GYNECOLOGIC EMERGENCIES

In evaluation of gynecologic emergencies in women, particularly women of reproductive age, a delay in or improper management of the patient may compromise care and jeopardize future reproductive capabilities. Although there are several gynecologic urgencies that warrant expeditious management, there are only three life-threatening gynecologic emergencies: (1) ruptured ectopic pregnancy, (2) ruptured hemorrhagic ovarian cyst, and (3) ruptured tuboovarian abscess. If these are kept constantly kept in mind, diagnostic failures should not occur and proper management of the similar-presenting but less concerning gynecologic urgencies will be enhanced.

The objective of this chapter is to provide a suggested approach to the evaluation and management of the more common and important urgent and emergency gynecologic problems occurring in women of reproductive age. The chapter will focus on early pregnancy-related problems, ectopic pregnancy, adnexal accidents, abnormal genital bleeding conditions, and pelvic inflammatory disease (PID).

EARLY PREGNANCY COMPLICATIONS AS CAUSES OF GYNECOLOGIC PAIN AND BLEEDING

A most useful dictum is that, until proved otherwise, amenorrhea is a normal result of pregnancy and abnormal uterine bleeding is a complication of pregnancy. The possibility of an ectopic pregnancy must be considered in every patient who presents with a clinical scenario that includes lower abdominal or pelvic pain or abnormal uterine bleeding. A spontaneous abortion, infected abortion, hemorrhagic corpus luteum of pregnancy, and uterine incarceration are additional early pregnancy complications that frequently present to the emergency department (ED).

ABORTION

Pathophysiology

About 15 to 20% of all known pregnancies end in what is known as a clinically recognized abortion. This incidence is increased with increasing maternal age, parity, and paternal age.

The causes of spontaneous abortion are divided into two categories, fetal and maternal. The major cause of abortion is by far genetic, with over 50% of abortuses having chromosomal anomalies, predominately of chromosomal number, with fewer involving structural abnormalities of individual chromosomes. Maternal factors include uterine abnormalities, incompetent cervix, intrauterine adhesions, progestin deficiency, and serious medical problems such as diabetes and hyperthyroidism.

Clinical Features

To firmly establish the possibility of a pregnancy in the woman with pelvic pain and/or bleeding, a brief but accurate gynecologic and menstrual history that provides the following information must be obtained.

Last menstrual period (LMP).

Not only the LMP, but also the timing of two or more immediate past periods should be ascertained to determine the intervals between "normal" menses. Any regularly menstruating woman whose LMP is greater than 4 weeks prior to the current date is very likely to be pregnant. If the LMP is determined to be normal and the patient is less than 4 weeks past the menses, the possibility of a pregnancy complication is highly unlikely, as spontaneous abortion and ectopic pregnancies do not present clinically before the first missed menses. If the stated LMP was lighter and shorter than normal, pregnancy must also be considered, since implantation can be associated with normal menstrual flow.

Most spontaneous abortions also occur prior to 8 or 9 weeks of gestation; however, abortion can occur up to the 20th week of gestation. The aborting patient initially experiences minimal intermittent or continuous spotting that progresses to very heavy bleeding with the passage of clots and gestational tissue. Volume is best assessed by determining the number of pads used per day. A soaked pad suggest 20 to 30 mL blood loss.

The pain associated with the abortive process usually occurs after bleeding has commenced and is very characteristically midline and cramping in nature, as opposed to the acute, severe, and unilaterally localized pain of an ectopic pregnancy or ruptured ovarian cyst.

The abdominal examination of the aborting patient is usually unremarkable, with the possible finding of midline suprapubic tenderness to deep palpation. On pelvic examination, a patient with a threatened abortion will be found to have a closed cervical os and minimal bleeding. In a women with an actively progressing abortion, however, the bleeding will be profuse and accompanied by the passage of blood clots and products of conception through an obviously dilated cervical opening. The uterus will usually be enlarged to a size compatible with gestational dates unless significant tissue sloughage has occurred. In the case of a complete abortion, the uterus may be found to be small and firm shortly after all tissue has been passed. The adnexal examination is unlikely to be abnormal, although slight tenderness and palpation of a fullness on the side of the corpus luteum of pregnancy is common. It should be noted that a complete abortion is unlikely to occur beyond week 7 of gestation. Ultrasound has been used with relative reliability to determine if the uterus is empty if in doubt.

In a full-blown abortive situation, the proper diagnosis is easy to determine. However, in earlier stages of the abortion process, a definitive diagnosis can be difficult and is easily confused with an ectopic pregnancy. An ultrasound examination can help to rule out an ectopic pregnancy if an intrauterine gestational sac is seen and may even be predictive of a possible abortion if absent heart tones or irregular margins of the sac are seen. However, the rare case of a twin intrauterine and ectopic pregnancy should also be considered. When the diagnosis of an intrauterine pregnancy is uncertain, intrauterine instrumentation must be avoided until an accurate diagnosis can be made. Most patients with early pregnancy bleeding problems have normal pregnancy outcomes.

