture usually occurs within first 2 wk; management—treat mild to moderate pain with
analgesics; patient with evidence of rupture requires emergent surgery; if diagnosis unclear, admit for observation
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Ovarian Torsion
| Differential diagnosis: ectopic pregnancy—if IUP identified on US, can rule out ectopic pregnancy; heterotopic (concurrent
IUP and ectopic) pregnancy rare, but more common in setting of assisted reproduction; pelvic inflammatory disease
(PID)—extremely unusual in pregnancy; progesterone-thickened cervical mucus prohibits ascent of bacteria to
upper tract; ruptured ovarian cyst—associated with acute onset of severe pelvic pain; typically, see decompression of
cyst after rupture; pain caused by fluid in peritoneal cavity; need fair amount of fluid to get significant pain; peritoneal irritation
from fluid results in diffuse abdominal pain; ovarian torsion—ovary and tube twist on pedicle, cutting off blood
supply; ovarian mass required to twist this structure; Doppler flow studies can aid in diagnosis, but not definitive; presence
of blood flow does not rule out torsion; absence of flow in patient with clinical presentation characteristic of torsion,
highly suggestive of torsion; acute onset of pain typical; more common in right adnexa than left and in early pregnancy;
localized pain occurs because of ovarian ischemia; prompt diagnosis and surgical management critical to avoid necrosis
and ovarian loss
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Ruptured Ovarian Endometrioma
| Differential diagnosis: ectopic pregnancy—rule out if pregnancy test negative; ruptured ovarian cyst or torsion—
consider in patient with mass; PID—consider in patient with diffuse peritoneal signs and fever
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| Ruptured endometrioma: fluid walled off into area; over time, fluid leaks into abdomen and peritoneal cavity, causing
diffuse pain symptoms; treat with cystectomy and peritoneal lavage
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Pelvic Inflammatory Disease
| Diagnostic dilemma: laparoscopy gold standard for diagnosis, but associated with indirect and direct costs and potential
for morbidity and mortality; physicians rely on clinical findings; PID associated with sepsis, infertility, markedly increased
risk for ectopic pregnancy and subsequent infections
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| Diagnosis: PID overdiagnosed when clinical criteria used, but overdiagnosis acceptable because of seriousness of sequelae
if diagnosis missed; Centers for Disease Control and Prevention (CDC) diagnostic criteria require uterine and/or
adnexal tenderness or cervical motion tenderness (need one criterion for diagnosis in high-risk patient); supporting criteria
that increase diagnostic accuracy include fever, mucopurulent discharge from cervical os, elevated erythrocyte sedimentation
rate, elevated C-reactive protein, and laboratory documentation of gonorrhea or chlamydia
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| Classification: mild to moderate—usually treated on outpatient basis; severe—requires admission for parenteral antibiotics;
acutely ill and unstable—requires emergent surgery
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| When to hospitalize: diagnosis uncertain and surgical emergency cannot be ruled out; patient pregnant; no response to
prior treatment with oral antibiotics; patient cannot tolerate oral medications; patient severely ill with nausea, vomiting,
or high fever; evidence of tubo-ovarian abscess (TOA; inflammatory mass in area of adnexa on US, usually without identification
of discrete ovary)
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| Parenteral treatment: IV antibiotics until patient clinically improved for 24 to 48 hr, then switch to 14-day oral antibiotic
regimen; clinical parameters used to judge improvement (eg, white blood cell [WBC] count, temperature)
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| Tubo-ovarian abscess: treat with parenteral antibiotics if not ruptured; ruptured TOA—rare; mortality rate ≈3%; rupture
can occur spontaneously or as result of emergency department (ED) evaluation; presents as acute onset of severe pelvic
pain, toxic appearance, dehydration, and shock; requires immediate surgical intervention with hysterectomy and
bilateral salpingo-oophorectomy; before surgery, stabilize patient with fluid resuscitation, central monitoring, electrolyte
normalization, oxygenation, and broad-spectrum antibiotics
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Necrotizing Fasciitis
