OB/GYN EMERGENCIES
From Topics in Emergency Medicine, presented by the University of California, San Francisco, School of Medicine,
Division of Emergency Medicine
Michael Policar, MD, MPH, Associate Clinical Professor of OB/GYN and Reproductive Sciences, University of
California, San Francisco, School of Medicine
| Case: woman, 27 yr of age, with worsening unilateral pelvic pain in last 24 hr; 7 wk since last menstrual period; used contraception
inconsistently; on physical examination, has 3 out of 4 right lower quadrant tenderness in lower abdomen, with mild
rebound tenderness on same side; on bimanual examination, has right-sided 4- to 5-cm tender cystic mass and uterus enlarged
to 7-wk size; clinical presentation most consistent with ruptured ectopic pregnancy, adnexal torsion, ovarian hemorrhage,
and ovarian rupture; until proven otherwise, all vaginal bleeding due to pregnancy, and all pelvic pain due to ectopic
pregnancy; most diagnoses made with history and physical examination, quantitative human chorionic gonadotropin (hCG)
testing, and pelvic (vaginal probe) ultrasonography (US)
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| Gynecologic origin of pelvic pain: infection, complication of pregnancy, or adnexal accident; infections—acute
pelvic inflammatory disease (PID) or complication (eg, tuboovarian abscess); complications of pregnancy—ectopic
pregnancy; septic abortion; postpartum or postabortion endometritis; postmedical abortion sepsis; adnexal accidents—
ovarian torsion; ovarian rupture; ovarian hemorrhage; other gynecologic problems—flare of symptoms from endometriosis
(classic patient has daily pelvic pain that waxes and wanes, and worsens during menstrual period and often
with intercourse); ovulation (mittelschmerz; usually transient pain)
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| Nongynecologic origin of pelvic pain: gastrointestinal (appendicitis, inflammatory bowel disease, or diverticular
disease); urinary tract problems (eg, cystitis, pyelonephritis, ureteral stone); orthopedic (some women experience menstrual
period as low back pain)
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| Adnexal torsion: ≈80% of cases occur in reproductive-aged women; 10% of cases in postmenopausal women and ≈10%
in premenarchal girls (often normal ovary); predisposing factors—mobile ovarian cyst (dermoid); functional cyst (follicle
cyst or corpus luteum cyst) single most common kind of cyst in ovary that undergoes torsion; previous abdominal
surgery; pregnancy (≈14% of women with torsion); treatment with fertility drugs to induce ovulation; occurrence—
more common on right side (60%); accounts for 3% of all gynecologic emergencies; mechanism—due to twisting of
ovarian mass on 2 pedicles (uteroovarian ligament and infundibulopelvic ligament) that feed into ovary; either torsion of
tube or ovary (most commonly both); as adnexa twists, venous outflow blocked; ovary becomes edematous and engorged;
ischemia and hemorrhage develop as arterial inflow blocked; presentation—usually related to recent physical
activity; especially common during or after intercourse; pain always unilateral (sometimes with referred flank pain); pain
ipsilateral to torsion (on opposite side in 25% of cases); torsion may be intermittent (with spontaneous untwisting; pattern
of recurrent pain); often associated with nausea and vomiting (50% of cases), increased white blood cell (WBC) count
(≈40%), peritoneal signs (≈30%), and fever (20%); pain often worsens initially, that improves with ischemia (due to loss
of nerve transmission); pelvic examination may reveal tender unilateral adnexal mass then becomes bigger over time due
to increasing venous congestion; evaluation—historically, with US (shows unilateral cystic mass [average 10 cm in diameter]);
solid mass in ≈25%; computed tomography (CT) and magnetic resonance imaging (MRI) often done as incidental
studies; radiologist looks for thickening of Fallopian tube and smooth wall of adnexal mass; ascites present two-
thirds of time, and deviation of uterus toward affected side one-third of time; in color Doppler US flow study, reduced or
absent vascular flow towards mass suggestive of torsion (whorl sign); diagnosis should not be based on vascular flow, as
almost 50% of women with torsion have normal flow; management—making diagnosis urgent to improve likelihood of
ovarian salvage; diagnostic laparoscopy used to confirm and treat (detorsion); rate of pulmonary thromboembolism in
detorsion 0.2%; 60% of torsions due to functional cysts (removal of cyst not necessary; detorsion reestablishes blood
flow); avoid oophorectomy, as black-blue appearance of adnexa due to vascular stasis, not gangrene; after detorsion
alone, ovarian function maintained in 88% to 100% of cases; if due to functional cyst, avoid recurrence with oral contraceptives
(OCs)
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| Ovarian hemorrhage: intracapsular (bleeding into ovary) or extracapsular (bleeding from ovary, causing hemoperitoneum)
