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