# Clinical Cases: Gynecologic Emergencies

## Case 1: Ruptured Ectopic Pregnancy

### Patient Demographics
- **Age:** 28 years
- **Sex:** Female
- **Occupation:** Graphic designer

### Chief Complaint
"I have sudden severe abdominal pain and I feel dizzy."

### History of Present Illness
The patient presents to the emergency department with sudden onset of severe lower abdominal pain that began 2 hours ago while at work. She describes the pain as sharp and constant, initially localized to the right lower quadrant but now diffuse across her lower abdomen. She felt lightheaded and nearly fainted at work, prompting her coworkers to call an ambulance. She reports right shoulder pain that began about 30 minutes after the abdominal pain started. She has had scant vaginal spotting for the past week. Her last menstrual period was 7 weeks ago, and her periods are usually regular every 28 days. She had unprotected intercourse with her partner, and they have been casually trying to conceive. She has not yet taken a home pregnancy test.

### Past Medical History
- Chlamydia infection treated at age 22
- Pelvic inflammatory disease at age 24, treated with outpatient antibiotics
- G1P0010 (one prior first-trimester surgical abortion at age 20)
- No prior surgeries other than the D&C

### Physical Examination Findings
- **Vital Signs:** BP 88/52 mmHg, HR 124 bpm, RR 22, Temperature 36.8 degrees Celsius, O2 saturation 98% on room air
- **General:** Pale, diaphoretic woman in moderate distress, clutching her abdomen
- **Cardiovascular:** Tachycardic, regular rhythm, weak peripheral pulses
- **Abdomen:** Diffusely tender with involuntary guarding, rebound tenderness throughout, absent bowel sounds, no distension initially noted
- **Pelvic Examination:** Scant dark blood in vaginal vault, cervix closed, exquisite cervical motion tenderness, fullness and tenderness in bilateral adnexa, bulging and tender cul-de-sac

### Diagnostic Workup
- **Urine Pregnancy Test:** Positive
- **Serum beta-hCG:** 8,450 mIU/mL
- **Complete Blood Count:** Hemoglobin 8.2 g/dL (low), Hematocrit 24%, WBC 11,200/microL, Platelets 245,000/microL
- **Type and Screen:** O positive, antibody screen negative
- **Point-of-Care Ultrasound (POCUS) - Bedside:** No intrauterine pregnancy visualized, complex free fluid throughout the abdomen and pelvis, large amount of echogenic fluid (hemoperitoneum) in Morison's pouch and pelvis
- **Formal Transvaginal Ultrasound:** Empty uterus with 6 mm endometrial stripe, no intrauterine gestational sac, large amount of echogenic free fluid in the cul-de-sac, right adnexal mass measuring 3.2 cm with possible extrauterine gestational sac (ring sign)

### Diagnosis
**Ruptured Ectopic Pregnancy** with hemoperitoneum and hemorrhagic shock
- Confirmed by: positive pregnancy test, empty uterus on ultrasound with beta-hCG above discriminatory threshold, right adnexal mass, large hemoperitoneum, hemodynamic instability

### Initial Resuscitation and Management

**Immediate Interventions (within minutes of arrival):**
1. Two large-bore IV access (16-gauge or larger) - bilateral antecubital
2. Activate massive transfusion protocol
3. Send type and crossmatch for 4 units PRBCs
4. Begin crystalloid resuscitation with 1-2 liters warmed lactated Ringer's
5. Obtain O-negative uncrossmatched blood if transfusion needed before crossmatch completed
6. Foley catheter to monitor urine output
7. Call OR for emergent surgery
8. Notify anesthesia and gynecology attending

**Blood Product Administration:**
- 2 units O-negative PRBCs transfused emergently
- Type-specific blood available within 20 minutes
- Goal: maintain hemoglobin >7 g/dL, blood pressure >90 mmHg systolic

### Surgical Management

**Procedure:** Emergent laparoscopic right salpingectomy

**Operative Findings:**
- 1,500 mL of blood and clot evacuated from the peritoneal cavity
- Ruptured right tubal ectopic pregnancy in the ampullary segment with active bleeding from the rupture site
- Left fallopian tube and both ovaries appear grossly normal
- No evidence of endometriosis or adhesions

**Procedure Performed:**
- Right salpingectomy (removal of the right fallopian tube)
- Salpingectomy chosen over salpingostomy because:
  - Ruptured ectopic with hemodynamic instability
  - Salpingostomy associated with higher persistent ectopic rate
  - Left tube appears normal, preserving fertility potential
- Copious irrigation of the pelvis
- Hemostasis achieved

