# Clinical Cases: Obstetric and Gynecologic Emergencies

## Case 1: Ectopic Pregnancy - The Ruptured Tubal Pregnancy

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Elementary school teacher

### Chief Complaint
"I have severe pain in my lower belly and I feel like I'm going to pass out."

### History of Present Illness
A 28-year-old female presents with sudden onset of severe left lower quadrant abdominal pain that began 2 hours ago. She reports associated lightheadedness, especially when standing. Her last menstrual period was 7 weeks ago, and she typically has regular cycles. She reports recent vaginal spotting (light) for 3 days. She has not had a positive home pregnancy test.

### Initial Assessment

**ESI Level:** 1 - Hemodynamically unstable with suspected ruptured ectopic

**First Impression:**
- Appearance: Pale, diaphoretic, in obvious distress
- Work of breathing: Mildly tachypneic
- Circulation: Pale, clammy skin

**Vital Signs:**
- Heart rate: 124 bpm
- Blood pressure: 86/52 mmHg (supine)
- Respiratory rate: 22 breaths/min
- SpO2: 98% on room air
- Temperature: 36.8C

**Orthostatic Assessment (not performed due to hypotension)**

### Primary Survey

**Airway:** Patent
**Breathing:** Tachypneic, clear lungs
**Circulation:** Tachycardic, hypotensive, weak peripheral pulses, cap refill 4 seconds
**Disability:** Alert but anxious, GCS 15
**Exposure:** No external hemorrhage, abdomen distended

### Resuscitation

**Immediate Interventions:**
1. Two large-bore IVs (16-gauge)
2. Aggressive crystalloid resuscitation: 2L LR bolus
3. Type and crossmatch for 4 units PRBCs
4. Activate massive transfusion protocol standby
5. Point-of-care pregnancy test
6. Bedside ultrasound

**Point-of-Care Results:**
- Urine pregnancy test: POSITIVE
- Hemoglobin: 7.2 g/dL (critical)

### Bedside Ultrasound (FAST + Pelvic)

**Findings:**
- **Free fluid:** Significant free fluid in Morison's pouch and pelvis
- **Uterus:** Empty - no intrauterine pregnancy (IUP)
- **Adnexa:** Left adnexal mass with surrounding complex free fluid
- **Interpretation:** Ruptured ectopic pregnancy with hemoperitoneum

### Secondary Survey

**SAMPLE History:**
- Symptoms: Sudden severe LLQ pain, lightheadedness, vaginal spotting
- Allergies: None
- Medications: None
- PMH: Chlamydia infection 3 years ago (treated), 1 prior pregnancy (G1P1)
- LMP: 7 weeks ago
- Last Meal: Lunch 4 hours ago
- Events: Sudden onset pain

**Risk Factors for Ectopic Pregnancy:**
- Prior pelvic infection (chlamydia) - PRESENT
- Tubal surgery - No
- Prior ectopic - No
- IUD use - No
- Infertility treatment - No
- Smoking - No

**Physical Examination:**

**Abdominal:**
- Distended
- Diffusely tender, worse LLQ
- Guarding and rebound present
- Involuntary rigidity

**Pelvic Exam (performed by OB/GYN):**
- Scant dark blood in vaginal vault
- Cervical os closed
- Significant cervical motion tenderness
- Left adnexal tenderness with mass
- Cul-de-sac fullness

### Diagnostic Testing

**Labs:**
- CBC: Hgb 7.2, Hct 22%, Plt 234
- Type and screen: O positive
- Quantitative beta-hCG: 4,200 mIU/mL
- Coagulation: PT/INR normal, PTT normal

**Transvaginal Ultrasound (if stable - not performed here due to hemodynamic instability):**
- Would show empty uterus, adnexal mass, free fluid

### Diagnosis

**Ruptured left tubal ectopic pregnancy** with hemorrhagic shock

### Management

**Resuscitation Continued:**
- Total 3L crystalloid
- 2 units PRBCs transfused
- Vitals improved: HR 108, BP 98/64

**Emergency OB/GYN Consultation:**
- Emergent operative intervention indicated
- Patient consented for surgery

**Surgical Management:**
- Emergent laparoscopy (converted to laparotomy due to hemorrhage)
- 1.5L hemoperitoneum evacuated
- Ruptured left tubal ectopic identified
- Left salpingectomy performed
- Estimated blood loss: 2L total

