Clinical Diagnosis and Management of Gynecologic Emergencies [1 ed.] 9780367443146, 9781003008910, 9781000281477, 1000281477, 0367443147

Citation preview

Clinical Diagnosis and Management of Gynecologic Emergencies

Clinical Diagnosis and Management of Gynecologic Emergencies

Edited by Botros Rizk, MD, MA, FRCOG, FRCS, HCLD, FACOG, FACS Medical Director, Elite IVF, Houston, Texas, USA President of the Middle East Fertility Society Formerly Professor and Head, Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology, University of South Alabama Mobile, Alabama, USA Adjunct Professor Department of Obstetrics and Gynecology, Cairo University Kasr Al-Aini Hospital, Cairo, Egypt Mostafa A. Borahay, MD, PhD Associate Professor of Gynecology and Obstetrics Director of Minimally Invasive Gynecologic Surgery Johns Hopkins Bayview Medical Center Baltimore, Maryland, USA Abdel Maguid Ramzy, MBBCh, MSc, MD Professor Formerly Head of Department of Obstetrics and Gynecology Cairo University Co-Founder, Senior Consultant, and Former Director Kasr Al-Aini Assisted Conception IVF Unit Cairo University, Egypt

First edition published 2021 by CRC Press 6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742 and by CRC Press 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN © 2021 Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, LLC This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not available on CCC please contact [email protected] Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. ISBN: 978-0-367-44314-6 (hbk) ISBN: 978-1-003-00891-0 (ebk) Typeset in Times by KnowledgeWorks Global Ltd.

Contents Contributors.............................................................................................................................................. vii

1. Gynecologic Emergencies: An Introduction................................................................................... 1 Dana N. Owens 2. Ectopic Pregnancy: Extrauterine Pregnancy and Pregnancy of Unknown Location............... 9 Peer Jansen and Ibrahim Alkatout 3. Interstitial, Cornual, and Angular Pregnancy............................................................................. 27 Nupur Tamhane and Emad Mikhail 4. Cervical Ectopic Pregnancy........................................................................................................... 35 Bassam H. Rimawi 5. Cesarean Section Scar Ectopic Pregnancy................................................................................... 45 Julio Ricardo Loret de Mola 6. Ovarian Ectopic Pregnancy........................................................................................................... 55 Weiwei Feng and Wei Jiang 7. Abdominal Ectopic Pregnancy...................................................................................................... 63 Weiwei Feng and Wei Jiang 8. Heterotopic Pregnancy................................................................................................................... 73 Aboubakr Elnashar 9. Pelvic Inflammatory Disease: An Underestimated Serious Health Problem............................ 81 Atef Darwish 10. Septic Abortion................................................................................................................................ 93 Bassam H. Rimawi 11. Toxic Shock Syndrome and Other Related Severe Infections...................................................101 Bassam H. Rimawi 12. Endometriosis.................................................................................................................................121 Ceana Nezhat, Pavan Ananth, and Dahlia Admon 13. Adnexal/Ovarian Torsion..............................................................................................................135 Hajra Takala, Mona Omar, and Ayman Al-Hendy 14. Hemorrhagic and Ruptured Ovarian Cysts and Acute Complications of Uterine Fibroids.........................................................................................................................151 Youssef Youssef and Mostafa A. Borahay

v

vi

Contents

15. Prediction and Management of Ovarian Hyperstimulation Syndrome...................................163 Mohamed A. Youssef, Abdel Maguid Ramzy, and Botros Rizk 16. Miscarriage.....................................................................................................................................179 Erich T. Wyckoff and Hadeer Usama Ebrahem Metwally 17. Pediatric Hematocolpos.................................................................................................................187 Omar M. Abuzeid and Mostafa I. Abuzeid 18. Vulvar and Vaginal Trauma and Bartholin Gland Disorders.................................................. 207 Malak El Sabeh and Mostafa A. Borahay Index........................................................................................................................................................215

Contributors Mostafa I. Abuzeid Reproductive Endocrinology and Infertility Department of Obstetrics and Gynecology Flint, Michigan and IVF Michigan Rochester Hills and Flint, PC Rochester Hills, Michigan Omar M. Abuzeid Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology and Reproductive Medicine Stony Brook University Hospital Long Island, New York Dahlia Admon Nezhat Medical Center Atlanta, Georgia Ayman Al-Hendy Department of Obstetrics and Gynecology University of Chicago Chicago, Illinois Ibrahim Alkatout Clinic for Obstetrics and Gynecology UKSH Campus Kiel Kiel, Germany Pavan Ananth Nezhat Medical Center Atlanta, Georgia

Malak El Sabeh Department of Gynecology and Obstetrics Johns Hopkins University Baltimore, Maryland Weiwei Feng Department of Obstetrics and Gynecology Ruijin Hospital and School of Medicine Shanghai Jiaotong University Shanghai, China Peer Jansen Clinic for Obstetrics and Gynecology UKSH Campus Kiel Kiel, Germany Wei Jiang Department of Gynecology, Obstetrics and Gynecology Fudan University Shanghai, China Julio Ricardo Loret de Mola Department of Obstetrics and Gynecology HSHS St. John’s Hospital Southern Illinois University Springfield, Illinois Hadeer Usama Ebrahem Metwally Department of Obstetrics and Gynecology University of Florida Gainesville, Florida

Atef Darwish Department of Obstetrics and Gynecology Assiut University Assiut, Egypt

Emad Mikhail Department of Obstetrics and Gynecology University of South Florida/Morsani College of Medicine Tampa, Florida

Aboubakr Elnashar Obstetrics and Gynecology Benha University Hospital Benha, Egypt

Ceana Nezhat Nezhat Medical Center Atlanta, Georgia

vii

viii Mona Omar University of Illinois College of Medicine Chicago, Illinois Dana N. Owens Advent Health Medical Group Advent Health Central Florida Division Orlando, Florida and Nova Southeastern University Fort Myers, Florida Bassam H. Rimawi Maternal-Fetal Medicine WakeMed Health and Hospitals Raleigh, North Carolina Hajra Takala University of Illinois College of Medicine Chicago, Illinois

Contributors Nupur Tamhane Department of Obstetrics and Gynecology University of South Florida/Morsani College of Medicine Tampa, Florida Erich T. Wyckoff Department of Obstetrics and Gynecology University of Florida Gainesville, Florida Mohamed A. Youssef Department of Obstetrics and Gynecology Cairo University Cairo, Egypt Youssef Youssef Hurley Medical Center Flint, Michigan

1 Gynecologic Emergencies: An Introduction Dana N. Owens

Introduction An emergency medical condition manifests itself by acute symptoms of sufficient severity that it is reasonably believed that, in the absence of immediate medical attention, it would result in any of the following: (1) serious jeopardy to the person’s health; (2) serious impairment of bodily functions; or (3) serious dysfunction of any bodily organ or part. An urgent medical condition, in contrast, is one that is non–life threatening but requires care within a timely manner, usually within 24 to 48 hours. Any urgent condition may progress to an emergent condition; therefore, accurate triage and evaluation are essential to guide appropriate treatment. Emergencies are unpredictable and can occur at any time, whether in the outpatient or the inpatient setting. Preparation for these emergent situations requires allocation of resources and supplies, planning, and collaboration [1]. Gynecologic emergencies are relatively common and include ectopic pregnancies, adnexal torsion, tubo-ovarian abscess, hemorrhagic ovarian cysts, gynecologic hemorrhage, and vulvovaginal trauma. With the evaluation of gynecologic emergencies, especially in women of reproductive age, a delay in proper diagnosis or improper management of the patient may compromise care, jeopardize future reproductive capabilities, put the patient at risk for sepsis, and/or subject the patient to severe hemorrhage and its associated consequences. Therefore, it is important that the clinician be able to triage the urgent versus emergent condition and to work up, evaluate, and treat the medical condition with a systematic approach. This applies to both the emergency physician who has initial contact with the patient and may need to stabilize the patient and the consultant gynecologist who may be asked to provide additional expertise for the care of the patient. If this is kept in mind, diagnostic failures should not occur, and proper management of similar presenting but less concerning gynecologic urgencies will be enhanced. One way of achieving this is by applying protocols and/or algorithms that allow the provider to distinguish among nongynecologic disorders, emergent and nonemergent gynecologic disorders, which will lead to rapid and efficient intervention. Standardized protocols that have been reviewed and are posted help the entire team or department streamline the workup of the acute patient. Every facility has a method to triage patients and has standard operating procedures which when adhered to that facilitate the safety and care of the patient. Conducting mock simulation drills in the acute care setting with both clinicians and staff will allow issues to be identified related to the physical environment, lack of resources, or common clinical errors made during emergencies [1]. Therefore, simulations may enhance adherence to protocols and allow for needed training. When providing immediate care to the gynecologic patient, several factors should be considered. The level of care of the treating facility is important in the stabilization and treatment of the gynecologic patient. Emergency departments are categorized into five levels of care. Level I is the highest level with immediate access to all surgical specialists and subspecialties to handle the most severe and complicated conditions. Level II facilities are usually present in medium- to large-sized hospitals with surgeons and anesthesia on 24-hour call with an intensive care unit staffed with emergency medicine physicians. Level III facilities may not have on-call surgeons daily but can handle most surgical problems within 24 hours. These facilities may not be staffed with emergency medicine specialists, but they are equipped to treat and stabilize sicker or more severely injured patients until a higher level of care can be provided. 1

2

Clinical Diagnosis and Management of Gynecologic Emergencies

For example, a level III facility may not be equipped to handle the needs of a patient with a ruptured ectopic pregnancy and hemoperitoneum. Level IV and V facilities are found mostly in rural areas and may not have a physician at all times and are intended to stabilize patients for transfer to another facility [2]. That lower-level facility will need to diagnose and stabilize the patient before transfer to a level I or II hospital for emergent intervention. Hence, the level of care of the treating facility may impact the ability to care for certain gynecologic emergent conditions. The ability to acquire the appropriate consultation of specialists is also dependent on the facility and the level of care. Providers at each level should be knowledgeable of resources and protocols, and should have training that prepares them and their staff for possible gynecologic emergencies. Several principles of medicine are needed for the emergency medicine clinician to be effective in evaluating and treating the emergent gynecologic patient. The first principle is taking a comprehensive medical history. This may be challenging and limited in some cases due to patient condition, need for translation, need for guardianship, and establishment of trust. The time allowed to establish trust is limited and can interfere with obtaining sensitive or personal information that may be needed from the patient. In the acute setting, this may be more apparent in the patient who has experienced sexual abuse or intimate partner abuse. The medical history for the gynecologic patient should include the following: all medical conditions, last menstrual cycle, sexual activity, prior sexually transmitted infection exposure or treatment, prior obstetrical history, recent and past surgical history, use of contraceptives (eg, intrauterine device in the patient with refractory pelvic inflammatory disease or tubo-ovarian abscess), and assessment of mental and emotional health. The latter is most significant in the setting of hemorrhage and spontaneous abortion. The institution should have access to a gynecologist for consultation. This will speed intervention as well as aid in counseling and reassuring the emotionally distraught patient. The ability of the clinician to quickly triage the patient, obtain a comprehensive history, and evaluate the patient while narrowing the differential diagnosis is especially important in the reproductiveage woman. This will help direct the clinician in his or her use of diagnostic testing and allow for a focused exam that may prevent delay in care. The physician or provider will need to perform a focused yet thorough examination. In most cases, this will allow for correct diagnosis and rapid intervention. For gynecologic “urgencies” and most emergencies, the exam can be done in a timely manner. Certain situations, however, can impede or postpone the exam, and the clinician should consider and be prepared for these situations. Because of the sensitivity of the exam and need to establish trust, consultation with a gynecologist may decrease any distress that may be caused during a gynecologic exam. Due to the nature of the examination, a chaperoned exam is mandatory to protect not only the provider but also the patient. This is especially prudent for the male clinician, who will require a female chaperone to be present during the exam. If a staff member is not available to assist in this role, this can cause a delay in assessment and treatment. The care of the adolescent or pediatric patient is another situation that requires certain guidelines and checks that may impede care. Examples include the ability to obtain consent, confidentiality, and guardianship [3]. It is important to plan for a designated area, the equipment and tools necessary to perform a thorough exam. In addition, the use of a pelvic bed with retractable stirrups and lighted speculums allows for better visualization of the perineum and internal tissues. Availability of appropriate testing swabs, kits, or materials to conduct necessary urine pregnancy tests, cervical cultures, or collection of tissue should be routinely monitored. Having the appropriate instruments to collect specimens may seem trivial, but in the acute setting, it may impact the ability to treat the patient effectively. Using disposable instruments as opposed to reusable instrumentation eliminates the need for processing and mitigates the possibility of contamination and transmission of disease. It also eliminates the need for an additional area for dirty and used supplies and training of staff to safely manage used equipment. With planning and organization, these logistical requirements should not be a hindrance to the evaluation and acute care of the female patient with a gynecologic issue. Imaging and laboratory diagnostics are essential components in the evaluation of the gynecologic patient. Providers should be aware of what imaging diagnostics (eg, computed tomography [CT], magnetic resonance imaging [MRI], or ultrasonography) are available in their facility because this may impact the care that can be administered in that facility. Ultrasonography is the imaging modality of choice for the obstetrician-gynecologist. Like surgery, ultrasonography is an operator-dependent technology. Having

