1. GYNECOLOGIC EMERGENCIES

2. Ectopic pregnancy

3. The most common reason of peritoneal signs in gynecology
DEFINITION Ectopic pregnancy- implantation outside of the uterine cavity
The most common reason of peritoneal signs in gynecology

4. Frequency of ectopic pregnancy in Europe 1-2: 100

5. Types of ectopic pregnancy by location
Ampullary %
Isthmic % % „tubal pregnancy”
Fimbrial %
Interstitial %
Ovarian % (3% after ART)
Abdominal 1-2% (high mortality)
Cervical ,5%

6. Risk factors for ectopic pregnancy
(30-50%) Salpingitis; PID
(Chlamydia trachomatis!!!)
damage for such infection may retard the passage of the fertilized ovum through the tube to the endometrial cavity
Operations
surgery of fallopian tubes
plastic reconstruction of fallopian tubes
ART
ovarian stimulation
embryo transfer reflux
Previous ectopic pregnancy
Age 35-45

7. Risk factors for ectopic pregnancy
Contraception ???
Endometriosis
Congenital defects of fallopian tubes
Psychical spasm of fallopian tubes
Smoking
Multiparous women
Black and Hispanic women
Idiopatic

8. Symptoms of unrupted ectopic pregnancy
Very different - depends of location and development of ectopic pregnancy
Abdominal/pelvic pain- unilateral or bilateral; intermittent or constant
Amenorrhea
Pregnancy symptoms
Vaginal bleeding
Pregnancy test or  HCG

9. Gynecological examination
Adnexal tenderness
Cervical motion tenderness
Adnexal mass
Uterus- normal size (70%) or enlarged (30%)
Hemoperitoneum; convexity of cul-de-sac

10. Ectopic pregnancy Diagnosis
Pregnancy test - detects level of  HCG
(Human Chorionic Gonadotropin)
a) 5 days after conception – serum assays
b) 14 days after conception – urinary tests
 HCG < 10 mIU/ml – no pregnancy
 HCG > 25 mIU/ml – pregnancy
4-5 Hbd  HCG > 750 mIU/ml (or 1000 mIU/ml) and visible in USG
Early pregnancy- up to 6 weeks
Increasing of  HCG > 66% in 48 hours
Increasing of  HCG > 114% in 72 hours
Increasing of  HCG > 175% in 96 hours

11. Ectopic pregnancy Diagnosis
2. USG:
4-5 weeks of pregnancy- visible in USG
Enlarged size of fallopian tube
Empty uterine cavity
Large endometrium

12. Ectopic pregnancy Diagnosis
3. Progesterone (always with HCG and USG)
> 25ng/ml - normal pregnancy
< 5 ng/ml - ectopic pregnancy or obsolete pregnancy
4. high concentration of:
Estradiol; Il 6; Il 8; TNFα; creatine kinase

13. The most common symptom of ruptured ectopic pregnancy
Hemoperitoneum

14. Symptoms of ruptured ectopic pregnancy
Hypovolemic shock- a decrease in blood pressure and an increase in pulse
Syncope
Acute abdominal pain
Temperature > 37º C
Urge to defecate or urinary urge
Vomiting
Peritoneal signs- hemoperitoneum
Irritation of the diaphragm- shoulder pain

15. Differential Diagnosis of Ectopic Pregnancy
any woman of reproductive age with
acute pelvic or lower abdominal pain
abnormal bleeding
amenorrhea
complications of intrauterine pregnancy (complited or incomplited abortion)
acute or chronic salpingitis

16. Differential Diagnosis of Ectopic Pregnancy
Follicular or corpus luteum cyst rupture
Endometriosis
Adnexal torsion
Gastroenteritis
Appendecitis

17. Combined pregnancy (heterotopic pregnancy)
intrauterine and extrauterine gestations 1:
after ART
1: 100
approximately 1 in 3 of the intrauterine pregnancies are reproted as surviving

18. Managment of Ectopic Pregnancy
expectant treatment
pharmacotheraphy (Methotrexate)
surgery

19. Managment of Ectopic Pregnancy
„ expectant treatment”
Indications
low  HCG level
ectopic gestation < 4 cm in diameter
ampullary localization
no bleeding
no symptoms of rupture

20. Managment of Ectopic Pregnancy
Pharmacotheraphy
Methotrexate (folinic acid antagonist)
Indications
 HCG level < mIU/ml
ectopic gestation < 4cm in diameter
cervix, ovarium, intramural localization
for 20% of women 1 dose is enough

21. Managment of Ectopic Pregnancy „surgery”
Unruptured
Laparoscopy
salpingtomy
salpingectomy
Laparotomy- surgical techniques
Ruptured
- Laparoscopy
- Laparotomy- surgical techniques
- salpingectomy

22. Ectopic Pregnancy
Rh- negative mothers with ectopic pregnancy should recieve Rh immune globulin to prevent Rh sensitisation
risk of Rh sensitisation < 1%

23. Pelvic Inflammatory Disease
PID is a polymicrobal infection involving endogenous aerobes and anaerobes as well as sexually transmitted pathogens.