### Disposition
- Post-operative recovery
- Total transfusion: 4 units PRBCs
- Stable post-operatively
- Discharged POD 2
- OB/GYN follow-up arranged
- Counseling regarding future fertility

### Teaching Points

1. **Think ectopic:** Any reproductive-age female with abdominal pain - pregnancy test first
2. **Ruptured ectopic is surgical emergency:** Hemodynamically unstable patients go to OR, not radiology
3. **Discriminatory zone:** Beta-hCG >2000-3000 should show IUP on TVUS; absence suggests ectopic
4. **Bedside ultrasound:** Identify free fluid and empty uterus to support diagnosis
5. **Hemorrhage management:** Aggressive resuscitation, blood products, and surgical control
6. **Risk factors:** Prior STI, ectopic, tubal surgery increase risk significantly
7. **Future fertility:** Counsel regarding increased risk of recurrent ectopic

### Clinical Image
![Transvaginal Ultrasound - Ectopic Pregnancy](case_01_image.jpg)

**Image Description:** Transvaginal ultrasound demonstrating an empty uterus with an adnexal mass (tubal ring sign) and surrounding free fluid, consistent with ectopic pregnancy.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Yuranga Weerakkody. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/ectopic-pregnancy-tubal

---

## Case 2: Placental Abruption - Third Trimester Bleeding

### Patient Demographics
- **Age:** 32 years
- **Sex:** Female
- **Occupation:** Nurse

### Chief Complaint
"I'm 34 weeks pregnant and having severe abdominal pain with bleeding."

### History of Present Illness
A 32-year-old G2P1 at 34 weeks gestation presents with sudden onset of severe constant abdominal pain and vaginal bleeding that began 1 hour ago. She describes the pain as "the worst ever" - different from contractions she experienced in her first pregnancy. She reports decreased fetal movement since the pain started. Her pregnancy has been uncomplicated until now.

### Initial Assessment

**ESI Level:** 1 - Obstetric emergency

**First Impression:**
- Appearance: Distressed, clutching abdomen
- Work of breathing: Tachypneic
- Circulation: Pale

**Vital Signs:**
- Heart rate: 118 bpm
- Blood pressure: 100/62 mmHg
- Respiratory rate: 24 breaths/min
- SpO2: 97% on room air
- Temperature: 37.1C

**Fetal Heart Tones:** 168 bpm with decreased variability (continuous monitoring initiated)

### Primary Survey

**Airway:** Patent
**Breathing:** Tachypneic, clear lungs
**Circulation:** Tachycardic, borderline hypotensive, pale
**Disability:** Alert, GCS 15, severe pain
**Exposure:** Vaginal bleeding (moderate), rigid abdomen

### Resuscitation

**Immediate Interventions:**
1. Left lateral decubitus positioning (avoid IVC compression)
2. Two large-bore IVs
3. Crystalloid bolus initiated
4. Type and crossmatch 4 units PRBCs
5. OB/GYN STAT consultation
6. Continuous fetal monitoring
7. Neonatology notification

### Third Trimester Bleeding - Differential Diagnosis

| Condition | Pain | Bleeding | Uterine Tone | Fetal Status |
|-----------|------|----------|--------------|--------------|
| **Placental Abruption** | Severe, constant | Variable (may be concealed) | Rigid, tetanic | Often compromised |
| Placenta Previa | Painless | Bright red, profuse | Soft | Usually stable initially |
| Vasa Previa | Minimal | With ROM, dark blood | Soft | Rapidly compromised |
| Uterine Rupture | Severe | Variable | May lose contour | Compromised |

**This presentation is most consistent with placental abruption**

### Secondary Survey

**SAMPLE History:**
- Symptoms: Sudden severe abdominal pain, vaginal bleeding, decreased fetal movement
- Allergies: None
- Medications: Prenatal vitamins
- PMH: G2P1, prior SVD at term, no complications
- LMP: N/A (34 weeks pregnant)
- Events: Sudden onset while at work

**Risk Factors for Abruption:**
- Hypertension/preeclampsia: Blood pressure has been normal
- Trauma: Denies
- Cocaine use: Denies
- Prior abruption: No
- Advanced maternal age: No
- Smoking: No