Gynecologic Emergencies

3

sonographers who are competent and trained in the performance of obstetrical and gynecologic exams can only be achieved by supervised experience with a large variety of normal and abnormal examinations [4]. Gynecologic sonography has multiple uses, including evaluation of menstrual cycle and endometrial thickness and follicular development, determination of intrauterine pregnancy, localization of an intrauterine device, assessment of an adnexal or pelvic mass, evaluation for sequelae of pelvic infection, and identification of congenital uterine anomalies [4]. For most gynecologic emergencies, if the patient is stable, there is time to perform formal imaging to aid in diagnosis. If an obstetrician-gynecologist is immediately available for consultation, depending on their experience, they may perform a bedside rapid scan, which can provide more details and a diagnosis. Quick scans, or limited exams, can be performed by the emergency medicine physician to address specific focused questions when immediate impact on management is anticipated and when time or other constraints make performance of a standard examination impractical or unnecessary. An example would be a reproductive-aged woman who presents with hypotension, tachycardia, and peritoneal signs. A quick scan can identify free fluid and possible adnexal mass with no intrauterine pregnancy. Other imaging modalities such as CT and MRI are used frequently and help to narrow the differential diagnosis in the female patient because many symptoms may overlap between disease processes. When evaluating the pediatric or adolescent female, using MRI instead of CT has the advantage of decreased exposure to ionizing radiation [5]. Having a relationship with the radiology department is beneficial, especially in the acute setting. Interventional radiologists are a key group to work closely with because they are very familiar with normal pelvic arterial anatomy and have experience with embolization for pelvic trauma, in addition to experience with uterine fibroid embolization (UFE) [6]. In the setting of acute hemorrhage, if available, emergent embolization may be performed in the angiography suite and can stabilize the patient until further intervention can be obtained. Gynecologic conditions that may present emergently and may benefit from interventional radiology procedures include cervical ectopic pregnancies, uterine arteriovenous malformations, and large uterine fibroids [6]. In most cases, laboratory diagnostics are necessary to narrow down the differential diagnosis. A clear example is having the ability to perform a pregnancy test on a reproductive-aged female patient, which can exclude multiple diagnoses. It is essential for providers to know the capabilities of their facilities. Depending on the facility, immediate access to lab testing may not be available. Limiting factors for obtaining and processing lab data include the following: availability of staff to draw blood for testing, transportation of specimens (either by hand or tube system), capacity of the lab for processing specimens, and location of lab facilities. Not all hospitals have on-site laboratories; in some cases, the lab may be off campus or located in another city, which may interfere with collection and time to review the results. This can put the clinician and patient in a precarious position and can impact the care of the emergent patient. Although this is an extreme case, delays in testing or release of results can also occur in larger facilities due to high volume. These delays can have severe consequences for the reproductive-aged patient who may have a ruptured ovarian cyst versus a ruptured ectopic pregnancy, because not having access to pregnancy test results may change the type of intervention that takes place. To bypass this potential hazard, the ability to use point-of-care (POC) testing in the acute care setting can give rapid results that can guide diagnosis and initiation of treatment protocols without delaying care. Routine training of staff and maintenance of control testing for POC should be instituted and monitored. The ability to accurately interpret lab data and imaging studies in a timely manner will impact the timely care of the gynecologic patient. In emergent situations, communication and the exchange or handoff of information needs to be done in a clear and concise manner to help ensure expedient care. Communication and handoff failures are both common and hazardous and have been identified by The Joint Commission and the Department of Defense as a contributing cause of approximately two out of every three sentinel events—serious, often fatal preventable adverse events in hospitals [7]. The exchange of information may be in the form of a verbal or written handoff system during transitions of care. Transitions of care between providers occur during emergent situations where critical clinical information is transmitted. Poor transitions, especially in the emergent situation, lead to uncertainty during clinical decision making, which can then lead to harm (near misses) or serious clinical consequences [8]. The use of a standardized language or communication protocol during the verbal handoff of care helps to ensure transmission of consistent information

4

Clinical Diagnosis and Management of Gynecologic Emergencies

and allows for questioning. SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool that can be used to facilitate information transfer [8]. Use of another communication tool, the I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) tool, has been researched and validated, and I-PASS is the only model associated with improved patient care. The use of these tools combined with a check back (closed loop communication strategy to verify and validate the information exchanged) or call out (strategy used to communicate important or critical information) may be used to ensure closed loop communication [1]. Training of staff and clinicians in the use of these communication models using sender and receiver strategies allows for expeditious and optimized care. Excellent communication and teamwork will further increase the efficiency and effectiveness of the emergency response.

Special Considerations Adolescent and Pediatric Care: Confidentiality and Consent Adolescent and pediatric care, especially emergent gynecologic conditions, can pose challenges for both the emergency room (ER) physician and the obstetrics/gynecology generalist. Because of the frequency of emergent conditions in children, all care providers need to ensure that pediatric-specific resources are available to provide adequate care. This can include consultation with subspecialists, social workers, or in some cases, law enforcement. Having trained ER staff and physicians who can attain an accurate history, workup, and diagnosis will minimize any delay and decrease anxiety in this patient population. A systematic approach to the evaluation of the child that considers the child’s age, presence of specific signs and symptoms, and selected ancillary studies generally identifies patients who have conditions that require emergency diagnosis and specific intervention [5]. One example is abdominal pain, which is a frequent and nonspecific symptom in children for which it can be a challenge to distinguish self-limiting conditions such as gastroenteritis and constipation from certain gynecologic conditions. In postmenarchal girls with abdominal pain, a pregnancy test should be performed regardless of whether sexual activity is reported. Pelvic inflammatory disease or ruptured ectopic pregnancy may present with abdominal pain or peritoneal irritation. Therefore, the evaluation and exam are crucial and should be deliberate, with careful attention to the clinical features of the illness. Examination of the female child should be performed with coordination of the caregiver. In the adolescent or pediatric patient, using analgesia for certain circumstances (eg, straddle injuries) can help the physician perform the exam, and decrease the stress and trauma of the evaluation. Younger patients may be less distressed if examined while sitting on the caregiver’s lap. Techniques for examination of the vulva and perineum can be done with the child lying supine with the legs in the “frog leg” or “butterfly” position [9]. The knee-chest position is used for visualization of the vagina and is useful for evaluation of trauma or foreign body. Knowledge of anatomy and normal hymenal variants is a must for clinicians in order to identify abnormal findings. For adolescent females, an algorithmic approach must include diagnosis related to reproductive organ development and function [5]. Pelvic ultrasonography is the imaging modality of choice used to identify most gynecologic conditions and should be used as an adjunct to the exam in pediatric and adolescent patients. By applying the above techniques, evaluation with exam and diagnostic tools and consultation of specialists will expedite an accurate diagnosis and decrease the delay of care or possible loss of fertility in the adolescent or pediatric female. Confidentiality concerns are heightened during adolescence, and these concerns can be a critical barrier to adolescents in receiving appropriate health care. This can cause delay of care, especially in urgent or emergent situations. To address confidentiality concerns that might pose a barrier to care, all states and the District of Columbia have created minor consent laws giving minor adolescents the right to receive health care without parental consent or notification for certain service [3]. Health care providers and staff caring for minors should be actively educated regarding the confidentiality of services and be aware of federal and state laws that affect that confidentiality. State statutes on the rights of minors to consent to health care services vary by state, and health care providers should be familiar with the regulations that apply to their practice.

Gynecologic Emergencies

5

Overweight, Obese, and Morbidly Obese Patients Since 1975, worldwide obesity has nearly tripled. In 2016, more than 1.9 billion adults (39%) aged 18 years and older were overweight. Of these, over 650 million (13%) were obese [10]. For the obese gynecologic patient, an understanding of how weight affects different systems is important and can affect patient care, especially in emergent situations [11]. It is important to have resources in facilities for overweight patients, including imaging capabilities, appropriate tables with clear weight limits, and equipment such as bariatric ports, instruments, and energy sources. Preparing for and understanding the changes in anatomy as a result of obesity are necessary in prepping for surgical intervention. Understanding patient positioning and incision/port site placement is key for patient safety and successful outcomes. Considering other physiologic changes and having appropriate anesthesia support for airway management are critical, especially for patients undergoing laparoscopic procedures. Coordination of teams, including specialists, with established protocols for care will decrease any delay in the care of the overweight, obese, or morbidly obese patients, especially in emergent situations. Being prepared will improve patient safety and procedural outcomes.

Sexual Assault and Intimate Partner Violence Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States [12]. Intimate partner violence (IPV) is also a significant yet preventable public health problem that affects millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational background [13]. Obstetricians-gynecologists are in a unique position to assess, provide support to, evaluate, and manage sexual assault or IPV survivors because of the nature of the patient-physician relationship. Individuals should be screened routinely for history of sexual assault and IPV, and if a positive history is elicited, the individuals should receive appropriate, compassionate, and timely care [12, 13]. Ensuring the safety of the abused patient is the foremost goal, especially in the emergent situation. It is important to remember that the legal definitions of rape and sexual assault are used interchangeably and vary from state to state. In the emergent situation, it is important to have the appropriate resources available or have access to protocols in order to treat patients. Many hospitals have implemented programs to provide acute medical and evidentiary examinations for sexual assault victims using sexual assault nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs) [12]. In facilities that do not have trained individuals, the obstetrician-gynecologist may be the first point of contact for the evaluation and care of the patient. Clinicians who evaluate survivors of sexual assault in the acute phase must comply with certain medical and legal requirements. If performing an evidentiary exam, the clinician must comply with state and local statutory or policy requirements involving the use of evidence-gathering collection kits. Documentation of history, examination, photographs, labeling of evidence, and ensuring the chain of evidence are of utmost importance. For hospitals that do not have the trained staff or local resources available, there are detailed protocols available from the US Department of Justice’s Office of Violence Against Women [12]. Technical assistance and clinical guidance are also available for clinicians through the SAFE Technical Assistance program [12]. For emergency physicians and obstetrician-gynecologists, knowledge of the available resources at their facilities and having clear protocols for this patient population will improve patient outcome and overall care.