hemorrhage; usually spontaneous, but often activity-related; more frequent in pregnancy; intracapsular
hemorrhage—hyperacute onset of severe unilateral abdominal pain; examination shows unilateral cystic adnexal mass;
US confirms finding, but difficult to differentiate from adnexal torsion (obtain CT to differentiate); pelvic US shows no
free fluid; extracapsular hemorrhage—tear on external covering of ovary, with occasional arterial bleeding causing
hemoperitoneum; diffuse lower abdominal pain; examination shows diffuse pelvic tenderness, with one side usually
worse than other due to hemoperitoneum; on pelvic US, see mass (bleeding ovary) and sometimes fluid within ovary;
management—bleeding often self-limited; observe with serial hematocrit (HCT) readings; admit patient for overnight
stay if pain severe and diagnosis uncertain; perform laparoscopy if significant fluid representing hemoperitoneum found
on US and HCT dropping
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| Ovarian rupture: due to rupture of ovarian cyst, with spillage of contents into peritoneal cavity; if contents follicular
fluid of functional cyst, pain transient and self-limited; if fluid from dermoid or endometrioma (“chocolate” cyst), chemical
peritonitis results; examination shows diffuse pelvic pain; palpating cyst may not be possible and may not be visible
on US (already deflated); intraperitoneal fluid may be seen on US; culdocentesis positive for substance; management—
if ruptured follicle, expectant management; if endometrioma or dermoid, laparoscopic irrigation of pelvis, removal of
fluid, and resection of cyst
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| Tests: pelvic or abdominal CT or MRI—preferred if torsion suspected; if peritonitis suspected, CT better (also in tuboovarian
abscess); if patient pregnant and has peritonitis, perform MRI (not CT); US—for woman with positive pregnancy
test, to determine whether ectopic or intrauterine pregnancy (IUP), and if IUP, whether viable; also better test if considering
ovarian hemorrhage or ovarian rupture or to work up woman with asymptomatic adnexal mass; if CT or MRI performed
first, and pelvic pathology found, go back and perform US (not necessary if lesion looks benign, patient heading
for surgery, lesion likely anatomic variant); if CT or MRI raises suspicion of cancer, follow-up US performed
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| Pelvic pain after pregnancy: problem if patient does not disclose recent abortion; acute pelvic pain after delivery usually
endometritis; if woman has acute pelvic pain after first or second trimester abortion, consider postabortal syndrome
(PAS), physiologic cramps, perforation of uterus, undiagnosed ectopic pregnancy, postabortal endometritis, or postmedical
abortion shock
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| Postpartum endometritis: tip-offs include infection in labor and cesarean delivery; pregnant women screened for
Group B Streptococcus at 36 wk gestation; increased risk due to—prolonged rupture of membranes, long labor, multiple
vaginal examinations in labor, scalp electrode on fetus, and manual placental extraction; presentation—not common
after vaginal deliveries (<5%); up to 25% to 33% in cesarean deliveries; usually starts before patient discharged, but can
present as late as 2 wk postpartum; symptoms—abdominal pain, constitutional symptoms (eg, fever, malaise, sweats,
chills), and frequently, purulent lochia; virtually all patients have uterine corpus tenderness, but adnexa usually nontender
(confined to uterus); if postpartum patient presents with lower abdominal pain and fever, postpartum endometritis becomes
diagnosis of exclusion; in postpartum woman with temperature >38°F, look for urinary tract infection, mastitis or
breast abscess, infected abdominal incision or episiotomy, or thrombophlebitis; management—use ring forceps to probe
uterine cavity gently to determine whether retained membranes or placental fragment present; dilate cervix as forceps
withdrawn (to ensure no blood collecting within endometrium) and drain appropriately; speaker does not culture endometrium;
treats empirically; consider using combination regimens for PID; clindamycin and gentamicin still used; if
patient not improving within 48 hr, ampicillin added to improve coverage for Group D Streptococcus (Enterococcus);
typically, clindamycin and gentamicin first-line therapy; if patient in hospital for 1 wk and not improving, septic pelvic
thrombophlebitis concern (add heparin); in emergency department (ED), patients with postpartum endometritis (“not that
sick”) treatable on outpatient basis; speaker uses oral fluoroquinolone and metronidazole for 14 days; other outpatient
regimen for PID includes initial dose of agent for Neisseria gonorrhoeae and 14-day course of doxycycline with or
without metronidazole; can also use ampicillin and clavulanic acid (Augmentin) as second-line therapy