Treatment

Threatened abortion is defined as any uterine bleeding from a gestation of less than 20 weeks. If the diagnosis of a threatened abortion is made, the patient may be sent home for continued expectant management and close follow-up by her obstetrician.

Discharge instructions should include bed rest, no intercourse, and no tampon use. The patient should instructed to return to the ED if bleeding or cramping intensify, if orthostatic symptoms develop, or if there is fever or chills. If the diagnosis is complete abortion, the patient should be followed up at the physician's office within 2 weeks of the event. Discharge instructions should include instructions for the patient to return if excessive bleeding, foul smelling menstrual blood, discharge, or fever ensues.

Incomplete or inevitable abortion usually requires operative intervention with suction curettage. The time frame for performance of the procedure is dependent on the amount and rate of uterine bleeding. Missed abortion defined as fetal death before the 20th week of gestation or blighted ovum is not an operative emergency and can be scheduled accordingly.

RETAINED PRODUCTS OF CONCEPTION

Retained gestational tissue following a spontaneous or induced abortion can serve as a nidus for an infection that is usually polymicrobial in etiology. Continued bleeding, cramping pain, fever, nausea, and generalized malaise usually accompany a postabortive endometritis. On examination, a purulent, hemorrhagic cervical discharge is seen associated with a boggy, tender, and enlarged uterus. Significant adnexal tenderness may also be elicited if the myometrium, parametrium, and fallopian tubes are involved in the process. In severe cases where uterine perforation has occurred, an infected tender mass compatible with an abscess may be palpated in the adnexae or in the cul-de-sac. Patients with postabortive endometritis require hospitalization, intensive parenteral antibiotic therapy, and repeat dilatation and curettage in an effort to prevent abscess formation and development of septic pelvic thrombophlebitis.

ECTOPIC PREGNANCY

Ectopic pregnancy is defined as any pregnancy occurring outside the uterine cavity. It can result from a fertilized ovum implanted in the abdomen, fallopian tube, cervix, ovary or peritoneal surface. Although changing etiologic factors are partly responsible, previous inconsistencies in reporting, improved diagnostic tools and an increase in acquired risks for the disease are some of the factors thought to contribute to the increase. Factors most commonly associated with ectopic pregnancy are assisted reproduction, in vitro fertilization, tubal surgery or tubal occlusion, and DES exposure.

Diagnosis

With recent technological advances the diagnosis of ectopic pregnancy can be made more accurately and earlier in gestation. As in the past, death is most often due to delay in diagnosis leading to rupture of the tube and hemorrhage. Even with the current diagnostic methods available, the diagnosis is missed 50% of the time, at first office visit, and 36% of the time at first emergency department visit.

The clinical presentation of ectopic pregnancy is variable. The physician cannot rely on history and clinical findings as the only criteria, as they are often nondiscriminatory, particularly prior to the time bleeding and distention of the tube have occurred. The most common symptom associated with ectopic pregnancy is abdominal pain, followed by amenorrhea and vaginal bleeding. Women rarely present with dizziness and syncope. Clinical signs include abdominal and adnexal tenderness, adnexal mass, and varying uterine size. Over 70% of the time the uterus is normal size, but one can sometimes be led astray when the uterus is enlarged. The usual presentation is a uterus which is softened but not as enlarged as expected for gestational age.

These symptom characteristics are indeed altered by the presence of a combined gestation. The incidence of combined gestation is most often quoted as 1/30,000. However this number is thought to be increasing secondary to the increased numbers of assisted reproduction. In fact, recent estimates place the incidence at 1 to 8:100 in an in vitro fertilization program to 1:4000 in the general population. Classical presentation of combined gestation is abdominal pain, adnexal mass, peritoneal irritation, and enlarged uterus.

Other clinical scenarios in which one might think of combined gestation are a fundus compatible with dates in a person believed to have an ectopic; absence of bleeding following removal of an ectopic; and hemoperitoneum following a pregnancy termination.

Differential diagnosis of a single ectopic gestation includes acute salpingitis, torsion, gastroenteritis, threatened or incomplete abortion or endometriosis. PID is the most common condition confused with ectopic pregnancy. Up to 20% of patients with ectopic pregnancy may have temperatures up to 38°C (100.4°F). PID is, however, rare in pregnancy, occurring less than 1% of the time.