**Intraoperative Management:**
- Total blood loss estimated at 1,800 mL
- 4 units PRBCs, 2 units FFP, 1 unit platelets transfused
- Hemoglobin post-transfusion: 9.8 g/dL
- Hemodynamically stable at end of case

### Postoperative Care

**Immediate Postoperative:**
1. ICU admission for monitoring overnight
2. Serial hemoglobin checks every 6 hours
3. IV fluids until tolerating oral intake
4. Incentive spirometry and DVT prophylaxis

**RhoGAM Administration:**
- Patient is Rh-positive, so RhoGAM not indicated
- *Note:* If Rh-negative, would administer 50 mcg RhoGAM for early pregnancy loss or 300 mcg if beyond 12 weeks

**Day 1 Postoperative:**
- Hemodynamically stable
- Hemoglobin stable at 9.4 g/dL
- Tolerating regular diet
- Ambulatory
- Transferred to floor

**Discharge Planning (Day 2):**
1. Oral iron supplementation for 3 months
2. Pelvic rest for 2 weeks
3. Follow-up beta-hCG in 1 week (should be undetectable)
4. Contraception counseling until ready for pregnancy
5. Future fertility counseling

**Future Pregnancy Counseling:**
- Risk of recurrent ectopic pregnancy: 10-15% (elevated due to history of PID and prior ectopic)
- Early ultrasound recommended in any future pregnancy (at 6 weeks) to confirm intrauterine location
- One remaining fallopian tube - pregnancy still possible
- If difficulty conceiving, may need IVF

**Follow-up:**
- Beta-hCG 1 week post-op: <5 mIU/mL (appropriately undetectable)
- 2-week postoperative visit: incisions healing well, no complications
- Histopathology confirmed ectopic pregnancy in right fallopian tube

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

**Image Description:** Transvaginal ultrasound demonstrating findings of ectopic pregnancy. The image shows an empty uterus without an intrauterine gestational sac (left panel). The right adnexa shows a tubal ring sign representing the extrauterine gestational sac with surrounding echogenic free fluid consistent with hemoperitoneum (right panel). These findings in the presence of a positive pregnancy test are diagnostic of ectopic pregnancy.

**Attribution:** Ectopic pregnancy ultrasound findings as described in Radiopaedia (https://radiopaedia.org/articles/ectopic-pregnancy) and radiology literature.

---

## Case 2: Ovarian Torsion

### Patient Demographics
- **Age:** 19 years
- **Sex:** Female
- **Occupation:** College student

### Chief Complaint
"I woke up with sudden severe pain on my right side and I keep throwing up."

### History of Present Illness
The patient presents to the emergency department at 3 AM with sudden onset of severe right lower quadrant pain that woke her from sleep approximately 4 hours ago. She describes the pain as sharp and stabbing, rated 10 out of 10, constant but with intermittent worsening episodes. She has vomited four times since the pain started. She denies any recent trauma or strenuous activity. She recalls having similar but milder episodes of right-sided pain twice in the past 2 months that resolved spontaneously after a few hours. She denies vaginal bleeding, discharge, or dysuria. Her last menstrual period was 2 weeks ago and was normal. She is sexually active with one male partner and uses condoms inconsistently. She has no history of sexually transmitted infections.

### Past Medical History
- Previously healthy
- No prior surgeries
- Menarche age 12, regular cycles
- G0

### Physical Examination Findings
- **Vital Signs:** BP 142/88 mmHg, HR 108 bpm, RR 20, Temperature 37.2 degrees Celsius
- **General:** Young woman in severe distress, lying very still, intermittently writhing with pain
- **Abdomen:** Soft but tender in the right lower quadrant extending to the right flank, voluntary guarding, mild rebound tenderness on the right, no distension, hypoactive bowel sounds
- **Pelvic Examination:** External genitalia normal, no vaginal discharge, cervix appears normal, uterus normal size and non-tender, right adnexal tenderness with palpable fullness, left adnexa non-tender

### Diagnostic Workup
- **Urine Pregnancy Test:** Negative
- **Complete Blood Count:** WBC 13,400/microL (mildly elevated), Hemoglobin 13.2 g/dL, Platelets 268,000/microL
- **Urinalysis:** Negative for infection, no hematuria
- **Transvaginal Ultrasound:**
  - Right ovary markedly enlarged at 8.5 x 6.2 x 5.8 cm (normal <3 cm3)
  - Right ovary contains a 4-cm simple cyst
  - Peripheral follicles displaced by central stromal edema
  - Color Doppler: Diminished arterial flow to the right ovary compared to left
  - Left ovary normal (2.8 cm3), normal arterial flow
  - Small amount of free fluid in the cul-de-sac
  - Uterus normal