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| Postabortal syndrome (PAS): uncommon; associated with performing abortion early with small (≈6 mm) cannula;
uterus fills with clots, internal cervical os blocked, and uterus unable to contract (atonic); the more atonic, the more
bleeding; presentation—as early as 1 hr and up to 7 days after abortion; symptoms—intense uterine cramps or abdominal
pain (one side may be worse than other); diaphoresis; lightheadedness; examination—uterus tender, tense, and enlarged;
treatment—evacuation of clot using manual aspirator or suction machine; methylergonovine for 2 days; uterine
bleeding may be more severe 3 to 5 days after abortion (due to lysis of clots), light for few days, then eases; on physical
examination, uterus firm and external os closed; US shows normal linear stripe (empty uterine cavity); treatment nonsteroidal
anti-inflammatory drugs, abdominal heat, rest, and time
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| Undetected perforation: causes pelvic pain after abortion; fairly uncommon; may cause delayed hemiperitoneum
(seen on US) or peritonitis; diagnostic laparoscopy if diagnosis uncertain
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| Postabortal endometritis: complication of abortion; incidence ≈3%; more likely with advanced gestational age at
time of abortion, if abortion done with local anesthesia, or if woman had gonorrhea or chlamydia at time of procedure;
whether infection by itself or whether retained products of conception (RPOC) present determines presentation; if uncomplicated
infection, uterus tender but firm, os closed, and abdominal signs absent; if RPOC present, uterus tender,
boggy, and enlarged, possibly with open os; pregnancy test not helpful; if uncomplicated infection, treat with any PID
regimen; if retained tissue present, treat with antibiotics and empty uterus
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| Postovulatory fertility control: woman who has unprotected intercourse near time of ovulation (day 14) can use emergency
contraception for up to 5 days or copper intrauterine device (IUD; ParaGard) up to 7 days; starting at day 35, can use
mifepristone (RU-486) and misoprostol (typically used between 35 and 49 days from LMP); traditional surgical abortion;
protocol for mifepristone and misoprostol—on first visit, counseling and pelvic US (to ensure eligibility); mifepristone;
second visit 2 days later, misoprostol given orally or vaginally; observation for 4 hr; bleeding for 1 to 2 wk; third visit follow-up
examination; fatal infection associated with medical abortion—4 reported cases (fifth in Canada), all in California;
all occurred within 1 wk of abortion; all had vaginal misoprostol; all women previously healthy; all had complete
uterine evacuation; all died very rapidly; all had evidence of bacterial infection with Clostridium sordellii (present with
highly elevated WBC counts, tachycardia, low blood pressure, hemoconcentration, and sometimes lung or abdominal effusion);
infections not related to mifepristone or misoprostol; rare occurrence (1 death/100,000 abortions); C sordellii—
gram-negative anaerobe; produces exotoxin that causes toxic shock; reported after vaginal deliveries, cesarean deliveries,
and spontaneous abortions; nonobstetric cases reported in men and women; maintain high index of suspicion in patient who
presents to ED postabortion with toxic shock-like syndrome, especially if myalgia, headache, and cramps present, with or
without fever; treat as toxic shock syndrome with fluid replacement and antibiotics; no data on value of antibiotic prophylaxis;
Planned Parenthood now forbids use of misoprostol administered vaginally, even though no cause-and-effect relationship
documented
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| Vaginal bleeding: normal—cycle length 25 to 35 days; menstrual flow, 20 to 80 mL; menorrhagia—prolonged duration
of menses or increased amount of bleeding; hypomenorrhea—shorter menses or less flow per day; patient’s perception
of amount of menstrual bleeding often different from actual blood loss; in patient with abnormal vaginal
bleeding—obtain history, physical examination, and pregnancy test; if pregnancy test positive, determine location of
pregnancy and gestational age; all vaginal bleeding in women of reproductive age pregnancy until proven otherwise
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| Abnormal vaginal bleeding: causes—structural problems (eg, fibroids, polyps); infections; hormonal problems (anovulation;
dysfunctional bleeding); peak and drop in estrogen and progesterone triggers normal menstrual cycle; if woman
anovulatory, either she has elevated estrogen levels (amenorrhea) or levels go up and down; drop in estrogen leads to estrogen
withdrawal bleeding (classic menometrorrhagia or heavy irregular bleeding); seen in any condition that causes anovulation