Coronavirus Disease 2019 (COVID-19) The Coronavirus disease 2019 (COVID-19) outbreak continues to challenge our nation. Expert projections estimate that, despite social distancing being practiced, we have yet to feel the full impact of COVID-19 [14]. The global pandemic has resulted in daily changes in the practice of medicine, and it is imperative that ER and obstetric and gynecologic clinicians be prepared and aware of changing data. Protocols and algorithms in the United States vary from state to state as well as between hospital systems. General overarching guidelines for using universal precautions and personal protective equipment (PPE) should be followed by both ER clinicians and specialists. In emergent situations that may require gynecologic surgical intervention, following local, state, and national guidelines for intraoperative care

6

Clinical Diagnosis and Management of Gynecologic Emergencies

is essential for the safety of the physician and patient. Per the American College of Surgeons, several principles are recommended for surgical cases. These include avoiding surgical cases at night, when possible, due to limited team staffing. Aerosol-generating procedures (AGPs) increase the risk to the health care worker but may not be avoidable. For patients who are or may be infected with COVID-19, AGPs should only be performed while wearing full PPE, including an N95 mask or powered air-purifying respirator that has been designed for the operating room. Examples of known and possible AGPs include those involving intubation, extubation, bag masking, bronchoscopy, chest tubes, electrocautery of blood, gastrointestinal tissue, any body fluids, laparoscopy, or endoscopy. To date, there are insufficient data to recommend for or against an open versus laparoscopic approach; however, the surgical team should choose an approach that minimizes operating room time and maximizes safety for both patients and health care staff [14]. In the acute care setting, clinicians anticipate that emergencies can happen at any time. Being prepared for the gynecologic emergency takes planning and interdisciplinary collaboration. Understanding the unique needs of the gynecologic patient requires a level of compassion and specific skill set that allow the clinician to illicit information, perform a workup, and administer timely care in the emergent setting. The Joint Commission expects certified hospitals to have adoption of evidence-based practice protocols, use of standardized team-oriented communication tools, and simulation to maximize a coordinated response to patient emergencies [15]. Standard protocols and a good working relationship between emergency clinicians and gynecologists will help facilitate the evaluation of the acute patient and minimize delay of care, especially in the reproductive-aged female. Additional chapters to follow will discuss specific workup and treatment of common gynecologic emergencies.

REFERENCES













1. Committee Opinion No. 590: Preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol [Internet]. 2014 Mar [cited 2020 Mar 1];123(3). Available from: https://journals.lww.com/ greenjournal/Fulltext/2014/03000/Committee_Opinion_No  590  Preparing_for_Clinical.44.aspx 2. American Trauma Society. Trauma care levels explained [Internet]. Falls Church, VA: ATS. [cited 2020 Mar 2]. Available from: https://www.amtrauma.org/page/traumalevels 3. Committee Opinion No. 599: Adolescent confidentiality and electronic health records. Obstet Gynecol [Internet]. 2014 May [cited 2020 Apr 27];123(5). Available from: https://journals.lww.com/greenjournal/Fulltext/2014/05000/Committee_Opinion_No  599  Adolescent.45.aspx 4. UpToDate. Overview of ultrasound examination in obstetrics and gynecology [Internet]. UpToDate. 2020 Apr [cited 2020 Mar 27]. Available from: https://www.uptodate.com/contents/overview-ofultrasound-examination-in-obstetrics-and-gynecology?search=Ultrasound%20examination%20 in&source=search_result&selectedTitle=1∼150&usage_type=default&display_rank=1 5. UpToDate. Emergency evaluation of the child with acute abdominal pain [Internet]. UpToDate. 2019 Aug [cited 2020 May 4]. Available from: https://www.uptodate.com/contents/emergencyevaluation-of-the-child-with-acute-abdominal-pain?search=emergency%20evaluation%20of%20 child%20with%20acute%20abdominal%20pain&source=search_result&selectedTitle=1∼150&usa ge_type=default&display_rank=1#H1 6. Josephs SC. Obstetric and gynecologic emergencies: A review of indications and interventional techniques. Semin Intervent Radiol [Internet]. 2008 Dec [cited 2020 Mar 1];25(4):337–346. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036527/ doi/pdf/10.1055/s-0028-1102992 7. I-PASS Study Group. About the I-PASS study group [Internet]. Boston, MA: Boston Children’s Hospital. 2014. [cited 2020 May 5]. Available from: http://ipassstudygroup.com/about 8. UpToDate. Patient handoffs [Internet]. UpToDate. 2017 Dec [cited 2020 Mar 27]. Available from: https://www.uptodate.com/contents/patient-handoffs?search=patient%20handoff&source=search_ result&selectedTitle=1∼10&usage_type=default&display_rank=1 9. UpToDate. Straddle injuries in children: Evaluation and management [Internet]. UpToDate. 2019 Mar [cited 2020 Apr 24]. Available from: https://www.uptodate.com/contents/straddleinjuries-inchildren-evaluation-and-management?search=straddle%20injuries%20in%20children&source=search_ result&selectedTitle=1∼19&usage_type=default&display_rank=1

Gynecologic Emergencies

7

10. World Health Organization. Obesity and overweight [Internet]. 2020 Apr [cited 2020 Apr 30]. Available from: https://www.who.int/newsroom/fact-sheets/detail/obesity-and-overweight 11. Williams J. The patient with morbid obesity. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide [Internet]. 9th ed. New York, NY: McGraw-Hill Education; 2020. [cited 2020 Apr 24]. Chapter 298. Available from: accessemergencymedicine.mhmedical.com/content.aspx?aid=1167031878 12. Committee Opinion No. 777: Sexual assault. Obstet Gynecol [Internet]. 2019 Apr [cited2020 Apr 27];133(4). Available from https://journals.lww.com/greenjournal/Fulltext/2019/04000/ACOG_ Committee_Opinion_No  777  Sexual_Assault.62.aspx 13. Committee Opinion No. 518: Intimate partner violence. Obstet Gynecol [Internet]. 2012 Feb [cited 2020 May 1];119(2). Available from: https://journals.lww.com/greenjournal/Fulltext/2012/02000/ Committee_Opinion_No  518   Intimate_Partner.51.aspx 14. American College of Surgeons. COVID-19: Elective case triage guidelines for surgical care [Internet]. Chicago, IL: American College of Surgeons. 2020 Mar [cited 2020 Apr 27]. Available from: https:// www.facs.org/covid-19/clinical-guidance/elective-case 15. McCue B, Fagnant R, Townsend A, et al. Definitions of obstetric and gynecologic hospitalists. Obstet Gynecol [Internet]. 2016 Feb [cited 2020 April 24];127(2). Available from: https://journals. lww.com/greenjournal/Fulltext/2016/02000/Definitions_of_Obstetric_and_Gynecologic.30.aspx doi/ pdf/10.1097/AOG.0000000000001235 Binz NM. Complications of gynecologic procedures. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide [Internet]. 9th ed. New York, NY: McGraw-Hill Education; 2020. [cited 2020 Apr 27]. Chapter 105. Available from: accessemergencymedicine.mhmedical.com/content.aspx?aid=1166591158 Crandall C, Alden SG. Intimate partner violence and abuse. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds, Tintinalli’s Emergency Medicine: A Comprehensive Study Guide [Internet]. 9th ed. New York, NY: McGraw-Hill Education; 2020. [cited 2020 Apr 24]. Chapter 294. Available from: accessemergencymedicine.mhmedical.com/content.aspx?aid=1167031592 UpToDate. Preparing an office practice for pediatric emergencies [Internet]. UpToDate. 2019 Jun [cited 2020 Mar 1]. Available from: https://www.uptodate.com/contents/preparing-anoffice-practice-forpediatric-emergencies?search=preparing%20an%20office%20practive%20for%20pediatric%20 emergencies&source=search_result&selectedTitle=1∼150&usage_type=default&display_rank=1

2 Ectopic Pregnancy: Extrauterine Pregnancy and Pregnancy of Unknown Location Peer Jansen and Ibrahim Alkatout

Definition Ectopic pregnancy is defined as the implantation of a fertilized oocyte outside the uterine cavity. It is a potential complication in the first trimester of pregnancy and used to be a common reason for maternal mortality in early pregnancy. The main reason for mortality was a ruptured vessel followed by heavy hemorrhage [1], in combination with a late or incorrect diagnosis. Currently, the mortality rate for ectopic pregnancies is about 0.05% [2–4]. According to other reports, ectopic pregnancy accounts for about 6% of pregnancy-related deaths [4, 5]. A late diagnosis or incorrect treatment may be associated with fairly high morbidity rates (11%) [6]. In the published literature, ectopic pregnancies are reported to account for 0.3% to 3% of all known pregnancies, and about 1% to 2% of all pregnant women experience an ectopic pregnancy [4, 7]. In Germany, ectopic pregnancies account for about 20 of every 1000 live births [8]. The incidence has been rising in the past few years. This may be due to better and more frequent diagnosis of the condition, fertility treatments, and increasing maternal age [4]. This chapter provides an overview of ectopic pregnancy, highlights the importance of its timely diagnosis, and addresses a variety of modern diagnostic and therapeutic options. The aims are to prevent late diagnosis, morbidity, or even mortality in women with ectopic pregnancies. The following abbreviations and terms are associated with ectopic pregnancy: • Intrauterine pregnancy (IUP): A gestational sac is seen in the intrauterine aspect on ultrasound, regardless of a yolk sac or embryo and regardless of viability. • Ectopic pregnancy (EP): A positive pregnancy test and extrauterine findings on ultrasound, such as adnexal mass or a gestational sac. • Pregnancy of unknown location (PUL): A descriptive term used for a woman with a positive pregnancy test but neither an IUP nor an EP on ultrasound. • Miscarriage/failed PUL: When the pregnancy test is positive but β-human chorionic gonadotropin (β-hCG) levels resolve without any intervention or the location of pregnancy cannot be found. Even modern ultrasound technology may not enable the clinician to establish the correct diagnosis at the first examination. Barnhart et al. [9] tried to find a common definition and suggested the following categories for the first ultrasound diagnosis: 1. Definite EP with an extrauterine gestational sac with a yolk sac and/or embryo 2. Probable EP with an nonspecific adnexal mass 3. PUL: no signs of either EP or IUP 4. Probable IUP with an intrauterine sac-like structure 5. Definitive IUP with an intrauterine gestational sac with a yolk sac and/or embryo 9

10

Clinical Diagnosis and Management of Gynecologic Emergencies

FIGURE 2.1  Pregnancy of unknown location (PUL) diagnoses: The route to the final diagnosis, as well as some diagnostic indications. It may be difficult to establish the correct diagnosis at the first investigation. However, with some delay, it should be possible to select the correct diagnosis from the other possible options [9]. (β-hCG, β-human chorionic gonadotropin; MTX, methotrexate.)