24. PID Variables that increase the incidence of PID: teenage years
multiple sexual partners
previous PID
intrauterine device (two months after insertion only)
uterine instrumentation

25. PID- etiology Chlamydia trachomatis Neisseria gonorrhoeae
Escherichia colli, Proteus, Klebsiella, Streptococcus- endogenous aerobes
Bacteroides, Peptostreptococcus, Peptococcus- endogenne anaerobes
Actinomyces israeli- IUCD

26. Chlamydia trachomatis (intracellular parasite)
Infection rates
20-40% of sexually active women have antibodies to Chlamydia
five times higher in women with three or more partners
four times higher in women using no contraception or nonbarrier methods
up to 20% has asymptomatic cervical infection

27. Chlamydia trachomatis (intracellular parasite)
Symptoms
subtle and nonspecific physical findings
mucopurulent cervicitis
acute urethritis
salpingitis
PID
Fitz-Hugh-Curtis syndrome (perihepatitis)
localized fibrosis with scarring of the liver and adjacent peritoneum

28. Chlamydia trachomatis (intracellular parasite)
Infertility and ectopic pregnancy
mild form of salpingitis with insidious symptoms
established infection remain active for many months
increasing tubal damage

29. Chlamydia trachomatis (intracellular parasite)
infection is suspected on clinical grounds
culture results (obtained after h) confirms the diagnosis
ELISA performed on cervical secretions
95% specificity
monoclonal fluorescent antibody test carried out on dried specimens
90% sensitivity; 95% specificity;

30. Neisseria gonorrhoeae (Gram-negative intracellular diploccocus)
Easy acquired – single encounter with infected partner leads to infection 80-90% of the time
First signs or symptoms of infection:
3-5 days after exposure, often mild
malodorous purulent discharge from the urethra, Skene`s duct, cervix, vagina or anus
„mucopus” – greenish or yellow discharge from the cervix
infection of the Bartholin`s gland
Fitz-Hugh-Curtis syndrome
15% of women with N. gonorrhoeae develop acute pelvic infection (PID)

31. Neisseria gonorrhoeae (Gram-negative intracellular diploccocus)
Laboratory diagnosis:
cultures obtained from the cervix, uretra, anus, pharynx
Thayer-Martin agar plates kept in
CO2-rich environment – 80-90% sensitivity

32. PID Hager’s criteria for diagnosing acute PID:
history of lower abdominal pain or tenderness
cervical motion tenderness and adnexal tenderness
(all necessary for diagnosis !)

33. PID Hager’s criteria for diagnosing acute PID: fever > 38°C
leukocytosis > WBC/mm3
culdocentesis fluid containing WBCs or bacteria
inflammatory mass on pelvic examination or USG
evidence of gonococcus or Chlamydia on cervical Gram’s stain
(one or more of the objective findings necessary for diagnosis !)

34. PID Clinical diagnosis of PID is often imprecise
white cell count above > 50% of patients
positive chlamydia cultures ~ 30% of patients
positive gonorrhea cultures ~ 25% of patients

35. PID Correct diagnosis in cases of misdiagnosis of PID
acute appendicitis 28% of cases
endometriosis 17% of cases
corpus luteum bleeding 12% of cases
ectopic pregnancy 11% of cases
adhesions 7% of cases
„other” % of cases

36. Indications for hospitalization
PID
Indications for hospitalization
presence of tuboovarian complex or abscess (TOA)
uncertain diagnosis
significant gastrointestinal symptoms
nulliparity
pregnancy

37. PID Recommendations for hospitalized patients cefoxitin 2g IV q6h
(no pelvic mass, IUD, recent history of pelvic instrumentation)
cefoxitin 2g IV q6h
cefotetan 2g IV q12h + doxycycline 100 mg q12h
regimen continued for at least 48 hours after the patient clinically improves

38. PID Recommendations for hospitalized patients
(pelvic mass, IUD, recent history of pelvic instrumentation)
clindamycin 900 mg IV q8h + gentamycin 2 mg/kg IV,
followed by gentamycin 1,5 mg/kg IV q8h
regimen continued for at least 48 hours after the patient clinically improves

39. PID Tests that should be also obtain:
Trichomonas vaginalis screening (wet preparat)
serology syphilis screening
HIV screening

40. PID
If outpatient treatment is used, the patient must be reexamined after 48 to 72 hours.
If the response for the treatment is suboptimal, the patient need to be hospitalized and intravenous antibiotics initiated.