Human Chorionic Gonadropin (hCG)

All currently used qualitative pregnancy tests are dependent on the ability to detect in serum or urine human chorionic gonadotropin, a glycoprotein hormone produced by trophoblast. In a normal intrauterine gestation, the hCG level increases by 66% every 2 days. A patient in whom hCG levels fall, plateau, or fail to reach a predicted slope has an abnormal pregnancy. The absolute value of a single hCG is not useful to determine the location of a pregnancy. However, ectopic gestations have a lower increase in hCG titer. Up to 15% of ectopic gestations have been reported to have a normal doubling time, and 10% of viable pregnancies will have an abnormal doubling time. The current monoclonal antibody technology allows detection of hCG within 2 to 3 days postimplantation. Serial hCG levels help to assess the viability of pregnancy and can be used to signal the optimal time for ultrasonography. In addition, after medical treatment with either an abortifacient or systemic methotrexate falling hCG levels help determine the effectiveness of treatment.

Progesterone

Testing of single serum progesterone has recently emerged as a controversial tool for the evaluation of potential ectopic pregnancy. This tool has been used as an absolute value to determine the diagnosis of normal or ectopic pregnancy or as a mechanism for assigning risk by using a discriminatory cutoff to distinguish a normal from an abnormal pregnancy. Use of this diagnostic tool is attractive as only one measure need be obtained. Stovall et al. performed receiver operator characteristics curve analysis on 1120 patients and compared them to hCG doubling times as predictors of ectopic pregnancy. Their data indicate that serum progesterone is a better predictor than hCG doubling time. Of note, however, is that the lowest progesterone level associated with a normal pregnancy is 5.1 ng/mL. This finding demonstrates the difficulty one has in using only serum progesterone to determine rather than predict the diagnosis. Normal intrauterine gestation is reported to exist in the presence of a low progesterone. Thus, this test should only be used to assign risk of an abnormal pregnancy and not as sole diagnostic criteria.

Ultrasound

Further localization of the pregnancy can then be attempted with a real-time ultrasound examination of the pelvis, the findings on which will be greatly dependent on the gestational age and the type of sonographic approach used. In general, real-time sonography using an abdominal transducer can find an interuterine gestational sac by the fifth week, a sac with an embryonic or fetal pole by the sixth week, and an embryonic mass with cardiac motion by the seventh week. The recent use of high resolution transvaginal US has improved the accuracy of diagnosis and decreased the gestational age at which an ectopic pregnancy can be diagnosed.

Timor-Tristsh, in a study of 145 patients, found the sensitivity of diagnosing ectopic pregnancy with transvaginal sonography to be 100%. The specificity was 98.2% with a positive predictive value of 98%. The negative predictive value in this study was 100%. Depending on the skill of the examiner, resolution of the probe and size and location of the ectopic pregnancy, pregnancies can be detected at as little as 31 to 32 days post-LMP. The minimal hCG titer that a sac should always be seen is unclear but an experienced transvaginal sonographer should be able to visualize a viable intrauterine pregnancy at > 2000 hCG mIU/ml. Transabdominal transducer can visualize a pregnancy at 6500 MIU/ml. Color doppler allows even better visualization of an ectopic gestation. It is important to remember that ultrasound is still considered diagnostic of an ectopic only when the sac is visible outside the uterus.

Culdocentesis

Whenever ectopic pregnancy is suspected culdocentesis may be used to determine whether intraperitoneal hemorrhage is present. If a significant hemorrhage has occurred, cervical motion tenderness may be present accompanied by cul-de-sac fullness or bulging. With or without such a finding, however, culdocentesis should be considered in all patients with a suspected ectopic pregnancy. Culdocentesis is negative if clear fluid is aspirated and positive if nonclotting blood is aspirated. Culdocentesis is not used to determine whether or not a tubal pregnancy has ruptured, since culdocentesis is positive in the majority of ectopics, ruptured or unruptured (85% and 65%, respectively). Failure to aspirate blood on culdocentesis is nondiagnostic and may represent technical difficulties. The presence of blood does not guarantee a diagnosis of ectopic pregnancy and may represent a false positive tap from a ruptured corpus luteum in about 5% of cases.

Dilation and Curettage and Laparoscopy

After identifying an abnormal pregnancy with either progesterone, serial hCG or ultrasound, curettage can be used to identify villi, rendering the diagnosis of ectopic gestation remote.

Treatment

Management of the unstable patient with ectopic pregnancy is aimed toward hemodynamic support. Oxygen should be administered and volume resuscitation started immediately. The patient should be given type-specific blood as indicated. Immediate gynecologic consult for surgical management is the obvious next step. With the increased use of tubal conservation procedures the risk of repetitive ectopic pregnancy is increased.