However, the authors also state that PUL is used for a preliminary classification and is not a final diagnosis and aimed to establish the ultimate diagnosis of IUP, EP, and spontaneous resolution of PUL [9]. Figure 2.1 shows the three possible final diagnoses with their definitions, starting with a PUL as the first step. An EP may be located at several sites, but 97% of them are found in the fallopian tubes. Even in the tube, the position may differ between the ampulla (75%), the isthmus (20%), and the infundibulum of the uterine tube (5%) (Table 2.1) [3]. One explanation for this phenomenon might be that the tube becomes increasingly narrow from the ampullary portion to the isthmus. Furthermore, the ampulla of the uterine tube is the most distal portion; ascending infection may cause phimosis. Another possibility is that the pregnancy may settle in the interstitium of the tubal tissue. The remaining 3% of EPs are mainly divided between the ovaries (1%) and the abdominal or pelvic cavity (1%). Because ovarian and abdominal/pelvic pregnancies are quite rare, the body of clinical experience in this regard is rather limited. Their diagnosis and treatment are difficult. Quite frequently, ovarian and abdominal/pelvic pregnancies are misdiagnosed as ruptured tubal pregnancies or hemorrhagic ovarian cysts. The correct diagnosis is frequently made during surgery and then confirmed by the pathology report [10]. However, an adnexal finding from transvaginal ultrasound (TVU) may be treated as an ovarian pregnancy before surgery and then prove to be a mere corpus luteum after surgery.

TABLE 2.1 Locations of Ectopic Pregnancies and Their Distribution in Percentages Fallopian tube Ovaries Abdominal/pelvic cavity Unusual position: uterine cervix, rudimentary uterine horn, scar after cesarean section, vagina, or a bilateral tubal ectopic pregnancy

97% (ampulla [75%], isthmus [20%], infundibulum [5%]) 1% 1% 1%

11

Ectopic Pregnancy

A rare but rather dangerous site of an EP is the uterine scar of a previous cesarean section. The trophoblast invades the myometrium at the site of the scar and may cause a rupture of the uterus. An EP at the site of a previous cesarean section is reported to account for about 6% of all EPs [11]. However, the frequency of this condition has been rapidly increasing in the past few years because cesarean sections are increasingly being performed and diagnostic methods based on TVU have been improved. Risk factors associated with this rare position of an EP are trauma to the myometrium caused by curettage, cesarean section, myomectomy, inflammatory pelvic disease, reproductive medicine, or a previous placental pathology [11, 12]. Given the increasing frequency of cesarean sections throughout the world [13], EPs at this location may occur even more frequently in the future. A few other rare locations have been reported for EPs. These include the cervix, the rudimentary uterine horn, and the vagina. A bilateral tubal EP is also possible [3]. Heterotopic pregnancies are defined as the simultaneous presence of one physiologic pregnancy in the uterine cavity and a second EP. EPs can cause an acute abdomen, which may develop into a hazardous condition for the patient.

Etiology The causes of EPs are manifold. The most common cause is a mechanical obstruction of the uterine tube caused by infection [14] (chlamydia, gonorrhea, salpingitis), anatomic abnormalities, or disrupted transport. An infection is liable to cause adhesions and stenosis in the entire tube and even in the pelvis around the ampullary region. Infections may also affect the movement of the tubal cilia; this may slow down or hinder the transport of the oocyte. However, because a sperm is much smaller than an oocyte and can move on its own, a pregnancy in the distal portion of the tube or the abdominal cavity is still possible. Further significant risk factors for a tubal pregnancy are prior EPs or surgery in the uterine tubes (cesarean section, sterilization, fertility surgery) (Table 2.2) [15]. Risk factors also include endometriosis, fertility treatment, intrauterine devices, prior appendicitis, abdominal surgery, and smoking [16]. However, approximately 50% of women with EPs have no risk factors [17].

Pathophysiology The oocyte and the sperm usually meet in the ampullary portion of the tube, where impregnation takes place. The growing morula is transported by cilia activity toward the uterine cavity while differentiating into the embryoblast and the trophoblast. The trophoblast grows invasively into maternal tissue, and implantation in the uterine cavity usually takes place on day 6 or 7 after conception. Specialized enzymes are found in the area of implantation. The trophoblast cannot differentiate between intrauterine and extrauterine location. Thus, the same process of implantation occurs at any site. The changes that

TABLE 2.2 Risk Factors for Ectopic Pregnancy High risk

Low risk

Mechanical obstruction caused by sexually transmitted infection, anatomic abnormality, tubal ligation, myoma, pelvic inflammation Prior ectopic pregnancy Surgery on the fallopian tube Endometriosis, fertility treatment, intrauterine devices, prior appendicitis, abdominal surgery, and smoking

12

Clinical Diagnosis and Management of Gynecologic Emergencies

occur in the beginning of an EP are the same as those in an IUP. The patient is amenorrhoeic, the hormone balance changes, and biochemical pregnancy tests are positive. However, the patient has no further symptoms. For some time, the pregnancy progresses quite normally. It then culminates in an abortion in the tube, and the trophoblast dissolves from the tube wall. The abortion is mainly induced by an insufficient supply of blood and nutrients. Bleeding occurs at the site of implantation. The bleeding may cause a hematosalpinx and free fluid in the abdominal cavity. By tube contractions, the aborted tissue can be delivered into the uterine cavity as well as the abdominal cavity. The abortion causes hormone levels to fall. The battered decidua is seen as extrauterine spotting or vaginal bleeding. If the pregnancy is located in the interstitium of the tube wall and continues to grow, it may culminate in a rupture of the tube. If the pregnancy is located in the isthmus of the tube, the rupture may damage the ovarian artery, and this may result in heavy intra-abdominal bleeding. Therefore, EPs are a part of the acute abdomen. In this emergency setting, the correct diagnosis should be established as early as possible. Even today, this condition is liable to cause maternal mortality. If the oocyte does not leave the ovary after ovulation and a spermatozoon inseminates the oocyte, the result is an ovarian pregnancy. The inseminated oocyte may also leave the ovary and not reach the tube. It then remains in the abdominal or pelvic cavity, resulting in an abdominal/pelvic pregnancy.

Symptoms The symptoms of an EP can be diverse and are frequently nonspecific. Typically, the symptoms lead to the correct diagnosis of an EP between the sixth and ninth week of gestation [4]. The EP starts with an amenorrheic phase of 6 to 8 weeks, caused by higher levels of progesterone produced by the corpus luteum. The higher levels of progesterone preserve the condition of the endometrium. The corpus luteum perishes after a few weeks and the EP is unable to produce enough progesterone on its own. The hormone cycle starts changing. Progesterone levels begin to decline. The endometrium begins to break down, and vaginal spotting occurs. Shortly before or at the start of spotting, the EP will have achieved its maximum size. Sometimes the growing size of the EP induces peritoneal irritation by distension, which may cause diffuse pain in the lower abdomen. The pain may intensify in some cases, and the patient reports with an abdominal emergency.

An Ectopic Pregnancy Is Marked by Three Consecutive Stages Stage I: Asymptomatic. An EP is marked by the same manifestations as an IUP, such as tenderness of the breasts, emesis, and fatigue. Laboratory tests reveal increasing β-hCG levels. Ultrasound does not show an intrauterine amniotic sac, but the latter may be in the tube. Stage II: Beginning symptoms. In case of a tubal abortion, the trophoblast dissolves from the tube wall and a hematosalpinx starts to develop after 6 to 8 weeks with secondary amenorrhea. Sometimes, this can be painful on abdominal palpation. The patient may experience attacks of pain for several days or weeks, usually on one side of the lower abdomen. The pain is caused by a dilatated tube and contractions of the tube. The spotting is now permanent or becomes stronger and is comparable with menstrual bleeding. It is caused by a battered decidua due to decreasing progesterone levels. In this stage, there might be a tenderness on vaginal examination due to passive movement of the adnexa during displacement of the vaginal portion of the cervix. The tenderness will most likely resolve when the abortion has occurred and parts of the aborted tissue or clots have moved toward the uterus.

13

Ectopic Pregnancy Stage III: Acute. Bleeding after the abortion at least drains in part into the abdominal cavity. The patient experiences peritoneal irritation and muscular defense of the abdomen during palpation. Vaginal bleeding becomes more severe and may even start to clot. Vaginal examination will now reveal a retrouterine hematocele, and the patient feels a distinct tenderness on cervical motion. During abdominal palpation, a distended tube and a peritubal hematoma may be felt.

Note that aggravation of the symptoms is indicative of a transition to an acute abdomen and calls for urgent intervention. In case of a tube rupture, which usually occurs only if the EP is located in the isthmus of the fallopian tube, stage I and II are skipped and the symptoms occur immediately. The symptoms might be similar to those of shock, such as tearing pain, cold sweat, a sensation of weakness, collapse, and dyspnea. The patient may experience heavy intra-abdominal bleeding. The abdomen is then very sensitive to pressure. A vaginal examination in this situation is usually not tolerated by the patient.

Differential Diagnosis The differential diagnoses include the following conditions: early IUP, abortion/miscarriage, corpus luteum (ruptured), tubo-ovarian abscess/infection, hydro-/pyo-/hematosalpinx, ovarian hyperstimulation syndrome, appendicitis, or adnexal tumor (causing peritoneal irritation) (Table 2.3). All of these conditions cause the same or similar clinical symptoms, but only the early IUP would show a positive pregnancy test, although a simultaneous pregnancy may well be possible.

Diagnosis Ascertaining the patient’s medical history is the first step of the diagnostic procedure. The clinician could inquire about risk factors such as previous surgeries, pregnancies, gynecologic diseases such as infection, fertility treatment, and prior EP. Secondary amenorrhea (6–8 weeks) is a sign of EP, but intermenstrual bleeding should also be taken into account. Medical history taking is followed by the clinical

TABLE 2.3 Differential Diagnoses for Ectopic Pregnancy Gynecologic origin

Other origin

Early intrauterine pregnancy Abortion/miscarriage Corpus luteum (ruptured) Tubo-ovarian abscess/infection Hydro-/pyo-/hematosalpinx Ovarian hyperstimulation syndrome Adnexal tumor (causing peritoneal irritation) Appendicitis Cystitis, pyelonephritis, nephrolithiasis Intra-abdominal inflammation (peritoneum, all abdominal organs, diverticulum) Perforation/obstruction of hollow organs (eg, stomach, bowel, gallbladder) Intra-abdominal inflammation (peritoneum, all abdominal organs, diverticulum) Vascular hemorrhagic disease (aorta, all abdominal vessels) Vascular ischemic disease (bowel, mesentery)

14

Clinical Diagnosis and Management of Gynecologic Emergencies

examination. The clinician might note spotting from the cervix. The patient may feel cervical motion tenderness, and abdominal palpation might be painful on one side, accompanied by muscular defense. The examiner may palpate a doughy tumor in the region of the adnexa. It would be meaningful to perform a pregnancy test on the patient’s urine and a blood test to determine β-hCG levels in serum. β-hCG rises 10 to 14 days after conception and doubles every 2 days in the first 6 weeks p.m. (Post menstruationem) in the case of a physiologic IUP [18, 19]. The increase is less pronounced later. In general, β-hCG levels are lower in an EP than in an IUP. The course of β-hCG levels is more important than the absolute β-hCG level. However, it should be noted that the course of about 20% of EPs is similar to that of IUPs, and about 10% resemble an early miscarriage. Thus, a reliable diagnosis cannot be made based on blood tests alone [20]. We do know that an EP is associated with a rise in β-hCG levels by no more than 66% or a fall of no more than 15% within 48 hours [21]. If the patient’s β-hCG levels proceed in this range and exceed 1500 IU/L, an ultrasound investigation should provide the final evidence. If no IUP can be found in a patient with β-hCG levels >1500 IU/L, the sensitivity of the diagnosis of an EP is 92% and its specificity 84%. In the presence of β-hCG levels of 1000 to 1500 IU/L, the clinician would find an embryo or yolk sac in the uterine cavity if the patient has an IUP. In a patient with β-hCG levels 90% [23]. A meta-analysis revealed that the β-hCG ratio is the best diagnostic tool to determine a PUL [20]. In addition to the unusual rise in β-hCG levels compared to those in IUPs, an EP can be differentiated from a spontaneous abortion by a slower decrease in β-hCG serum titers [19, 24, 25]. Progesterone levels should be checked in the blood test. An EP is unlikely in the presence of progesterone levels in excess of 20 to 25 mg/mL. This value is indicative of an IUP. Progesterone levels 5000 IU/L β-hCG 2 weeks after an ultrasound that showed a gestational sac without a yolk sac, or absence of an embryo with heartbeat >11 days after an ultrasound that showed a gestational sac with a yolk sac (see the full list in Doubilet et al. [10]). Even though these are diagnostic ultrasonic findings of nonviable pregnancy, there still remain several findings that are suspicious of a nonviable pregnancy but are not diagnostic. If any of these criteria are found, further investigation must be performed in order to rule out the possibility of a normally developing pregnancy. Recurrent pregnancy loss is traditionally defined as three or more consecutive spontaneous abortions and is beyond the scope of this chapter.