**Physical Examination:**

**Abdominal/Uterine:**
- Uterus rigid, "board-like"
- Severe tenderness diffusely
- Fundal height >dates (may indicate concealed hemorrhage)
- Unable to palpate fetal parts (uterine tension)

**Pelvic Exam (NO DIGITAL EXAM until placenta previa ruled out):**
- Sterile speculum: Dark blood in vaginal vault
- Cervix visualized: Closed, no placenta visible
- Digital exam (after US): 2cm/50%/−2 station

### Diagnostic Testing

**Labs:**
- CBC: Hgb 9.8 (baseline 11.2), Plt 142
- Type and screen: A positive
- Fibrinogen: 180 mg/dL (low - DIC concern)
- PT/INR: 14.2/1.3
- PTT: 38
- BMP: Normal except K 5.1

**Bedside Ultrasound:**
- Retroplacental clot visualized
- Fetal heart rate present but with minimal variability
- Biophysical profile: 4/10

**Fetal Monitoring:**
- Fetal heart rate: 170 bpm baseline
- Minimal variability
- Recurrent late decelerations
- Sinusoidal pattern emerging - OMINOUS

### Diagnosis

**Severe placental abruption** with:
- Fetal compromise (non-reassuring tracing)
- Maternal hemorrhage
- Early DIC

### Management

**Emergency Cesarean Section Decision:**
- Non-reassuring fetal status with late decelerations
- Maternal hemorrhage with DIC
- Decision-to-incision time goal: <30 minutes

**Pre-operative Interventions:**
- 2 units PRBCs transfusing
- FFP ordered for coagulopathy
- Anesthesia at bedside
- Neonatology in OR

**Cesarean Section Findings:**
- 40% placental abruption with 500mL retroplacental clot
- Couvelaire uterus (blood infiltrating myometrium)
- Live female infant delivered - vigorous after brief resuscitation
- Apgars: 5, 7, 9
- EBL: 1.5L

### Disposition

**Mother:**
- ICU admission for monitoring
- Total transfusion: 4 units PRBCs, 2 units FFP
- Fibrinogen improved with transfusion
- Stable, transferred to postpartum floor POD 1
- Discharged POD 4

**Neonate:**
- Birth weight: 2.1 kg (appropriate for 34 weeks)
- Brief respiratory support, weaned to room air
- NICU admission for prematurity
- Discharged at 2 weeks of life

### Teaching Points

1. **Painful third trimester bleeding = abruption until proven otherwise**
2. **Concealed hemorrhage:** Amount of visible bleeding doesn't correlate with severity; 20% of abruptions have no external bleeding
3. **DIC risk:** Abruption releases thromboplastin; monitor coagulation closely
4. **Fetal monitoring is critical:** Non-reassuring tracing mandates urgent delivery
5. **No digital exam until previa ruled out:** Risk of catastrophic hemorrhage with previa
6. **Ultrasound sensitivity is limited:** May not visualize all abruptions; clinical diagnosis
7. **Rhogam:** Give to Rh-negative mothers after any significant bleeding

### Clinical Image
![Ultrasound showing Placental Abruption](case_02_image.jpg)

**Image Description:** Obstetric ultrasound demonstrating a retroplacental hematoma (arrow) separating the placenta from the uterine wall, consistent with placental abruption.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Hani Salam. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/placental-abruption-2

---

## Case 3: Ovarian Torsion - The Acute Surgical Abdomen

### Patient Demographics
- **Age:** 22 years
- **Sex:** Female
- **Occupation:** College student

### Chief Complaint
"The pain in my side is unbearable and I keep throwing up."

### History of Present Illness
A 22-year-old female presents with sudden onset of severe right lower quadrant pain that began 6 hours ago. Pain is constant, sharp, and radiates to her back. She has had 5 episodes of vomiting. She was in her normal state of health prior to onset. She denies fever or urinary symptoms. LMP was 2 weeks ago, and she has a history of an ovarian cyst found incidentally 6 months ago on imaging for unrelated symptoms.