### Diagnosis
**Right Ovarian Torsion** with associated ovarian cyst
- Clinical presentation strongly suggestive: sudden severe unilateral pain with nausea/vomiting
- Ultrasound findings supportive: enlarged edematous ovary with diminished Doppler flow
- Prior intermittent episodes consistent with intermittent torsion/detorsion

### Key Teaching Point
**Normal Doppler flow does NOT exclude ovarian torsion.** Clinical suspicion alone warrants surgical exploration. This patient has diminished but present flow - some patients with torsion have preserved flow due to dual blood supply or intermittent torsion.

### Management

**Decision for Emergent Surgery:**
- Clinical presentation and ultrasound findings highly suspicious for torsion
- Time-sensitive emergency - delays lead to irreversible ovarian necrosis
- Proceed to operating room without further imaging

**Procedure:** Emergent diagnostic laparoscopy with right ovarian detorsion and cystectomy

**Operative Findings:**
- Right ovary torsed 720 degrees (two complete twists) on its pedicle
- Right ovary enlarged, edematous, and dusky blue-purple in color
- 4-cm simple ovarian cyst present
- Left ovary and both fallopian tubes normal
- No endometriosis or adhesions

**Surgical Procedure:**
1. **Detorsion:** The ovary was untwisted counterclockwise
2. **Observation period:** Warm saline irrigation applied; ovary observed for 10-15 minutes
3. **Color return:** Ovary gradually regained pink coloration indicating return of arterial perfusion
4. **Cystectomy:** Simple cyst enucleated to reduce risk of recurrent torsion
5. **Oophoropexy:** Ovary sutured to the pelvic sidewall using permanent suture to prevent recurrence
6. **Decision NOT to remove ovary:** Despite initial dusky appearance, the ovary was preserved because:
   - Young patient with desire for future fertility
   - Evidence of reperfusion after detorsion
   - Studies show ovarian function often recovers even when ovary appears necrotic

**Why Preserve the Ovary?**
- Multiple studies demonstrate that ovaries appearing "nonviable" at surgery often regain function
- Oophorectomy should be reserved for clearly necrotic ovaries (black, no reperfusion)
- Fertility preservation is paramount in young patients
- Follow-up ultrasound can assess ovarian function

### Postoperative Course

**Day 0 (POD #0):**
- Pain controlled with oral analgesics
- Tolerating clear liquids
- Ambulating

**Day 1 (POD #1):**
- Discharged home on oral ibuprofen and acetaminophen
- Instructions provided for wound care and activity restrictions

**Discharge Instructions:**
1. Pelvic rest for 2 weeks
2. No heavy lifting for 4 weeks
3. Report fever, worsening pain, or unusual vaginal discharge
4. Follow-up in 2 weeks for wound check
5. Follow-up ultrasound in 6-8 weeks to assess ovarian viability

**6-Week Follow-up:**
- Healing well, no complications
- **Follow-up Ultrasound:**
  - Right ovary now measures 4.2 x 3.1 x 2.8 cm (normal size)
  - Normal follicular development visualized
  - Doppler flow normal and symmetric bilaterally
  - Left ovary unchanged, normal
- **Conclusion:** Right ovary has recovered function

**Pathology of Cyst:**
- Simple serous cystadenoma (benign)

### Clinical Image
![Ovarian Torsion Ultrasound and Laparoscopy](image_02.jpg)

**Image Description:** Panel A shows transvaginal ultrasound of an enlarged right ovary with peripheral follicles displaced by central stromal edema, characteristic of ovarian torsion. Panel B shows the corresponding laparoscopic view of the torsed ovary with dusky discoloration prior to detorsion. Panel C shows the same ovary after detorsion with return of pink coloration indicating restored perfusion.

**Attribution:** Ovarian torsion ultrasound images available on Wikimedia Commons, Category: Ultrasound images of ovarian torsion (https://commons.wikimedia.org/wiki/Category:Ultrasound_images_of_ovarian_torsion).