Pregnancy of Unknown Location In a normal viable pregnancy, the β-hCG level should increase by at least 30% every 48 hours. In patients with abnormal gestation or ectopic pregnancy, the β-hCG level would be slowly rising, plateauing, or dropping [1]. An intrauterine pregnancy can be first be visualized via transvaginal ultrasound at a β-hCG level of 1500 to 3000 mIU/mL; this is known as the discriminatory zone, or the level of β-hCG that one should see an intrauterine gestation if one exists [10]. If no intrauterine pregnancy is found at this level of β-hCG and no evidence of ectopic pregnancy is found, hemodynamically stable patients should undergo a follow-up β-hCG and ultrasound in order to further evaluate a pregnancy of unknown location.

Ectopic Pregnancy An ectopic pregnancy is an implanted embryo outside of the uterus and is most commonly located in the ampulla of the fallopian tube [11]. According to ACOG, these account for 2% of all pregnancies and cause about 2.7% of all pregnancy-related deaths if rupture occurs [11]. Often, the β-hCG is trended and a plateauing pattern is found. In addition, often an adnexal mass is noted on transvaginal ultrasound, which aids in the diagnosis of an ectopic pregnancy [11].

182

Clinical Diagnosis and Management of Gynecologic Emergencies

Multiple Gestations Miscarriage of a twin pregnancy is more commonly referred to as vanishing twin syndrome. It occurs when a twin gestation pregnancy is spontaneously reduced to one remaining viable fetus.

Molar Pregnancy Molar pregnancies are defined as abnormalities of placental origin. These can become invasive and malignant if not diagnosed properly. They are occasionally characterized by extremely elevated β-hCG levels usually >100,000 mIU/mL and often a heterogeneous collection inside the uterus. The evaluation and management of molar pregnancies are beyond the scope of this chapter.

Management The shift in early diagnosis has enabled women to process their diagnosis and reflect on their management options in nonemergent clinical scenarios. Furthermore, this has challenged physicians to integrate patient needs, goals, and preferences into a shared decision-making framework to better counsel and meet the needs of women [5]. It is normal for patients to experience a wide range of emotions after miscarriage. Some may blame themselves. It is important to offer patients reassurance and aim to assist in emotional support whenever feasible. All patients who experience miscarriage who are Rh negative should receive RhoGAM to prevent Rh isoimmunization. Treatment options are determined based on the patient’s clinical presentation, patient preferences, and risk versus benefits discussion. A complete abortion does not normally require additional treatment after evaluation for the administration of RhoGAM. Inevitable, missed, or incomplete abortion requires management and monitoring to ensure complete evacuation of the uterine contents [2]. The three main categories of treatment are as follows: expectant, medical, or surgical management. Medications such as β-hCG, vitamin supplementation, uterine muscle relaxants, and Chinese herbal medicine are not supported for use by evidence-based medicine [12, 13]. Vaginal progesterone supplementation is not associated with reduced miscarriage risk or improved live birth rates among women with threatened miscarriage [14]. Bed rest is commonly recommended, but randomized trials have not found that bed rest at home or in the hospital is beneficial in preventing fetal loss [15]. Recommendations for abstinence from sexual intercourse and physical exertion also have no data to support decreased risk of miscarriage. Although the risk of alloimmunization is low in first-trimester pregnancy loss, ACOG advises consideration of Rh(D) immune globulin. Women who undergo surgical evacuation should receive immune globulin because of the higher risk of alloimmunization resulting from the procedure [2]; the standard dose of Rh(D) immune globin is 300 µg intramuscularly, ideally administered within 72 hours of surgery.

Expectant Management Expectant management is the likely choice for patients who wish to avoid surgical instrumentation or have reservations regarding surgery in general. However, when compared to medical management, the risk of progression to surgical management is higher, at 44% versus 13%, in women with spontaneous abortion at 2 cm. For smaller lesions, warm compresses and sitz baths may be attempted. An empiric antibiotic that has MRSA coverage should be prescribed because of the high prevalence of MRSA infections [34]. Pain out of proportion to the physical exam findings should raise the suspicion for necrotizing fasciitis and should prompt immediate management because it is a life-threatening infection. Risk factors for necrotizing gangrene include immunocompromised state, diabetes mellitus, cancer, vascular disease, HIV infection, and alcohol abuse [35]. Symptoms begin insidiously with mild discomfort that evolves to include swelling, pain, fever, chills, and, in some cases, crepitation. Infections include the vulva and can spread to the perineum. Isolated organisms can vary, and in most cases, the infection is polymicrobial. Management includes ensuring hemodynamic stability, providing prompt systemic antimicrobial therapy, and surgical debridement followed by reconstruction surgery, if possible.

212

Clinical Diagnosis and Management of Gynecologic Emergencies

REFERENCES





1. Albers L, Garcia J, Renfrew M, McCandlish R, Elbourne D. Distribution of genital tract trauma in childbirth and related postnatal pain. Birth. 1999;26(1):11–7. 2. Hordnes K, Bergsjo P. Severe lacerations after childbirth. Acta Obstet Gynecol Scand. 1993;72(6):413–22. 3. Mirza FG, Gaddipati S. Obstetric emergencies. Semin Perinatol. 2009;33(2):97–103. 4. Rani S, Verma M, Pandher DK, Takkar N, Huria A. Risk factors and incidence of puerperal genital haematomas. J Clin Diagn Res. 2017;11(5):QC01–QC3. 5. Perlman SE, Hertweck SP, Wolfe WM. Water-ski douche injury in a premenarcheal female. Pediatrics. 1995;96(4 Pt 1):782–3. 6. Berkenbaum C, Balu L, Sauvat F, Montbrun A, Harper L. Severe vaginal laceration in a 5-year-old girl caused by sudden hydro-distention. J Pediatr Adolesc Gynecol. 2013;26(6):e131–2. 7. Niv J, Lessing JB, Hartuv J, Peyser MR. Vaginal injury resulting from sliding down a water chute. Am J Obstet Gynecol. 1992;166(3):930–1. 8. Lacy J, Brennand E, Ornstein M, Allen L. Vaginal laceration from a high-pressure water jet in a prepubescent girl. Pediatr Emerg Care. 2007;23(2):112–4. 9. Lopez HN, Focseneanu MA, Merritt DF. Genital injuries acute evaluation and management. Best Pract Res Clin Obstet Gynaecol. 2018;48:28–39. 10. Lincoln C, Perera R, Jacobs I, Ward A. Macroscopically detected female genital injury after consensual and non-consensual vaginal penetration: A prospective comparison study. J Forensic Leg Med. 2013;20(7):884–901. 11. Bechtel K, Santucci K, Walsh S. Hematoma of the labia majora in an adolescent girl. Pediatr Emerg Care. 2007;23(6):407–8. 12. Weiler-Mithoff EM, Hassall ME, Burd DA. Burns of the female genitalia and perineum. Burns. 1996;22(5):390–5. 13. Tresh A, Baradaran N, Gaither TW, Fergus KB, Liaw A, Balakrishnan A, et al. Genital burns in the United States: Disproportionate prevalence in the pediatric population. Burns. 2018;44(5):1366–71. 14. Harpole BG, Wibbenmeyer LA, Erickson BA. Genital burns in the national burn repository: Incidence, etiology, and impact on morbidity and mortality. Urology. 2014;83(2):298–302. 15. Birdsell DC, Mattatall F, Rosengarten AM, Watson SD. Vulvar burn: A complication of hysteroscopic endometrial ablation. J Obstet Gynaecol Can. 2010;32(11):1021. 16. Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol. 2006;23(4):311–20. 17. Meneux E, Paniel BJ, Pouget F, Revuz J, Roujeau JC, Wolkenstein P. Vulvovaginal sequelae in toxic epidermal necrolysis. J Reprod Med. 1997;42(3):153–6. 18. Boyraz G, Basaran D, Salman MC, Ozgul N, Yuce K. Vaginal reconstruction for vaginal obliteration secondary to Stevens Johnson syndrome: A case report and review of literature. Oman Med J. 2017;32(5):436–9. 19. Berg RC, Underland V, Odgaard-Jensen J, Fretheim A, Vist GE. Effects of female genital cutting on physical health outcomes: A systematic review and meta-analysis. BMJ Open. 2014;4(11):e006316. 20. Berg RC, Underland V. Immediate health consequences of female genital mutilation/cutting (FGM/C). NIPH Systematic Reviews: Executive Summaries. Oslo, Norway, 2014. 21. Guerriero S, Ajossa S, Bargellini R, Amucano G, Marongiu D, Melis GB. Puerperal vulvovaginal hematoma: Sonographic findings with MRI correlation. J Clin Ultrasound. 2004;32(8):415–8. 22. McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88(2):265–83, vi. 23. Perkins JD, Morris PF. Traumatic vulvar hematoma masquerading as a Bartholin duct cyst in a postmenopausal woman. J Miss State Med Assoc. 2013;54(1):8–10. 24. Mok-Lin EY, Laufer MR. Management of vulvar hematomas: Use of a Word catheter. J Pediatr Adolesc Gynecol. 2009;22(5):e156–8. 25. Villella J, Garry D, Levine G, Glanz S, Figueroa R, Maulik D. Postpartum angiographic embolization for vulvovaginal hematoma. A report of two cases. J Reprod Med. 2001;46(1):65–7. 26. Jones IS, O’Connor A. Non-obstetric vulval trauma. Emerg Med Australas. 2013;25(1):36–9. 27. Sachs CJ, Thomas B. Sexual Assault Infectious Disease Prophylaxis. Treasure Island, FL: StatPearls; 2019.