Management of the stable patient varies depending on the degree of suspicion and the possible gestational age. Patients who have a low degree of suspicion and have just missed a menses may be followed as outpatients with serial quantitative hCG measurements or serum progesterone. Not every patient in this situation needs an ultrasound. Even if the diagnosis is delayed 48 to 72 hours little harm is done because rupture of such a small pregnancy is not life-threatening. Once the hCG value has reached the critical value for your institution ultrasound can be obtained if indicated.

Surgical Treatment

Operative laparoscopy has virtually replaced laparotomy for the first-time treatment of ectopic pregnancy. This has occurred not only to reduce morbidity but also to preserve fertility and reduce cost. Tubal conservation procedures, linear salpingectomy or segmental resection are an attempt to preserve fertility. Unfortunately, these conservative treatments have led to the occurrence of repetitive ectopic gestations.

In addition, persistent ectopic pregnancy or the continued growth of the trophoblast after incomplete removal by conservative surgery complicates 5 to 20% of tubal operations. Occasionally this persistent tissue grows and tubal rupture occurs requiring salpingectomy for hematasis.

More recently, systemic methotrexate, discussed below, has been used to treat this condition.

Medical Treatment

Systemic Methotrexate

Methotrexate has been used for years in the treatment of gestational trophoblastic disease. Its mechanism of action is through inhibition of spontaneous synthesis of purines and pyrimidines, thus interfering with DNA synthesis and the multiplication of cells.

Stable patients with unruptured ectopic gestation of less than 4 cm in diameter by ultrasound are eligible for treatment.

Numerous dosing regimens have been published. However, current practice is to use single dose treatment (50 mg/m2) which is accompanied by fewer side effects. Patients are followed on post therapy doses 2, 4 and 7 with serial qualitative hCG titer mengo. If there is a < 15% decline in hCG between day 4 and 7, a second dose is given. High doses of methotrexate can cause bone marrow suppression, acute and chronic hepatotoxicity, stomatitis, pulmonary fibrosis, alopecia and photosensitivity. These side effects are rarely seen in the dosing schedules used in the treatment of ectopic pregnancy.

To ensure the patient remains unruptured, care should be taken to minimize pelvic exams. Transient pelvic pain frequently occurs three to seven days after the start of methotrexate therapy. This pain is presumably due to tubal abortion and normally lasts less than four to twelve hours. Distinguishing between this pain and the pain of tubal rupture can be difficult. Observation in the hospital may be required when in doubt. Surgical intervention is required in the case of tubal rupture leading to interabdominal hemorrhage. Rupture remote from administration has been reported but was accompanied by a plateau or rise in hCG titer. Patients with rise titers should be observed constantly for rupture.

INCARCERATED UTERUS

An uncommon complication of a late 1st-trimester pregnancy, but one that can be associated with pelvic pain and other signs and symptoms of a threatened abortion, is an incarceration of a pregnant uterus. Laceration occurs only in patients who have an introverted and retroflexed uterus as a neonal anatomic variant or as a result of endometriosis or retrouterine adhesions. Normally the uterus rises out of the pelvis as it enlarges as a result of a pregnancy and is safely beyond the bony confines of the pelvic walls by 12 to 13 weeks of gestation. However, if anteversion of such a uterus does not occur during the expansion process, the uterus may become trapped with the bony pelvis. Clinically, the patient will note progressively severe pelvic and rectal pressure, and because of marked anterior displacement of the cervix to a position behind the pubic symphysis, urinary retention may also be noted. The diagnosis is easily made by noting the cervical displacement and by an inability to mobilize the uterus on a combined abdominal-vaginal examination.

Treatment of this condition must be fairly immediate, to both deviate urinary retention and prevent a certain spontaneous abortion. Placing the patient in a knee-chest position may spontaneously, or with appropriate pressure applied through the rectum, correct the problem. If needed, repositioning can be accomplished under a general or regional anesthetic.

NON-PREGNANCY-ASSOCIATED CAUSES OF PELVIC PAIN

In the initial evaluation of a woman with lower abdominal or pelvic pain, there is a tendency for physicians to quickly assume a gynecologic etiology for the presenting symptoms. The prudent physician, however, should first always approach each such patient with the thought of ruling out nongynecologic conditions as the source of the problem. The following common causes of pain may, with varying degrees of likelihood, falsely suggest a gynecologic problem: (1) lower lobe pneumonia, (2) cholecystitis, (3) pancreatitis, (4) gastric or duodenal ulcers, (5) gastroenteritis, (6) colitis, (7) ileitis, (8) diverticulitis, and, most commonly, (9) appendicitis. A few moments of initial history-taking will usually correctly rule out these causes or at least minimize their priority in an eventual differential diagnosis. Having done so, one can then proceed to the consideration of specific problems.