41. PID Recomendation for outpatient therapy
cefoxitin 2g IM + probenecid 1g PO
ceftriaxon 250 mg IM + doxycycline 100 mg PO q12h for days
tetracycline 500 mg PO q6h for days
erythromycin 500 mg PO q6h for days

42. PID Laparoscopy - diagnosis of PID is in doubt
- the patient does not respond to medical therapy

43. Laparoscopic criteria for acute PID
minimum criteria
erythema of fallopian tubes
edema and swelling of fallopian tube
exudate from fimbria or on serosa of fallopian tube

44. PID Scoring mild: minimum criteria, tubes freely movable and patent
moderate: more marked , tubes not freely movable, patency uncertain
severe: inflammatory mass

45. PID Complications of PID formation of tuboovarian abscess (TOA)
ectopic pregnancy (rate seven to ten times normal)
infertility (rate increase proportional to the number of episodes of acute PID)
chronic pelvic pain (approximately 20%)
recurrent PID (approximately 25%)

46. Surgical treatment of PID (extirpation)
Ruptured TOAs,
TOAs that do not respond to medical therapy within 4 to 5 days
TOAs that results in chronic pain

47. PID Ectopic pregnancy Infertility Chronic pain Recurent PID
teenanger
multiple sexual partners
previous PID
IUD
uterin instrumentation
pain
pelvic tenderness
fever
mass
vaginal discharge
Ectopic
pregnancy
Infertility
Chronic
pain
Recurent PID
Discharge on
antibiotic
Response
Outpatient
treatment
Complications
PID
Antibiotic
Hospitalization
No response
Tuboovarian
abscess
WBC
Chlamydial culture
or antigen detection test
Gonorrhea culture
Syphilis wet prep., serology
HIV
USG
Laparoscopy
Operative
drainage

48. PID
Therapy of the symptomatic as well as asymptomatic male partners is an integral part of treatment PID.

49. PID use of mechanical contraceptives use of oral contraceptives
Variables that decreases the incidence of PID
use of mechanical contraceptives
use of oral contraceptives

50. Other causes of bleeding into the abdominal cavity
Rupture of follicular cyst
Corpus hemorrhagicum
Rupture of ovarian tumor
Postoperation bleeding

51. Adnexal torsion (10%) DEFINITION:
partial or complete rotation of the ovary, fallopian tube or both, on its vascular pedicle.

52. Adnexal torsion Etiology 50-60% - ovarian and/or adnexal mass
increased weight of the ovary
reduced venous return from the ovary

53. Adnexal torsion All ages, usually: women in their mid 20s
postmenopausal women
20% of cases of torsion occur during prgnancy

54. Symptoms – variable and nonspecific
Adnexal torsion
Symptoms – variable and nonspecific
- acute abdominal pain
nausea, vomiting
anorexia,
peritoneal signs
diarrhea
hypovolemic shock
½ of the patients have had a similar episode in the past
approximately ½ of the patients have a palpable mass

55. Adnexal torsion Sonography Colour Doppler
multiple peripheral cysts in an enlarged ovary – relatively specific
free pelvic fluid
adnexal cysts and tumors
Colour Doppler
shows whether the vascular flow is impaired:
absence of vascular flow is not specific for torsion
presence of vascular flow does not rule out torsion
(flow may be seconadry to the dual blood supply of the ovary or from venous thrombosis which causes symptoms before the loss of arterial flow)
CT, MRI

56. Adnexal torsion differental diagnosis
Based on clinical presentation:
appendicitis
intussusception
gastroenteritis
pyelonephritis
salpingititis
inflammatory bowel disease
Based on sonography:
hemorrhagic ovarian cyst
ovarian mass or neoplasm
parovarian cyst
pelvic inflammatory disease
abscess

57. Adnexal torsion management
surgery
oophoropexy (if the ovary is thougt to be viable during surgery)
preserves the ovary, reduces the incidence of reccurent torsion
also for contralateral ovary to prevent its subsequent torsion

58. Rupture of ovarian cyst (3%)
Bleeding into abdominal cavity
Symptoms
acute abdominal pain
peritoneal signs
hypovolemic shock

59. Diagnosis General examination Gynecological examination USG
Abdominal X- ray
Laboratory tests

60. Vaginal bleeding Injury- sexual intercorses Abortion Carcinoma
Cervical carcinoma
Endometrial carcinoma
Vaginal carcinoma
Myomas
Functional bleeding

61. Gynecological iatrogenic emergencies
Laparotomy
Laparoscopy
Other (D&C; HSG)

62. Laparoscopy, laparotomy – iatrogenic complications
Anesthesial complications
Postoperation bleeding
Mechanical obstruction
Paralytical obstruction
Peritonitis

63. Sepitic Pelvic Thrombophlebitis
Multiple bacteria infection
Septic thrombosis in vessels
Subseqent microembolisation in lungs or other organs by way of the inferior vena cava is possible
Symptoms: residual fever and tachycardia
Antibiotics and anticoagulation therapy is recommended for at least 7 and up to 30 days

64. thank you