Genital Trauma and Bartholin Gland Disorders

213

28. Ching JA, Kuykendall LV, Troy JS, Smith DJ Jr. Estrogen treatment of acetic acid burns to the vagina, cervix, and perineum: A case report and review of the literature. J Burn Care Res. 2014;35(5):e368–71. 29. Niemeijer IC, van Praag MC, van Gemund N. Relevance and consequences of erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis in gynecology. Arch Gynecol Obstet. 2009;280(5):851–4. 30. Marzano DA, Haefner HK. The Bartholin gland cyst: Past, present, and future. J Low Genit Tract Dis. 2004;8(3):195–204. 31. Lee WA, Wittler M. Bartholin Gland Cyst. Treasure Island, FL: StatPearls; 2019. 32. Wechter ME, Wu JM, Marzano D, Haefner H. Management of Bartholin duct cysts and abscesses: A systematic review. Obstet Gynecol Surv. 2009;64(6):395–404. 33. Kilpatrick CC, Alagkiozidis I, Orejuela FJ, Chohan L, Hollier LM. Factors complicating surgical management of the vulvar abscess. J Reprod Med. 2010;55(3–4):139–42. 34. Sand FL, Thomsen SF. Skin diseases of the vulva: Infectious diseases. J Obstet Gynaecol. 2017;37(7):840–8. 35. Cabrera H, Skoczdopole L, Marini M, Della Giovanna P, Saponaro A, Echeverria C. Necrotizing gangrene of the genitalia and perineum. Int J Dermatol. 2002;41(12):847–51.

Index Note: Page numbers in italics represent figures and bold indicate tables in the text.

A Abdominal ectopic pregnancies, 69, 69 anatomic locations, 64 clinical diagnosis, 66–67 clinical manifestations, 64 diagnosis, 67–68 epidemiology, 63 follow-up, 70 lithopedion, 64, 64–66 management, 68–69 pathophysiology, 63–64 prevention strategies, 70 risk factors, 63 Abdominal or vaginal mass, 199 Abdominal pain, 4 Abdominal palpation, 13 Abdominal pregnancies, 63–64 Abdominal surgery, 11 Abdominopelvic fibrosis and adhesions, 132, 132 Abnormal implantation, 56 Abnormally invasive placenta (AIP), 45 Abortion, 12, 36–37 Active bleeding, ultrasound examination, 183 Acute abdomen, EP, 11 Acute appendicitis, 125–126, 156, 159 Acute diverticulitis, 159 Acute excessive hemorrhage, 159 Acute-onset lower abdominal, 140 Acute respiratory distress syndrome (ARDS), 110 Adenocarcinoma, 211 Adenomyosis, 123 Adjacent myometrial thickness (AMT), 46 Adnexal surgery, 138 Adnexal torsion, 1, 159 blood supply, 135 clinical presentation, 140 diagnosis clinical presentation and differential diagnosis, 141 computed tomography (CT), 142–143 laboratory investigations, 141 magnetic resonance imaging, 142–143 ultrasound imaging, 141–142 epidemiology, 136 management, 143–145 ovaries and tubes, anatomy, 135 pathogenesis after adnexal surgery, 138 infertility treatments and ovarian torsion, 138 in neonates, 139 normal vs. abnormal adnexa, 137 ovarian cysts, 136–137

paraovarian and paratubal cysts, 137 in pediatric patients, 139 postmenopausal ovarian torsion, 139 during pregnancy, 138–139 recurrence, 139–140 tubo-ovarian vs. isolated torsion, 137 tumors and ovarian torsion, 138 Adnexal tumors, 138 Adnexa uteri, 136 Adolescent and pediatric care, 4 Aerosol-generating procedures (AGPs), 6 AGPs, see Aerosol-generating procedures Alloimmunization, 182 α-toxin, 106, 179 Amenorrhea, 13 American College of Obstetricians and Gynecologists (ACOG), 181 Amniocentesis, 180 Ampicillin/sulbactam, 108 AMT, see Adjacent myometrial thickness Anaerobic organisms, PID, 83 Anatomic abnormalities, 11 Anesthesia-related complications, 184 Angiomyxoma, 211 Angular pregnancy definition, 27 diagnostic criteria, 28 different ultrasound techniques, 28 interstitial pregnancy and, 27 laparoscopic management comparing management options, 32 cornuostomy, 30 delivery planning for subsequent pregnancy, 32 laparoscopic cornual resection, 30, 31 transcervical evacuation, 29–30 ultrasound diagnosis, 27 vascularity in, 29 Animal bites, female genital area, 208 Antibiotic prophylaxis, 208, 210 Anticoagulation therapy, 151–152 Anti-D prophylaxis, 18 Anti-inflammatory cytokine interleukin, 105 Appendiceal intussusception, 126 Appendicitis, 11, 125–126, 141 Arias-Stella reaction, 68 Artery embolization, 69 Ascites, 129 Asherman syndrome, 39 Assisted reproductive technologies (ARTs), 73–74, 168 Asymmetric myometrium, 28

215

216 B Bacteremia, 111 Bacterial colonization, 109–110 Bacterial vaginosis (BV), 82 Bartholin cyst/abscess etiology and prevalence, 210–211 evaluation and differential diagnosis, 211 management and prognosis, 211 Bicornuate uterus, 29 Bilateral hydroureteronephrosis, 190 Bilateral pelvic tenderness, 141 Bilateral salpingectomy, 63 Bilateral tubal EP, 11 Bleeding, 12 active bleeding, ultrasound examination, 183 intermenstrual, 13 vaginal, 123, 179 Blind hemivagina, 199 Blood pressure monitoring, 152 Blue-black ovaries, 144 Blunt injuries and hydrotrauma, 207–208 Bowel obstruction, 124, 159 Burns, 208

C Calcified and mummified abdominal pregnancy, 64, 64–66 Calcium-magnesium ATPase, 107 Cardiac sarcoplasmic reticulum, 107 Catamenial hydroureteronephrosis, 126 Catastrophic hemorrhage, 27 Cecal perforation, 124 Cefoxitin, 108 Centers for Disease Control and Prevention (CDC), 81, 109 Cephalosporin, 97 Cervical cancer, cervical ectopic pregnancy, 39 Cervical ectopic pregnancies, 3 abortion, 36–37 cervical cancer, 39 cervical mass, 39 cervical twin pregnancy, 37, 41 cesarean section scar ectopic pregnancy, 39 classical findings, 38 clinical issues associated with, 39–40 color Doppler, 35 diagnosis, 35–39 endocervical canal, 36 grayscale ultrasound, 35 hysterectomy treatment, 42, 42 live embryo embedded within cervical stroma, 36 nabothian cyst, 39 pathologic associations with, 39 polyps, 39 thickened endometrial stripe, 38 transabdominal ultrasound aids, 35–36 transvaginal ultrasound, 35–36 treatment, 40–42 ultrasound imaging, 38 uterine implantation, 36

Index Cervical endometriotic lesion, 121–122, 122 Cervical mass, cervical ectopic pregnancy, 39 Cervical microorganisms, 83 Cervical mucosa, 39 Cervical stroma, 39 Cervical twin pregnancy, 37, 41 Cervicovaginal epithelium, 83 Cesarean deliveries, 39 Cesarean section (C-S), 32, 39, 45–46 Cesarean section scar ectopic pregnancy (CSEP) adverse effects, 51 alternate modes of management, 51–52 assisted reproductive technologies, management in, 52 cesarean section scar identification, 46–48 gestational sac, 48 hysteroscopy, 50 intrauterine Foley balloon, 50 management, 49 medical management, 49–50 potassium chloride (KCl), 49–50 surgical and nonsurgical treatment modalities, 45 surgical management, 50–51 TVS criteria, 48 types, 48 uterine artery embolization (UAE), 51 wedge resection, 51 Chlamydia, 85, 211 Chlamydia trachomatis (CT), 82, 96–97 Chloramphenicol, 105 Cholecystitis, 141 Chorionic villi, 39, 180 Chromosomal anomalies, 179 Classical cesarean delivery, 123 Clindamycin, 105, 108, 110 Clostridial infections, 110 Clostridial species, 102–109 Clostridium perfringens diagnosis and treatment, 108–109 microbiology, 107–108 pathophysiology of infection, 108 Clostridium septicum diagnosis and treatment, 107 microbiology, 106 pathophysiology of infection, 106–107 Clostridium sordellii infections antibiotic treatment for invasive infections in, 106 diagnosis and treatment, 105–106 hemorrhagic toxin (TesH), 102 laboratory findings, 105 lethal toxin (TesL), 102 microbiology, 102–103 pathophysiology of infection, 103–105 virulence factors, 102 Coasting, 168 COH, see Controlled ovarian hyperstimulation Color Doppler, cervical ectopic pregnancy, 35 Combined oral contraceptive (COC), 82 Communication protocol, 3–4 Complete abortion, 179, 180

Index Complete blood count (CBC), 152 Confidentiality, 2 Congenital agenesis of lower vagina investigation, 195, 195–196 signs, 195 symptoms, 194 treatment, 196–197 Congenital or acquired thrombophilia, 151–152 Conization, 39 Consent, 2 Controlled ovarian hyperstimulation (COH), 167 Cornual pregnancy, 28 Cornual transection, 30 Cornuostomy, 30 Coronavirus disease 2019 (COVID-19), 5–6 Corpus luteum and ovarian pregnancy, 57–58 C-reactive protein, 86, 141 Crown-rump length (CRL), 181 Cryopreservation of embryos (freeze-all strategy), 171–172 Cryosurgery, 39 CSEP, see Cesarean section scar ectopic pregnancy Culdocentesis, 56 Curettage, 39 Cyclic hemorrhage, 125–126 Cyclooxygenase inhibitors, 111 Cystadenomas, 139 Cystectomy, 144 Cystic endometriotic lesion, 121

D Dactinomycin, 40 Decidual sloughing, ectopic pregnancy and IUP abortion, 58–59 Dehydroepiandrosterone (DHEA), 145 Depo-Provera, 199 Dermoid cyst, 156 Desquamating rash, 109 Desquamation, 110 Dilatation and curettage, 39–40, 43, 45, 59, 97, 184 Dilated cervix, ultrasound examination, 183 Dilation and evacuation (D&E), 184 Diluted vasopressin, 30 Disrupted transport, EP, 11 Disseminated intravascular coagulation (DIC), 107 Dopamine agonist administration, 170 on vascular permeability, 171 Douglas puncture, 157 Dysgerminoma, 138 Dysmenorrhea, 157, 199

E Ectopic pregnancies, 1, 39, 82, 156 arthritis types and, 40 definition, 9–11, 27 diagnosis, 13–17, 18 differential diagnoses, 13, 13

217 etiology, 11 locations, 10 miscarriage, 181 mortality rate, 9 pathophysiology, 11–12 risk factors for, 11 stages acute, 13 asymptomatic, 12 beginning symptoms, 12 symptoms, 12 therapeutic options and indications, 19 treatment, 18–22 Electrocoagulation, 30 Embryo cryopreservation, 164 migration, 55 spontaneous retrograde migration, 63 Embryo transfer (ET), 52 frozen embryo transfer (FET), 52 intracytoplasmic sperm injection–embryo transfer (ICSI-ET), 63 ovarian hyperstimulation syndrome (OHSS), 171–172 in vitro fertilization (IVF), 27 Emergency room (ER) category, 1 physician, 4 stages, 12–13 Empty follicle syndrome, 55 Empty uterine cavity, 28 Endocervical canal, cervical ectopic pregnancy, 36 Endometrial sampling, 84 Endometriosis, 11, 138, 159, 194, 199, 211 abdominopelvic fibrosis and adhesions, 132, 132 ascites, 129 endometriosis-related ascites, 130–131 extensive, 131 gynecologic, 121–124 gynecologic malignancy diagnosis, 131 hematosalpinx, 132 intestinal, 124–126 leukocytosis, 131 Mossy, 130 multiple cysts, 132 multiple ovarian cystectomies, 131 obstetric, 128 suspected pelvic abscess, 131 thoracic, 127–128 torsion, 132 urologic, 126–127 Endometriosis-related ascites, pathophysiology, 130–131 Endometrium and ectopic pregnancy, 12 Erythrocyte sedimentation rate, 86 Escherichia coli, 83 Estimated date of delivery (EDD), 181 Estrogen-dependent diseases, 159 Etoposide, ovarian pregnancy, 59 Exotoxin, 110 Extensive endometriosis, 131 Extragenital endometriosis, 124