ADNEXAL ACCIDENTS (NON-PREGNANCY-ASSOCIATED) AS CAUSES OF PELVIC PAIN

Clinical Features

The most common noninfectious causes of pelvic pain are rupture or torsion of a cyst or a solid ovarian, tubal, or uterine mass. With the exception of rupture of a persistent corpus luteum cyst, all such adnexal accidents occur in patients whose menstrual cycles have been normal, and, except for the pain itself, any other associated localizing or systemic symptoms are unlikely. Most such problems occur in reproductive-age women who commonly have ovarian endometriomas, benign cystic teratomas (dermoid cysts), dysfunctional follicular cysts, or serous or mucinous cystadenomas.

Ovarian enlargement due to cystic or neoplastic processes is usually asymptomatic as a result of poor afferent innervation of ovarian tissue. The patient may experience pelvic and abdominal discomfort due to ovarian pressure on adjacent visceral organs. When ovarian rupture occurs, acute pain is caused by the irritation of pelvic peritoneum, from spillage of ovarian contents. Only in the case of dermoid tumor is this catastrophic, causing a chemical peritonitis.

Confronted with such an acute pelvic problem, there are few specific diagnostic modalities that will be helpful to the ED physician. Most importantly, a complication of pregnancy or an infectious process must be ruled out. Aside from pregnancy testing, other laboratory and routine radiologic studies are of no value. An emergent ultrasound evaluation of the pelvis may be revealing if an adnexal mass cannot be palpated on pelvic examination.

Patient Disposition

If the cyst is detected, but unruptured, the patient should be referred for observation and follow-up. If the cyst has ruptured and there is no evidence of hemorrhage, the patient should be discharged with analgesics.

OVARIAN TORSION

Clinical Features

Ovarian torsion is an uncommon event and will not occur unless limited enlargement has developed. In such a circumstance the enlarging ovarian mass may stretch the mesovarium to the point where the ovary effectively becomes a pedunculated structure that may acutely twist on its pedicle. When torsion occurs, the ovarian blood supply is compromised, causing painful progressive anoxic degeneration of the ovary and eventual gangrenous necrosis. Torsion of tubal masses (hydrosalpinx, pyosalpinx) and pedunculated uterine leiomyomata (fibroids) may also cause acute pelvic pain.

Diagnosis

Patients with this condition usually describe sudden onset of acute, severe, unilateral, lower abdominal and pelvic pain. Up to two thirds of patients describe associated nausea and vomiting often leading to a missed diagnosis of appendicitis. In addition, many patients will recount previous intermittent episodes of similar pain. Pelvic exam reveals a unilateral tender adnexal mass.

Treatment

Laparoscopic treatment by adnexal conservation or removal is the treatment of choice.

MITTELSCHMERZ

Clinical Features

Adnexal pain in the reproductive-age patient may be due to mittelschmerz (middle pain) which is unique to ovulatory cycles. The key to the diagnosis of mittelschmerz is the relationship of the timing of the pain to the menstrual cycle. In a woman with typically regular 28- to 33-day cycles, the pain associated with ovulation will usually occur between cycle days 14 to 16, be unilateral in location, be mild to moderate in severity, and often last less than a day. The pain may also be accompanied by light midcycle endometrial spotting. Although the source of the pain has not exactly been determined, it is thought to be due to follicular fluid irritation of the periovarian visceral peritoneum at the time of ovulation.

Diagnosis and Treatment

No diagnostic studies are helpful in evaluating the possibility of mittelschmerz, and treatment is symptomatic, with analgesics or non-steroidal antiinflammatory agents.

Patient Disposition

Patients should be told the pain will resolve spontaneously and instructed to keep a menstrual calendar noting the timing of the pain to confirm the diagnosis.

ENDOMETRIOSIS

When the tissue that characterizes the normal epithelial lining of the uterine cavity, the endometrium, is found in ectopic locations, it is called endometriosis. Most commonly, endometriosis is found on or in the ovaries. All pelvic tissues, however, are subject to endometriosis growth, including the uterine serosal surface, fallopian tubes, ovarian fossae, uterosacral ligaments, cul-de-sac peritoneum, and the utero-vesical peritoneal fold.

Diagnosis

The diagnosis of endometriosis should be considered in any reproductive-aged women complaining of any one or combination of the following signs and symptoms: acute adnexal pain, premenstrual pelvic pain, worsening dysmenorrhea, and deep dyspareunia. The most serious complication is rupture of an ovarian endometrioma. The approach is that directed at acute adnexal accidents.