| Differential diagnosis: Bartholin duct cyst abscess—rule out if no fluctuant mass; herpes simplex—not likely in patient
with fever and systemic symptoms, especially if not sexually active; get culture to rule out; vulvar cellulitis—treat
with IV antibiotics; necrotizing fasciitis—consider when evaluating infected vulva; not common diagnosis, but highly
aggressive infection with significant mortality rate (20%-30%); if diagnosis delayed >48 hr, mortality rate increases dramatically
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| Necrotizing fasciitis: polymicrobial infection that produces necrosis that extends along fascial planes in subcutaneous
tissue; more common in women with diabetes, obesity, hypertension, and vascular disease; often no precipitating event;
diagnosis—difficult, but outcome relies on early diagnosis and treatment; keep suspicion high to avoid poor outcome;
usually presents with local induration, edema, tenderness, and pain; as subcutaneous tissue necrotizes, skin discoloration
and necrosis occurs, along with formation of bullae; hallmark is systemic illness incongruent with physical signs; diagnostic
tests sometimes helpful; make diagnosis if plain films show gas in soft tissue; can use fine needle aspiration (FNA)
or tissue biopsy to look for evidence of necrotic tissue; treatment—start broad-spectrum antibiotics early; serial examinations
every few hours; intervene surgically with wide debridement of necrotic tissue; note—ED physician should
make sure patient admitted to surgical service, not medical
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| TRAUMA AND PREGNANCY —M. Margaret Knudson, MD, Professor of Surgery, University of California, San Francisco,
School of Medicine; Director, San Francisco Injury Center
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| Initial evaluation and resuscitation: early in pregnancy (10-11 wk), one third increase in plasma volume; use IV
fluids liberally during resuscitation because when mother hypotensive, fetus already in danger (placenta contracts and
mother starts taking blood volume from fetus); shock induced by compression of inferior vena cava (IVC); when transporting
patient on backboard, tilt backboard to patient’s left side to have uterus roll away from IVC; do not allow mother
to become hypoxic; fetus has steep hemoglobin dissociation curve; when mother shows signs of hypoxia, fetus often too
hypoxic to recover
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| Secondary assessment: get prenatal history if possible; determine approximate fetal age; ask conscious patient if she
feels fetal movements or uterine contractions; examine patient for vaginal bleeding and amniotic fluid leakage; fetal
monitoring—important if pregnancy ≥25 wk gestation; monitor patient without contractions, amniotic fluid leakage,
or severe injuries for 6 hr and send home; monitor for 24 hr if patient has contractions, vaginal bleeding, is in later
stages of pregnancy (high percentage deliver, even with minor injuries), or is unstable; US—evaluate pericardial and
peritoneal fluid (≈80% sensitivity in pregnant patients); assess fetus for age, movement, heart rate, placental position,
and amount of amniotic fluid
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 | X-rays: large dose of radiation during preimplantation phase can cause embryo death; during organogenesis (wk 3 to wk
16), excessive irradiation can result in cerebral anomalies, skeletal or genital abnormalities; after 16 wk of pregnancy,
irradiation can cause neurologic damage to fetus that persists and is cumulative; cumulative doses of radiation shown
to cause childhood cancers; safe dose to uterus <10 rad; prevent overexposure by shielding uterus in pregnant patient;
pelvic x-ray exposes fetus to 1 rad; abdominal CT gives 0.2 to 0.5 rad per slice (avoid multiple overlapping slices or
pelvic reconstruction); can safely scan through abdomen and uterus without toxic dose to fetus; place film badge on
uterus of pregnant patient in intensive care unit (ICU) to determine amount of radiation patient receives
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| Treatment of injuries during pregnancy: hypotension and abdominal infection from missed bowel injury jeopardize
pregnancy; diagnostic studies important; pelvic fractures—highest rate of fetal mortality of all traumatic injuries;
≈25% of patients who sustain major pelvic fracture during pregnancy lose fetus because of maternal shock; large size of
pelvic blood vessels in late pregnancy can result in severe blood loss and shock; placental laceration sometimes occurs because