218 F Fallopian tube damage, 74 Female genital mutilation, 208–209 Fertility treatment, 11 FET, see Frozen embryo transfer Fetal chromosomal abnormalities, 179 Fetal membranes, rupture, 93–94 Fetal MRI, imperforate hymen, 190 Fibroids, 159 degeneration, 141, 159 torsion, 141 Fibroma, 211 First-trimester pregnancy loss, 180 Fitz-Hugh–Curtis syndrome, 81, 88 Flare-up phenomenon, 159 Flexible sigmoidoscopy, 125 Foley catheter, 194 Follicle-stimulating hormone (FSH), 169 Follicular ring sign, 142 Folliculitis, 211 Follow-up ultrasounds, cervical ectopic pregnancies, 41 Food poisoning, 107 Frozen embryo transfer (FET), 52, 172 Frozen-thawed cycles, IVF cycles, 73 Fundal myomectomy, 123

G Gas gangrene, 107 Gastroenterology ulcerative disease, 183 Genital burns, 208 Genital trauma, 207, 209 Gentamicin, 108, 110 Gestational age, 29 Gestational sac, 9, 48 Glucocorticoids, 105, 111 Gonadotropin-releasing hormone (GnRH) agonists, 159, 163, 196 dysmenorrhea, 199 final oocyte maturation in GnRH antagonist cycles, 168–169 for pituitary desensitization, 167 Gonorrhea infections, 85 Graafian follicle, 152 Gram negative enteric bacilli, 98–99 Grayscale ultrasound, 35 Group A Streptococcus (GAS), 111 Guanosine triphosphate (GTP)-binding proteins, 102 Guardianship, 2 Gynecologic emergencies, 1–4 Gynecologic endometriosis, 121–124 Gynecologic hemorrhage, 1 Gynecologic malignancy diagnosis, 131 Gynecologic sonography, 3 Gynecologic urgencies, 2

H Haemophilus influenzae, 83 Hematic vaginal discharge, 199

Index Hematocolpos, 194 Hematoma, 211 Hematosalpinx, 132 Hematoureter due to endometriosis, 126, 127 Hemihysterectomy, 203 Hemivagina hemihysterectomy, 203 high, 200 investigation, 200–202 low, 201 obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), 197–202, 198, 200–201 signs, 199–200 symptoms, 199 treatment, 202–203 Hemoperitoneum, 55, 151–152 Hemoptysis, 127 Hemorrhage and spontaneous abortion, 2 Hemorrhagic cysts, 143 Hemorrhagic ovarian cysts, 1, 10 Hemostasis, 30 Hemothorax, 127 Hepatitis B virus (HBV), 210 Herlyn-Werner-Wunderlich syndrome, 197–199 Heterotopic pregnancy (HP) clinical manifestations, 74 definition, 73 diagnostic evaluation, 74 differential diagnosis, 75 follow-up, 77 incidence, 73 outcome, 77 risk factors, 74 risks of, 76 sites, 73 treatment, 76–77 with twin intrauterine pregnancy and concomitant ectopic pregnancy, 75 Heterotopic scar pregnancy, 76 Heterotopic triplet pregnancy, 77 HIFU, see High-intensity focused ultrasound High hemivagina, 200 High-intensity focused ultrasound (HIFU), 51 High-risk pregnancy, 29 Human chorionic gonadotropin (hCG), 56, 163 β-Human chorionic gonadotropin (β-hCG) levels, 9, 10, 14, 18, 37, 74 ovulation triggering using, 169 suspected ovarian tumors, 141 withholding, 169 Hyalinization, 157–158, 158 Hydrometrocolpos, 194 Hymenal variants, 4 Hyperbaric oxygen therapy, 107 Hyperosmolar glucose, 40 Hyperperistalsis, 126 Hypertrophy, 126 Hypervascular or epithelial primary ovarian tumors, 143 Hypocalcemia, 113 Hypoechoic lesion, 159 Hypotension, 109–110

219

Index Hysterectomy, 42, 42, 113–114 Hysterosalpingography, 84 Hysteroscopy, 50, 84

I Imaging and laboratory diagnostics, 2–3 Imipenem, 105 Immunohistochemical staining, ovarian pregnancy, 58 Imperforate hymen, 187–188 investigation, 191, 192 signs, 191, 191 symptoms, 190–191 transabdominal and endorectal ultrasonography, 191, 192 treatment, 192–193 Incomplete abortion, 179, 180 Individualized ovarian stimulation protocols, 167 Induced ovarian hyperstimulation syndrome, 22 Inevitable abortion, 180 Infected abortion, 180 Infections clinical approach and management, 113–114 Clostridium perfringens, 107–109 Clostridium septicum, 106–107 Clostridium sordellii, 102–106 early recognition, 101–102 S. aureus, 109–111 Streptococcus pyogenes, 111–113 Infertility, 82 prevention, 30 treatments and ovarian torsion, 138 Inflamed appendix, 199 Infundibulopelvic ligaments, 135 Inseminated oocyte, 12 Intermenstrual bleeding, 13 Interstitial line, 28 Interstitial pregnancy, 27–28 Interventional radiologists, 3 Intestinal endometriosis, 124–126 Intimate partner violence (IPV), 5 Intracardiac potassium chloride (KCl), 69 Intractable rectal hemorrhage, 126 Intracytoplasmic sperm injection–embryo transfer (ICSI-ET), 63 Intracytoplasmic sperm injection (ICSI), 138 Intralesional methotrexate, 69 Intramuscular 17-hydroxyprogesterone caproate, 144 Intramuscular methotrexate, 69 Intraperitoneal hemorrhage, 124 Intrathoracic KCl injection, 69 Intrauterine adhesions, 184 Intrauterine contraceptive devices (IUCDs), 55, 82–83 Intrauterine devices, 11 Intrauterine insemination (IUI), 163 Intrauterine pregnancy (IUP), 3, 9, 14, 56, 179 Intravenous volume expander administration, 170–171 In vitro fertilization (IVF) cycles, 73 embryo transfer (ET), 27 In vitro maturation (IVM), OHSS, 167

I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) tool, 4 Ischemia-modified albumin, 141 Ischemia-reperfusion (I/R) injury, 141, 144 Isolated fallopian tube torsion, 137 IUP, see Intrauterine pregnancy

J Jackson-Pratt drain, 132

K KCl, see Potassium chloride Knee-chest position, 4

L Labial adhesions and hymenal atresia, 187 β-Lactamase–resistant antibiotics, 110 β-Lactams, 105 Laparoscopic bilateral salpingectomy, 132 Laparoscopic cornual resection, 30, 31 Laparoscopic cornuostomy, 30 Laparoscopic-guided suction curettage, 29 Laparoscopic partial oophorectomy, ectopic pregnancy, 59 Laparoscopic salpingotomy, 19, 21 Laparoscopy, 19, 60, 60–61 Laparotomy, 19, 59 Leiomyoma, 211 Leiomyosarcoma, 158 Lethal toxin (TesL), 102 Leukocytosis, 107, 131, 159 Linezolid, 105 Lipoma, 211 Live embryo embedded within cervical stroma, 36 Longitudinal vaginal septum, 189 Loop electrosurgical excision procedures (LEEP), 39 Low hemivagina, 201 Luteal phase interventions, OHSS, 172

M Magnetic resonance–guided focused ultrasound surgery (MRgFUS), 51 Malignant neoplasm, 138 Maternal age, 179 Mature cystic teratoma, 139 Medically assisted reproduction (MAR), 163 Menorrhagia, 157 Mesosalpinx, 135 Mesovarium, 135 Methicillin-resistant Staphylococcus aureus (MRSA), 110, 211 Methotrexate (MTX), 10, 18, 19, 22, 40 lipiodol emulsion, 69 ovarian pregnancy, 59 Metronidazole, 105, 108 Mid-cycle pain, 151 Mifepristone, 40, 183–184

220 Minimally invasive surgery, 18, 22 Miscarriage clinical presentation, 179–180 differential diagnosis, 181–182 ectopic pregnancies, 181 etiology, 179 expectant management, 182–183 failed PUL, 9 management, 182–184 medical management, 183–184 risk factors, 180 surgical management, 184 Misoprostol, 183 Missed abortion, 179, 180 Mittelschmerz pain, 151 Mock simulation drills, 1 Molar pregnancies, 40, 182 Morbidly obese patients, 5 Mortality rate, ectopic pregnancies, 9 Mossy endometriosis, 130 MRgFUS, see Magnetic resonance–guided focused ultrasound surgery Müllerian ductal system, 188 Multiorgan failure, 107 Multiple cysts, 132 Multiple gestations, miscarriage, 182 Multiple ovarian cystectomies, 131 Multisystem dysfunction, 109–110 Mupirocin, 210 Mycobacterium tuberculosis, 83 Mycoplasma genitalium, 83 Mycoplasma hominis, 83 Myeloid sarcoma, 211 Myometrial thickness, 49 Myometritis, 85 Myometrium, 27 Myxoid fibroid, 158 Myxoid leiomyosarcoma, 211

N Nabothian cyst, 39 Necrotic leiomyoma, 87 Necrotic metastases, 143 Necrotizing enterocolitis, 107 Neisseria gonorrhoeae, 83, 96–97, 211 Neonatal cysts, 139 Neonatal torsion, 139 Neonates, adnexal torsion in, 139 Niche, 46, 46–47 Nonhemolytic Streptococcus, 83 Nonmigratory pain, 141 Nonobstetric trauma blunt injuries and hydrotrauma, 207–208 burns, 208 female genital mutilation, 208–209 genital trauma, diagnosis, 209 management and prognosis, 209–210 sexual trauma, 208 Stevens-Johnson syndrome (SJS), 208 toxic epidermal necrolysis (TEN), 208

Index Nonsteroidal anti-inflammatory drugs (NSAIDs), 111, 199 Normal vs. abnormal adnexa, 137 Nuclear factor (NF)-κB–mediated neutrophil migration, 109

O Obese patients, 5 Obstetric endometriosis, 128 Obstetrician-gynecologist, 2–3, 5 Obstetrics/gynecology generalist, 4 Obstetric trauma, 207 Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), 190, 197–202, 198, 200–201 Obstructive Müllerian anomalies, 194 OHSS, see Ovarian hyperstimulation syndrome OHVIRA, see Obstructed hemivagina and ipsilateral renal anomaly Omental pregnancy, 64 Oocytes cryopreservation, 164 Oophoropexy, 144 Operative laparoscopic conservative treatment, 138 Operator-dependent technology, 2–3 Oral contraceptives, 199 Ovarian and abdominal/pelvic pregnancies, 10 Ovarian cysts, 136–137, 139 hemorrhagic and ruptured clinical presentation, 151–152 differential diagnosis, 156 imaging, 152–155, 153–155 investigation, 152 management, 156–157 pathophysiology, 151 Ovarian ectopic pregnancy, 57, 57–58 differential diagnosis, 59 epidemiology, 55 laboratory testing, 56 management, 59–61 ovarian pregnancy, diagnostic challenge of, 58–59 pathophysiology, 55 pelvic ultrasonography, 56–58 physical findings, 56 risk factors for, 56 symptoms, 55–56 Ovarian endometrioma, 125–126 Ovarian hyperstimulation syndrome (OHSS), 141, 163 ascites in, 165 bilateral enlarged cystic ovaries, 164 challenges to the anesthesiologist in, 172 complications ectopic pregnancy, 173 ovarian torsion, 173 prediction high-risk patient profile, 164 human chorionic gonadotropin (hCG) pathophysiology, 166 ovarian stimulation during IVF treatment, 164–166 predictive markers for patients at risk for, 166 randomized controlled trials (RCTs), 165 prevention, 163–164 preventive strategies