Treatment and Patient Disposition

Treatment and Patient Disposition The diagnosis of endometriosis of any extent or variety cannot be made by any combination of historical, examination, laboratory, or radiographic studies. Visual inspection of the disease either at laparoscopy or laparotomy is necessary to confirm the clinical suspicion. Therefore, unless the clinical circumstances warrant immediate operative diagnostic or therapeutic intervention by the gynecology team, the emergency physician should offer the patient analgesia and refer her to a gynecologist for definitive diagnosis and management.

ABNORMAL GENITAL BLEEDING (NONPREGNANCY)

When abnormal bleeding occurs, pregnancy complications such as an ectopic pregnancy, an abortion, or a ruptured corpus luteum cyst will probably be the first considerations. Once these have been ruled out, it is then necessary to systematically consider pathologic and traumatic causes of lower genital tract and uterine bleeding. Except for trauma, the bleeding is usually painless.

Trauma to the vulva and vagina from a variety of causes may result in profuse bleeding and hypotension. Patient stabilization with intravenous fluids is the first priority, and a thorough pelvic examination will easily indicate the bleeding source. In most cases, hemostasis and other indicated surgical procedures will require an anesthetic and the assistance of a gynecologist.

If the bleeding is determined not to be of vulvar, vaginal, rectal, or bladder origin, attention must then be given to the following pathologic causes of uterine cervix or corpus bleeding: (1) erosion of the cervical vasculature by an invasive cervical carcinoma, (2) endometrial carcinoma, (3) endometrial polyps, and (4) submucosal leiomyomata. Pelvic exam will aid in identification of the bleeding source, i.e., if multiple myoma is palpable or a large cervical lesion is visible.

Management of these conditions requires gynecologic consultation after stabilization of the patient.

If pathologic and pregnancy-related causes of uterine bleeding have been eliminated, it is then possible to ascribe the cause of uterine bleeding to that of anovulatory dysfunctional uterine bleeding (DUB). Fortunately, most DUB problems do not require emergency treatment and are comfortably dealt with in an office or clinic setting. Virtually all severe cases of DUB occur in adolescent girls shortly after the onset of menstruation. Bleeding is occasionally severe enough to cause hemorrhagic shock. The ED management of such a patient should follow these suggested steps in an expeditious and overlapping manner:

Ascertain the adolescent perimenarcheal status of the patient and historically rule out a pregnancy. A lack of pain and profuse, tissue-free blood loss dramatically reduces the possibility of a ruptured ectopic pregnancy or spontaneous abortion.

Localize the bleeding source to the uterine cavity and assure normal uterine and adnexal anatomy with a pelvic examination.

Stabilize the patient with intravenous fluids or blood or bloodcomponent transfusions as needed. Obtain the following minimum laboratory studies: (a) complete blood count including platelet count; (b) blood type and Rh factor for a transfusion cross match; (c) pregnancy test; and (d) coagulation profile. Coagulopathies, particularly platelet function disorders, may first manifest as severe perimenarcheal bleeding.

Administer 20 mg of conjugated estrogen intravenously slowly over 10 to 15 min. Acute intravenous estrogen therapy causes vasospasm of the uterine arterial vasculature and initiates several coagulation-related functions that often dramatically decrease the uterine bleeding. Oral estrogen of up to 25 mg can have some effect.

Seek emergency gynecologic consultation for continuing hormonal or surgical management.

OLDER WOMEN WITH DYSFUNCTIONAL UTERINE BLEEDING

More commonly patients do not present with acute blood loss but report a history of prolonged heavy bleeding now complicated by systemic symptoms, i.e., lightheadedness and patagia. Physical exam is usually unremarkable with the exception of vaginal bleeding.

Treatment

If the patient is hemodynamically stable, treatment with the combination oral contraceptive pill; four pills a day for seven days, will arrest the bleeding; alternate doses of progesterone 20 to 30 mg per day for 7 days is useful in patients in whom estrogen is contraindicated.

Patient Disposition

The patient should be told to expect to resume menses after stopping either regimen, take iron for anemia and follow-up with a gynecologic as soon as possible.

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease (PID) is the most common serious infection among reproductive-age women in the United States. It is defined as an ascending infection arising from the cervix causing endometritis, salpingitis, and/or peritonitis. An estimated 2.5 million physician visits occur annually for acute salpingitis, resulting in 250,000 hospitalizations and 150,000 surgical procedures for complications of this disease. The disease causes tubal occlusion in 11% of women after their first episode. Over 25% of women are infertile after two episodes and 50% are infertile after greater than two episodes. Long-term sequelae of salpingooophoritis may include chronic pelvic pain, dyspareunia, infertility due to tubal occlusion or pelvic adhesions, tuboovarian abscess, and an increased risk of tubal ectopic pregnancies. The seriousness of the acute and chronic problems associated with PID makes it mandatory to recognize the diagnosis as early as possible in order to institute early, appropriate, and intensive antibiotic therapy.