of pelvic fractures; fetal head injury associated with pelvic fracture; penetrating trauma—uterus often target; stab
wounds may not injure fetus because uterus thick when out of pelvis; gunshot wounds (GSW)—rate of fetal mortality
65%; cesarean delivery—may be required for successful outcome; indicated for severe maternal shock if fetus viable outside
of womb, impending maternal death, severe uterine injury, if access to severe maternal injury impeded by uterus, and
disseminated intravascular coagulation (DIC) due to ruptured membranes; speaker’s study—fetal survival 45% in patients
who required cesarean delivery after trauma; survival rate 75% if cardiac activity present in fetus >26 wk gestation; also
found use of fetal monitoring poor, even in level 1 trauma centers (associated with delayed recognition of fetal distress and
increased fetal mortality); algorithm—listen for fetal heart tone; if not present, continue with acute trauma life support
(ATLS) resuscitation and ignore pregnancy; if fetal heart tone present, obtain US; if fetal age estimated at <25 wk gestation,
pay attention to mother; if fetal age estimated as >25 wk gestation and no maternal distress, recommend fetal monitoring
for 6 to 24 hr, depending on degree of maternal injuries; if maternal or fetal distress present and fetal age estimated at
>26 wk, cesarean delivery indicated; consider perimortem cesarean delivery
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| Critical care obstetrics: consider that pregnancy can induce hypertension that resembles head injury (eg, seizures,
DIC); amniotic fluid embolism associated with high mortality rate; pregnant patients have high risk for deep venous
thrombosis and pulmonary embolism; surveillance Doppler studies recommended; can give heparin to pregnant patients;
warfarin (Coumadin) contraindicated (crosses placenta); premature labor defined as contractions and dilatation of cervix;
when considering use of tocolytics, if mother unstable and experiencing contractions after trauma, stopping contractions
not recommended
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Educational Objectives
| The goal of this activity is to provide the listener with a greater understanding of pelvic pain, gynecologic emergencies, and
trauma during pregnancy. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Summarize the diagnosis and medical management of an ectopic pregnancy.
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| 2. Evaluate a patient for ovarian torsion.
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| 3. Describe the presentation and management of a ruptured ovarian cyst.
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| 4. Determine when to admit a patient with pelvic inflammatory disease.
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| 5. Discuss the evaluation, resuscitation, secondary assessment, and treatment of a pregnant trauma patient.
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Discussed on This Program
Heparin (systemic)
Warfarin sodium [Coumadin]
Suggested Reading
Cabrera H et al: Necrotizing gangrene of the genitalia and perineum.Int J Dermatol. 41(12):847, 2002; Eckstein M:
Managing the pregnant trauma patient. JEMS. 30(5):110, 2005; Lambert MJ et al: Gynecologic ultrasound in emergency
medicine. Emerg Med Clin North Am. 22(3):683, 2004; Lawrence LL: Unusual presentations in obstetrics and gynecology.
Emerg Med Clin North Am. 21(3):649, 2003; Lavery JP et al: Management of moderate to severe trauma in
pregnancy. Obstet Gynecol Clin North Am. 22(1):69, 1995; Lee C et al: Emergent surgical complications of genitourinary
infections. Emerg Med Clin North Am. 21(4):1057, 2003; Seeber BE et al: Suspected ectopic pregnancy. Obstet
Gynecol. 107(2 Pt 1):399, 2006; Shah AJ et al: Trauma in pregnancy. Emerg Med Clin North Am. 21(3):615, 2003;
Sotiriadis A et al: Expectant, medical, or surgical management of first-trimester miscarriage: a meta-analysis. Obstet
Gynecol. 105(5 Pt 1):1104, 2005; Zeger W et al: Gynecologic infections. Emerg Med Clin North Am. 21(3):631, 2003.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Everson was recorded in San Francisco, CA, at Topics in Emergency Medicine, held October 24-27, 2005, and sponsored
by the University of California, San Francisco School of Medicine. Dr. Knudson was recorded in Dearborn, MI, at the
Detroit Trauma Symposium, held November 10-11, 2005, and sponsored by the Wayne State University School of Medicine,
Detroit Receiving Hospital, and the University Health Center. The Audio-Digest Foundation thanks the speakers and
the sponsors for their cooperation in the production of this program.
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