Obstetrics and Gynaecology Problems
Assume that any woman of childbearing age is pregnant until proven otherwise. Pregnancy up to the time of foetal viability (approx 23/40 weeks) is managed by gynaecology, after that by obstetrics.
PV bleed + abdo pain + shock = ruptured ectopic pregnancy
A ruptured ectopic pregnancy can bleed faster than blood can be replaced. Immediate surgery is necessary: ensure large bore intra-venous access, with minimal volume resuscitation (Chapter 3). Speculum examination allows exclusion of possible alternatives: ‘cervical shock’ (see below) or toxic shock syndrome (Chapter 38).
• Possible pregnancy, menstrual cycle including last normal menstrual period (LNMP);
• Previous pregnancies/miscarriages and Rhesus status, if known;
• Pain – site/nature and associations/radiation – shoulder tip suggests peritoneal irritation/onset rapid/slow;
• Bleeding/discharge – volume/nature;
• Sexual history including sexually transmitted infections (STIs);
• General symptoms, and those that might indicate other causes for abdominal pain, e.g. fever, bowel and urinary symptoms (Chapters 19 and 20).
Lower abdominal tenderness suggests a gynaecological cause for pain, but also consider other causes of abdominal pain, particularly appendicitis (Chapter 19) or bowel obstruction. Estimate fundal height in pregnancy.
Speculum and internal examination
A chaperone must always be present when performing internal examination. With speculum examination, take swabs first if necessary. In bleeding in early pregnancy, if the os is open, this indicates an ‘inevitable abortion’. If closed, it suggests a ‘threatened abortion’ or ectopic pregnancy. Manual examination allows assessment of pain on cervical movement – ‘cervical excitation’, which occurs in pelvic inflammatory disease (PID).
• Urinalysis, βhCG, STI swabs, ultrasound.
• Blood group if pregnancy possible.
• Quantitative βhCG according to local protocol.
• Ultrasound is sensitive for detecting the intrauterine gestational sac and is now an essential component of assessment of problems in early pregnancy. If there is no intrauterine sac and the quantitative βhCG is >1500 units it is assumed that there is an ectopic pregnancy. There is a small risk ( I with IVF) of heterotopic pregnancy – simultaneous ectopic and intrauterine pregnancy.
• A full bladder is essential for trans-abodominal ultrasound, providing a ‘window’ through which the pelvic organs are seen. Transvaginal ultrasound can detect a gestational sac at about 4–5 weeks, 1 week before it would be visible on abdominal ultrasound.
Bleeding in early pregnancy
Significant vaginal bleeding occurs in 20% of pregnancies, and of these, half will abort. Ultrasound is essential in the assessment of these patients. Possible diagnoses include the following.
• Ectopic pregnancy: Presents with abdominal pain and bleeding. A positive βhCG (quantitative >1500 units) and an empty uterus confirms the diagnosis. While ruptured ectopic pregnancy requires resuscitation and immediate surgery as described above, many patients with stable ectopic pregnancy are treated medically, pre-serving the fallopian tubes.
• Threatened abortion: mild pain, bleeding, closed cervical os: if intrauterine gestational sac seen, reassure as most settle.
• Inevitable abortion: ongoing pain and bleeding, open cervical os: refer.
• Missed abortion: the fetus dies but is not expelled: refer.
• Incomplete abortion: ongoing pain/bleeding but no sac: refer.
• Complete abortion: closed os, no sac on ultrasound, no ongoing symptoms: no further treatment necessary.
If diagnosis is uncertain and the quantitative βhCG is below 1500 units, the quantitative βhCG should be repeated 48 hours later – in normal pregnancy, levels should double within this time.
In all cases, consider anti-D immunoglobulin, provide information about support groups, and arrange outpatient follow-up.
Vomiting in mid pregnancy
Vomiting is common between weeks 6/40 and 16/40. Exclude alter-native causes, treat symptomatically with intravenous fluids and metoclopramide, and discharge with follow-up if otherwise well.
After ruling out pregnancy, this common symptom is treated with tranexamic acid and mefenamic acid, with GP review.
Pelvic inflammatory disease
Vaginal discharge, fever and pelvic pain, with cervical excitation on examination. Consider STIs – take swabs and arrange follow- up for contact tracing according to local protocol.
This sharp pain, localised to one side of the lower abdomen, results from rupture of the ovarian follicle during ovulation. After excluding pregnancy and more serious pathology (e.g. appendicitis), reassure and advise simple analgesia: paracetamol/NSAIDs.
Diagnoses not to miss
Products of conception in the cervical canal can provoke a very intense parasympathetic response, resulting in extreme bradycardia and shock. Removal of the tissue results in rapid resolution of the symptoms.
Many ovarian cysts are incidental findings on ultrasound and cause no symptoms. Ovarian torsion is rare, and may present with non-specific low/mid abdominal pain.
The triad of hypertension, proteinurea and oedema can occur from week 12/40 to the immediate postpartum period, but is most common in the third trimester. If untreated, this can progress to full eclampsia with seizures.
Magnesium is used to increase the seizure threshold, benzodi-azepines being relatively ineffective. The foetus should be monitored, and delivered at the earliest safe opportunity.
Auto-immunisation occurs if a significant amount of rhesus-positive foetal blood mixes with rhesus-negative maternal blood, causing foetal haemolysis in future pregnancies. Consider in abortion or trauma affecting a pregnant woman. A Kleihauer test detects foetal blood, but may miss small amounts. Anti-D immunoglobulin should be given according to local guidelines.
Bleeding in late pregnancy
Large amounts of blood may be lost, so large-bore cannulae are necessary. Urgent obstetric review is necessary.
• Placental abruption: bleeding occurs between the placenta and the uterine wall, jeopardising the foetus.
• Placenta praevia: the placenta extends over the cervical os, and bleeding may occur as the uterus enlarges.