Etiology

The etiology of PID is polymicrobial, involving sexually and nonsexually transmitted organisms. Neisseria gonorrhoeae and Chlamydia trachomatis are the major offenders residing first in the cervical canal, then colonizing higher organs through an ascending infection. Secondary invaders are predominately anaerobes, including Bacteroides sp., Peptococcus and Peptostreptococcus, and E. coli.

Pathophysiology

Primary PID is a result of spread of bacteria from the lower genital tract to the normally sterile endometrium and endosalpinx. These bacteria must first bypass the natural barriers to infection, the cervix through its mucus and small diameter canal, the endometrium through the monthly sloughing, and the utero tubojunction via ciliary action.

Risk factors for the development of PID include (1) a history of previous gonococcal salpingitis, (2) frequent sexual activity with multiple partners, (3) adolescence, and (4) use of an intrauterine contraceptive device. As with other sexually transmitted diseases, single, sexually promiscuous, non-white, poor women are most commonly affected. Dilatation and curettage, endometrial biopsy, hysterosalpingography, tubal insufflation, and cautery or cryotherapy of the cervix may also predispose to the development of endometritis and salpingitis.

Protective Factors

Pregnancy offers the best protection as the decidua effectively seals off the uterus from bacterial invasion. However, PID in pregnancy, although rare, can occur because the uterine cavity is not completely sealed until 12 weeks gestation. Infection prior to this time must be aggressively treated to prevent fetal loss. Barrier contraception offers some protection through obvious means as well as through the bactericidal effect of spermicide. Oral contraceptives also offer protection to the user possibly by increasing the density of cervical mucous.

Diagnosis

Acute salpingitis may present with a variety of clinical manifestations including lower abdominal pain, adnexal and cervical motion tenderness, fever and generalized malaise. The discharge of pus from the tubes onto adjacent peritoneal surfaces or around the liver may cause a more localized pain of pelvic peritonitis (Fitz-Hugh Curtis syndrome). Gastrointestinal symptoms of nausea and anorexia are not uncommon and may suggest appendicitis or viral gastroenteritis. Onset frequently occurs shortly after a menstrual flow, but uterine bleeding abnormalities are uncommon. Minimal criteria for diagnosis of PID includes abdominal direct tenderness, adnexal tenderness, cervical motion tenderness, temperature greater than 38°C and leukocytosis (see Table 1). Laboratory studies should include Gram stain to detect gram-negative diplococci, gonococcal and chlamydial cultures, CBC with diff and urine or serum hCG. The finding of unilateral or bilateral adnexal or cul-de-sac masses strongly suggests the presence of a tuboovarian or pelvic abscess.

Of 814 patients with clinically diagnosed acute PID, or with clinically suspected PID, only 65% were confirmed to have the disease at the time of laparoscopy. Remember not every non-white young women with pain and fever has PID. PID uncomplicated by abscess formation is treated with antibiotics. Treatment goals include eradication of infection and preservation of tubal function. Inpatient parenteral (intravenous) antibiotic therapy should be considered for patients who exhibit any of the following criteria: (1) diagnosed or suspected pyosalpinx or tuboovarian abscess, (2) temperature greater than 38°C (100.4°F), (3) pregnancy, (4) nausea and vomiting that prevent the use of oral antibiotics, (5) upper peritoneal sips, (6) presence of an IUCD, (7) failure to respond to oral antibiotics within 48 h, (8) uncertain diagnosis, (9) WBC greater than 12,000, (10) presence of adnexal mass, and (11) primary fertility.

The CDC's (Table 2) most current treatment schedules should be used. The presence of penicillinase producing gonorrhea (PPNC) dictates the use of ceftriaxone 250 mg/m. For those communities in which PPNG is not a problem, follow CDC guidelines. Ambulatory treatment should be reserved for patients with suspected gonorrheal cervicitis, chlamydial cervicitis, or the mildest forms of salpingitis. In all such cases, the treatment regimen must include a 10- to 14-day course of a tetracycline derivative to cover chlamydia and the patient must be reevaluated after 2 days of such therapy. Other outpatient treatment for gonorrhea includes: erythromycin 500 mg P.O. ´ 7 (safe in pregnancy), cefixime 400 mg P.O. (single dose), ciprofloxacin 500 mg P.O. (single dose) or ofloxacin 400 mg P.O. (single dose). Alternative to outpatient treatments for chlamydia are azithromycin 1.0 g m P.O. (single dose), ofloxacin 300 g P.O. qid ´ 7 days, and erythromycin 500 mg P.O. bid ´ 7 days (safe in pregnancy) sulfisoxazole 500 mg P.O. qid for 10 days (inferior to other regimens). Failure to respond to oral outpatient therapy mandates hospitalization and parenteral antimicrobial therapy.