(eg, polycystic ovary syndrome [PCOS], prolactinomas); age-related (anovulatory cycles more likely to happen
around menarche and around menopause); obtain history and physical examination; laboratory tests include pregnancy test
and complete blood cell count (to determine whether patient anemic); also thyrotropin and prolactin; treatment—agent
that provides substitute luteal phase (progestin); medroxyprogesterone (eg, Provera) or micronized progesterone (eg,
Prometrium) for 10 days; bleeding usually stops after 3 days; if bleeding present for weeks, give combination of estrogen
and progestin (monophasic OCs given bid or tid for 1 wk; avoid tapering doses); if patient desires pregnancy, refer to obstetrician-gynecologist
to determine ovulation; if contraception desired, cycle with OCs, vaginal ring, or transdermal system;
if not interested in pregnancy or contraception, consider pharmacologic luteal phase every month (1st to 10th of every
calendar month)
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| Questions and answers: PAS after medical abortion—no case described; bleeding more gradual; treatment of incomplete
spontaneous abortion—rather than performing suction curettage, misoprostol given vaginally to cause intense
uterine cramps to extrude placental fragments; whether case of C sordellii seen after misoprostol alone (without
mifepristone)— none; cases reported only when combination used; misoprostol increasingly used to complete miscarriage;
inducing ovulation to help woman become pregnant—historical treatment clomiphene; new method, especially
in woman with PCOS, combination of clomiphene (given 5 days of every month) and metformin (850 mg bid daily);
combination more effective than either alone; in woman with PCOS—inherited insulin resistance and hyperinsulinemia
present (manifests as hirsutism and acne); treated with metformin (makes cycles regular, induces ovulation, and helps in
weight loss)
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Suggested Reading
Bracken H et al: Mifepristone followed in 24 hours to 48 hours by misoprostol for late first-trimester abortion. Obstet
Gynecol 109:895, 2007; Crossman SH: The challenge of pelvic inflammatory disease. Am Fam Physician 73:859,
2006; Erratum in: Am Fam Physician. Davidson KG et al: Ultrasonographic evaluation of the endometrium in postmenopausal
vaginal bleeding. Radiol Clin North Am 41:769, 2003; Erdahl KJ et al: Emergency contraception care. J
Fam Pract 55:1073, 2006; Fischer M et al: Fatal toxic shock syndrome associated with Clostridium sordellii after medical
abortion. N Engl J Med 353:2352, 2005; Guest J et al: Randomised controlled trial comparing efficacy of same day
administration of mifepristone and misoprostol for termination of pregnancy with the standard 36- to 48-hour protocol.
BJOG 112:1457, 2005; Havrilesky LJ et al: Predictors of clinical outcomes in the laparoscopic management of adnexal
masses. Obstet Gynecol 102:243, 2003; Hiller N et al: CT features of adnexal torsion. AJR Am J Roentgenol
189:124, 2007; Kaya D et al: MDCT findings of active bleeding from the ovarian cyst wall. AJR Am J Roentgenol
188:W392, 2007; Ma R: Emergency contraception is not just for the morning after. BMJ 333:756, 2006; Magann EF
et al: Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J 98:419, 2005;
Mar;105(3):673.Murray S et al: Septic shock after medical abortions with mifepristone (Mifeprex, RU 486) and misoprostol.
CMAJ 173:485, 2005; Webb EM et al: Adnexal mass with pelvic pain. Radiol Clin North Am 42:329, 2004;
Wiebe E et al: A fatal case of Clostridium sordellii septic shock syndrome associated with medical abortion. Obstet Gynecol
104:1142, 2004; Retraction in: Obstet Gynecol. 2005.
Educational Objectives
| The goal of this program is to improve the management of obstetric and gynecologic emergencies. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Describe the gynecologic and nongynecologic origins of pelvic pain.
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| 2. Differentiate between intra- and extracapsular ovarian hemorrhage, based on findings on examination.
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| 3. Utilize the appropriate test to confirm the cause of pelvic pain.
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| 4. Prescribe the appropriate antibiotic regimen to treat postpartum endometritis.
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| 5. Recognize the causes of abnormal vaginal bleeding.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members
to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgments
Dr. Policar was recorded at Topics in Emergency Medicine, held October 1-4, 2007, in San Francisco, CA, and sponsored
by the University of California, San Francisco, School of Medicine, Division of Emergency Medicine. The Audio-Digest
Foundation thanks Dr. Policar and the sponsor for their cooperation in the production of this program.
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