Index embryo transfer phase, 171–172 luteal phase interventions, 172 ovulation trigger phase, 168–171 pituitary downregulation phase, 167 stimulation phase, 167–168 surgery in, 172–173 treatment, 172–173 Ovarian ligament, 135 Ovarian pregnancies, 55 Ovarian stimulation therapy, 73 Ovarian stimulation with gonadotropins, 163 Ovarian torsion (OT), 136, 156 blood supply, 135 clinical presentation, 140 diagnosis clinical presentation and differential diagnosis, 141 computed tomography (CT), 142–143 laboratory investigations, 141 magnetic resonance imaging, 142–143 ultrasound imaging, 141–142 epidemiology, 136 management, 143–145 ovaries and tubes, anatomy, 135 pathogenesis after adnexal surgery, 138 infertility treatments and ovarian torsion, 138 in neonates, 139 normal vs. abnormal adnexa, 137 ovarian cysts, 136–137 paraovarian and paratubal cysts, 137 in pediatric patients, 139 postmenopausal ovarian torsion, 139 recurrence, 139–140 tubo-ovarian vs. isolated torsion, 137 tumors and, 138 Ovarian tumors, 139, 141 Overweight, 5 Ovulation induction, 163 Ovulation trigger phase, OHSS, 168–171 Ovulatory dysfunction, 55 Oxacillin, 110

P Palpable mass, 139 Paraovarian and paratubal cysts, 137 Paraovarian/paratubal cysts, 136 Partial ovariectomy, ectopic pregnancy, 59 PCOS, see Polycystic ovary syndrome Pediatric hematocolpos clinical presentation congenital agenesis of lower vagina, 194–197 hemivagina, 197–203 imperforate hymen, 190–193 transverse vaginal septum, 188, 188, 193–194 labial adhesions and hymenal atresia, 187 longitudinal vaginal septum, 189 obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), 190 uterus didelphys, 189 vaginal atresia, 189

221 Pediatric patients, adnexal torsion in, 139 Pedunculated fibroid, 157 Pelvic adhesions, 82 Pelvic inflammatory disease (PID), 4, 73, 138, 141 ambulatory outpatient protocol for management of, 89 CDC diagnosis, 84 definition, 81 diagnosis, 84–86 differential diagnosis, 86–87 epidemiology, 82 follow-up, 90 health education, 88–89 inpatient protocol for management of, 90 intensive behavioral counseling, 88 magnitude, 82 microbiology, 83 mode of transmission, 84 prevention of, 88 risk factors and risk markers, 82, 83 risk reduction guidelines, 88 sequelae of, 88 treatment, 89–90 tubo-ovarian abscess with pus, 85 in vitro fertilization, 83 Pelvic pressure, 157 Pelvic septic thrombophlebitis, 88 Pelvic ultrasonography, 4 Penicillin, 108 Peptococcus, 83 Peptostreptococcus, 83 Perforated viscus, 159 Perineal lacerations, 207 Peritonitis, 128, 136 Personal protective equipment (PPE), 5–6 Phospholipase C, 107 PID, see Pelvic inflammatory disease Piperacillin, 108 Pituitary desensitization, GnRH antagonists for, 167 downregulation phase, OHSS, 167 Pneumothorax, 127 Point-of-care (POC) testing, 3 Polycystic ovary syndrome (PCOS), 167 Polymerase chain reaction (PCR) gene analysis, 105 Polymorphonuclear leukocytes, 85–86, 108 Polyps, cervical ectopic pregnancy, 39 Postmenopausal ovarian torsion, 139 Potassium chloride (KCl) injection, 40–41, 49–50, 76 PPE, see Personal protective equipment Pregnancy of unknown location (PUL), 9–10, 10, 181 Pregnancy-related deaths, 9 Pregnancy-unrelated disorders, 56 Primary ovarian pregnancy, 55 Principles of medicine, 2 Prior instrumentation, cervical ectopic pregnancies, 39 Progesterone level and ectopic pregnancy, 12 Prostaglandins, 40 PUL, see Pregnancy of unknown location Pulmonary nodules, 127 Pyometra, 88 Pyosalpinx, 88

222 Q Quinolones, 110

R Rabies prophylaxis, 208 Rape and sexual assault, 5 Rash, 110 Reactive oxygen species (ROS), 144 Recurrent ascites, 130 Recurrent pregnancy loss, 181 Recurrent tubal pregnancy rates, 20 Red degeneration, 157–159 Renal and urethral endometriosis, 126 Reperfusion, 144 Reproductive-aged female, 6 Residual myometrial thickness (RMT), 46 Retroperitoneal pregnancies imaging manifestations, 67, 67 neovascularization and invasion, 68 surgical resection, 68 Rheumatoid arthritis, 40 Ring-like calcification, 158 Ring of fire, 152, 153 RMT, see Residual myometrial thickness Ruptured benign adnexal cysts, 141 Ruptured ectopic pregnancy, 4 Ruptured interstitial pregnancy, 29 Ruptured tubal pregnancies, 10

S Salpingectomy, 55 Salpinges, 135 Salpingotomy, 19–20 S aureus, see Staphylococcus aureus SBAR (Situation, Background, Assessment, Recommendation), 4 Sebaceous cysts, 211 Secondary ovarian pregnancy, 55 Second-trimester miscarriages, 179 Second-trimester spontaneous abortion, 180 Septic abortion, 179–180 antibiotic treatment regimens for, 96 cause and risk factors, 93–94 diagnosis, 94–95 intrauterine infection, routes, 94 intravenous (IV) antibiotics, 97 management, 96–97 microorganisms, 96–97 pertinent laboratory findings associated with severe forms of, 95 spontaneous, types, 94 transvaginal ultrasound, 95 tubo-ovarian abscess collections, 97 Serologic microfluorescence testing, 86 Serum pregnancy test, 86 Sexual assault forensic examiners (SAFEs), 5 Sexual assault nurse examiners (SANEs), 5 Sexually transmitted infections (STIs), 81

Index Sexual trauma, 208 Sexual violence, 5 SHiP, see Spontaneous hemoperitoneum in pregnancy Silver sulfadiazine, 210 Smoking, 11 Spermatozoa migration, 55 Spleen pregnancy, 67 Spontaneous abortion, 179, 184 Spontaneous hemoperitoneum in pregnancy (SHiP), 123, 128 Spontaneous heterotopic triplets, 77 Squamous cell carcinoma, 211 Standardized language, 3–4 Staphylococcus aureus diagnosis and treatment, 110–111 microbiology, 109 pathophysiology of infection, 109–110 Stevens-Johnson syndrome (SJS), 208 Stimulation phase, OHSS, 167–168 Straddle injuries, 4 Streptococcus pyogenes diagnosis and treatment, 113 infectious sequelae from untreated, 112 microbiology, 111–112 pathogenesis of infection, 112–113 Streptococcus species, 83, 96–97, 110 Subacute hematoma, 143 Sulfamethoxazole-trimethoprim (Bactrim), 110 Suspected pelvic abscess, 131 Suspensory ligaments, 135 Suture ligation, 121 Symptomatic cysts and abscess, 211

T T1 contrast-enhanced gadolinium imaging, 85 Technical assistance, 5 TES, see Thoracic endometriosis syndrome Testing swabs, 2 Tetracycline, 105 Thickened endometrial stripe, 38 Thiol-activated hemolysin, 107 Thoracic endometriosis syndrome (TES), 127–128 Threatened abortion, 179, 180 Thrombosed veins, 158 Torsion; see also Ovarian torsion endometriosis, 132 fibroids, 141 isolated fallopian tube, 137 neonatal, 139 tumors and ovarian, 138 Toxic epidermal necrolysis (TEN), 208 Toxic shock syndrome toxin-1 (TSST-1), 109 Toxic shock syndrome (TSS), 101 infectious sequelae from untreated Streptococcus pyogenes, 112 in obstetrics and gynecology, algorithm, 103 Transabdominal ultrasound aids, 35–36 Transcatheter arterial chemoembolization, 69 Transcervical evacuation, 30

223

Index Transvaginal color Doppler sonography (TV-CDS), 142 Transvaginal high-definition ultrasound machine, 56–57 Transvaginal sonography (TVS), 46, 58 Transvaginal ultrasound (TVUS), 10, 27–28, 35–36 Transverse vaginal septum, 188, 188, 193–194 Trichomonas vaginalis, 86 Trichomoniasis and PID, 83 Trophoblastic invasion, 39 TSS, see Toxic shock syndrome Tubal blockage, 30 Tubal ectopic pregnancy, 77 Tubal or ovarian pregnancies, 63 Tubo-ovarian abscess, 1, 88, 156 Tubo-ovarian vs. isolated torsion, 137 Tumor markers, 141 Tumors and ovarian torsion, 138 Tunica albuginea, 151 TVUS, see Transvaginal ultrasound Twin intrauterine pregnancy and concomitant ectopic pregnancy, 75 and ectopic pregnancy, 74, 75 Twin pregnancy, 77 Two-dimensional ultrasonography, 48

U UAE, see Uterine artery embolization Ultrasonography, 2–3 Ultrasound, 14–17 adnexal mass in patient with suspicion of extrauterine gravidity, 15 circular hypervascularization in color Doppler, 16 empty uterus with a built-up endometrium, 14–15 extrauterine gravidity in the adnexal area, 16 intra-abdominal fluid, 17 pseudogestational sac, 15 yolk sac of extrauterine gravidity, 17 Uni- or bilateral salpingectomy, 76 Unruptured interstitial pregnancy, 29 Ureaplasma urealyticum, 83 Ureteral endometriosis, 126 Urinary collecting system calculi, 141 Urine pregnancy test, 180 Urologic endometriosis, 126–127 US Food and Drug Administration (FDA), 183

US-guided feticide, 69 Uterine arteriovenous malformations, 3 Uterine artery embolization (UAE), 41, 51, 160 Uterine curettage, PID, 84 Uterine fibroid embolization (UFE), 3 Uterine fibroids, 3 imaging, 159–160 management, 160 pathophysiology and clinical picture, 157–159 Uterine implantation, 36 Uterine isthmocele, 46, 46–47 Uterine leiomyomas, 158 Uterine myomectomies, 39 Uterine perforation, 184 Uterine rupture, 30, 123 Uterine tubes, 11, 135 Uterine wall adenomyosis, 121 Utero-ovarian (UO) ligament, 135 Uterus didelphys, 200–201

V Vaginal bleeding, 123, 179 Vaginal douching, 82 Vaginal hemorrhage, 121 Vaginal insufflation injuries, 207 Vaginal microflora, 83 Vaginal or intraperitoneal hemorrhage, 157 Vaginal stenosis, 194 Vaginal tamponade, 121–122 Vaginoplasty, 197 Vancomycin, 105, 110 Vascular endothelial growth factor (VEGF), 163 Vasopressin, 20 Venous thromboembolism (VTE), 159 Venous thrombosis, 157 Vesicovaginal fold, 46 Virulence factors, 102 Vulvar and vaginal hematomas, 207 Vulvar angiomyofibroblastoma, 211 Vulvar cellulitis and vulvar abscess, 211 Vulvovaginal trauma, 1

W Watch-and-wait strategy, 18, 22