Patient Disposition

Discharged patients should be instructed that they must be seen within 48 hours. Instructions to return prior to 48 hours should include worsening pain or fever and inability to ingest antibiotics.

Other outpatient treatments for gonorrhea include ofloxacin 400 g P.O. XI. Patient education about the scope and severity of the problem along with close follow-up are key.

HEMORRHAGIC CORPUS LUTEUM

The corpus luteum of pregnancy usually persists until the 8th week or so of gestation and frequently is palpable as a 3- to 4-cm adnexal-ovarian mass associated with a normal intrauterine pregnancy. Rupture of the luteal cyst or hemorrhage into the corpus luteum may occur in early pregnancy and cause a clinical picture indistinguishable from that of a ruptured ectopic pregnancy, in terms of the patient's menstrual history and physical examination. An ultrasound examination demonstrating an intrauterine pregnancy will clearly distinguish between the two entities.

More common than a ruptured corpus luteum of pregnancy, however, is the rupture of a persistent corpus luteum in a nonception menstrual cycle. In normal circumstances, the corpus luteum of an ovulatory cycle undergoes spontaneous luteolysis 2 weeks after ovulation. For reasons poorly understood, the corpus luteum may persist for an interval greater than 2 weeks. In such a case, the patient usually will experience amenorrhea for an additional 1 to 3 weeks, after which luteolysis occurs and a heavy menstrual flow results. If the corpus luteum persists and the cyst ruptures, the clinical presentation again could be very similar to that of an ectopic pregnancy or spontaneous abortion. HCG determinations and ultrasonography will be required for differentiation between the possible diagnoses.

Acute rupture of a corpus luteum cyst with consequent hemoperitoneum, in either a pregnant or nonpregnant state, usually requires surgical intervention and ovarian cystectomy. Outpatient management in suspected cases is contraindicated, although expectant management on an inpatient basis may be feasible if, in the judgement of the consultant gynecologist, the clinical picture warrants close observation only.

TABLE 1
Criteria for Clinical Diagnosis of Acute PID

All three of these conditions must be present:

Abdominal direct tenderness with or without rebound tenderness
Tenderness with motion of cervix and uterus
Adnexal tenderness

One of these conditions must be present:

Gram stain of endocervix-positive for gram-negative, intracellular diplococci
Temperature greater than 38°C (100.4°)
Leukocytosis greater than 10,000/mm3 (µL)
White blood cells and bacteria in peritoneal fluid collected by culdocentesis or laparoscopy
Inflammatory mass documented by pelvic examination and/or sonogram

TABLE 2
CDC Recommended Treatment for Acute PID

Outpatients

Cefoxitin 2 g IM plus probenecid, 1g orally or
ceftriaxone 250 mg IM or
equivalent cephalosporin

plus

Doxycycline 100 mg orally 2 times a day for 10–14 days or
Regimen B: Ofloxacin 400 mg PO bid for 14 d plus either clindamycin 450 mg PO qid or metronidazole 500 mg PO bid for 14 d.

Inpatients

Recommended regimen A

Cefoxitin 2 g IV every 6 hours or
Cefotetan 2 g IV every 12 hours
plus
Doxycycline 100 mg every 12 hours orally or IV for at least 48 hours
After hospital discharge, doxycycline 100 mg PO bid for 10–14 days

Recommended regimen B

Clindamycin 900 mg IV every 8 hours
plus
Gentamicin loading dose IV or IM (2 mg/kg) followed by a maintenance dose (1.5 mg/kg) every 8 hours for at least 48 hours

After hospital discharge, doxycycline 100 mg orally 2 times a day for 10-14 days. Continuation of clindamycin, 450 mg orally, 4 times a day for 10-14 days may be considered.

BIBLIOGRAPHY

Carson SA, Buster JE: Ectopic pregnancy. N Engl J Med 329(16): 117, 1993. Centers for Disease Control and Prevention. 1993 sexually transmitted diseases treatment guidelines. MMWR 1993; 42(RR14): 1-102.

Grimes DA, Cates W JR: Family planning and sexually transmitted diseases. In: Holmes KK, Mardh P-A, Sparling PF, Wiesner PJ, eds: Sexually Transmitted Diseases, 2nd ed. New York: McGraw-Hill, 1990:1087-95.

Stovall TG, Ling FW: Some new approaches to ectopic pregnancy. Cont Ob/Gyn 35, 1992.

Stovall TG, Ling FW: Single-dose methotrexate: An expanded clinical trial. Cont Ob/Gyn 168:1759, 1993.