### Initial Assessment

**ESI Level:** 2 - Severe pain, potential surgical emergency

**First Impression:**
- Appearance: Writhing in pain, pale, diaphoretic
- Work of breathing: Normal, but splinting due to pain
- Circulation: Pale but well-perfused

**Vital Signs:**
- Heart rate: 108 bpm
- Blood pressure: 138/82 mmHg (pain response)
- Respiratory rate: 20 breaths/min
- SpO2: 99% on room air
- Temperature: 37.3C

### Primary Survey

**Airway:** Patent
**Breathing:** Normal effort
**Circulation:** Tachycardic (pain), good perfusion
**Disability:** Alert, GCS 15, severe pain (10/10)
**Exposure:** No abnormalities

### Key Clinical Feature: Waxing and Waning Pain

Patient reports the pain is constant but with episodes of more severe "waves" - this pattern is classic for torsion (intermittent torsion/detorsion)

### Secondary Survey

**SAMPLE History:**
- Symptoms: Sudden RLQ pain, nausea/vomiting, no fever
- Allergies: None
- Medications: Oral contraceptives
- PMH: 5cm right ovarian cyst on US 6 months ago (was to follow up but didn't)
- LMP: 2 weeks ago, regular cycles
- Last Meal: Breakfast this morning
- Events: Sudden onset during class

**Risk Factors for Ovarian Torsion:**
- Ovarian cyst/mass >5cm - YES (known cyst)
- Ovarian hyperstimulation - No
- Pregnancy - Pending test
- Prior torsion - No

**Physical Examination:**

**Abdominal:**
- RLQ tenderness with guarding
- No rebound (early)
- No peritoneal signs
- Normoactive bowel sounds

**Pelvic Exam:**
- External: Normal
- Speculum: No discharge or bleeding
- Bimanual: Right adnexal tenderness and fullness, cervical motion tenderness minimal

### Diagnostic Testing

**Point-of-Care:**
- Urine pregnancy test: Negative
- Urinalysis: Normal (ruling out UTI/stone)

**Labs:**
- CBC: WBC 12.4, Hgb 12.8
- BMP: Normal
- Lipase: Normal

**Pelvic Ultrasound with Doppler:**
- Right ovary enlarged (8cm) with peripheral follicles ("string of pearls")
- Complex cystic structure within right ovary
- **Absent Doppler flow to right ovary** - CRITICAL FINDING
- Left ovary normal
- No free fluid

### Diagnosis

**Right ovarian torsion** (likely on background of ovarian cyst)

### Management

**Time-Sensitive Surgical Emergency:**
- Ovarian viability decreases with time
- Goal: Detorsion within 6-8 hours for best salvage rate

**Pre-Operative:**
1. NPO status
2. IV fluid hydration
3. Pain management: Morphine 4mg IV + Ketorolac 30mg IV
4. Antiemetic: Ondansetron 4mg IV
5. Emergent OB/GYN consultation

**Surgical Management:**
- Diagnostic laparoscopy
- Right ovarian torsion confirmed (720-degree twist)
- Ovary initially dusky/blue
- Detorsion performed
- Ovary observed - color improved over 10 minutes
- Ovarian cystectomy performed (dermoid cyst found)
- Ovary preserved (oophoropexy considered but not performed)

### Disposition
- Post-operative recovery
- Oral intake tolerated
- Discharged home POD 1
- OB/GYN follow-up in 2 weeks
- Education on warning signs of recurrence

### Teaching Points

1. **Think torsion in young women with acute unilateral pelvic pain and vomiting**
2. **Ovarian cysts/masses are risk factors:** Cysts >5cm more likely to torse
3. **Doppler ultrasound:** Absent or decreased flow is concerning, but presence of flow doesn't rule out torsion (intermittent)
4. **"Whirlpool sign":** Twisted vascular pedicle on ultrasound is pathognomonic
5. **Surgery is diagnostic AND therapeutic:** Don't delay for definitive imaging if clinical suspicion high
6. **Ovarian salvage possible:** Even dusky-appearing ovaries often recover after detorsion
7. **Pregnancy increases risk:** Corpus luteum cysts and hormonal changes predispose to torsion
8. **Recurrence:** 10% risk; consider oophoropexy in high-risk patients

### Clinical Image
![Pelvic Ultrasound - Ovarian Torsion](case_03_image.jpg)

**Image Description:** Transvaginal ultrasound with Doppler demonstrating an enlarged ovary with peripheral follicles and absent central Doppler flow (arrow), consistent with ovarian torsion.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. Amanda Er. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/ovarian-torsion-ultrasound-1