---

## Case 3: Acute Hemorrhagic Uterine Bleeding

### Patient Demographics
- **Age:** 16 years
- **Sex:** Female
- **Occupation:** High school student

### Chief Complaint
"I've been bleeding heavily for 3 weeks and I feel really weak and dizzy."

### History of Present Illness
The patient is brought to the emergency department by her mother due to heavy vaginal bleeding for the past 3 weeks. She reports soaking through a super tampon and pad every 1-2 hours around the clock, passing large clots "the size of golf balls," and having to wake up multiple times at night to change protection. She feels weak, lightheaded, especially when standing, and has had to miss 2 weeks of school. She denies abdominal pain. Her mother reports the patient has appeared increasingly pale over the past week. The patient had menarche at age 12. Her periods have always been irregular, occurring every 2-6 weeks, and have been heavy since menarche. This is the worst bleeding episode she has experienced. She denies sexual activity. She denies easy bruising, bleeding gums, or nosebleeds.

### Past Medical History
- Heavy menstrual bleeding since menarche
- Never evaluated or treated for menstrual problems
- No history of bleeding disorders
- No prior surgeries
- Denies sexual activity

### Family History
- Mother: Heavy periods, had hysterectomy at age 38
- Maternal aunt: History of "bleeding problems"
- No known diagnosed bleeding disorders in family

### Physical Examination Findings
- **Vital Signs:** BP 92/58 mmHg (supine), HR 118 bpm (supine), standing BP 78/50 mmHg with HR 142 bpm (positive orthostatic changes), RR 20, Temperature 37.0 degrees Celsius
- **General:** Pale, fatigued-appearing adolescent, alert but anxious
- **Skin:** Pallor of conjunctivae and nail beds, no petechiae, no purpura, no ecchymoses
- **Cardiovascular:** Tachycardic, regular rhythm, grade II/VI systolic flow murmur (likely anemia-related)
- **Abdomen:** Soft, non-tender, non-distended
- **External Genitalia:** Normal female, blood present at introitus, active moderate bleeding visualized
- **Speculum/Bimanual Examination:** Deferred given patient denies sexual activity and is hemodynamically unstable

### Diagnostic Workup
- **Urine Pregnancy Test:** Negative (confirmed not pregnant)
- **Complete Blood Count:**
  - Hemoglobin: 5.8 g/dL (severe anemia)
  - Hematocrit: 17.4%
  - MCV: 68 fL (microcytic)
  - WBC: 7,200/microL (normal)
  - Platelets: 412,000/microL (reactive thrombocytosis)
  - Reticulocyte count: 4.2% (appropriate response)
- **Iron Studies:**
  - Ferritin: 4 ng/mL (severely depleted)
  - Iron: 18 mcg/dL (low)
  - TIBC: 485 mcg/dL (elevated)
- **Coagulation Studies:**
  - PT/INR: 12.8 seconds / 1.0 (normal)
  - PTT: 42 seconds (mildly prolonged; normal <35)
- **Additional Workup for Bleeding Disorder:**
  - **Von Willebrand Panel:**
    - VWF antigen: 28% (low; normal >50%)
    - VWF activity (Ristocetin cofactor): 22% (low)
    - Factor VIII: 35% (low)
  - **Blood type:** A positive
- **TSH:** 2.8 mIU/L (normal)

### Diagnosis
1. **Severe Acute Blood Loss Anemia** (Hemoglobin 5.8 g/dL) secondary to:
2. **Acute Abnormal Uterine Bleeding - Heavy Menstrual Bleeding** secondary to:
3. **Von Willebrand Disease Type 1** (newly diagnosed)

### Management

**Immediate Resuscitation:**
1. Two large-bore IV lines established
2. IV fluid bolus: 1 liter normal saline
3. Blood bank: Type and crossmatch for 3 units PRBCs
4. **Blood transfusion initiated:**
   - 2 units packed red blood cells transfused
   - Goal hemoglobin >8 g/dL initially

**Medical Hemostasis - Multi-Agent Approach:**

*Given severe bleeding and newly diagnosed VWD, aggressive multimodal therapy initiated:*

1. **Tranexamic Acid (TXA):**
   - Loading dose: 1 gram IV over 10 minutes
   - Maintenance: 1 gram IV every 8 hours
   - Antifibrinolytic - stabilizes clots at endometrial surface

2. **High-Dose IV Conjugated Estrogens:**
   - 25 mg IV every 4-6 hours for first 24 hours
   - Rapidly stabilizes the endometrium
   - Maximum 6 doses

3. **High-Dose Combined Oral Contraceptive (once tolerating oral):**
   - Monophasic OCP containing 30-35 mcg ethinyl estradiol
   - One tablet every 8 hours until bleeding controlled (usually 24-48 hours)
   - Then taper to one tablet every 12 hours x 2 days
   - Then one tablet daily (continuous, no placebo week initially)

4. **Von Willebrand Disease-Specific Treatment:**
   - Hematology consultation emergently
   - **Desmopressin (DDAVP):** 0.3 mcg/kg IV (releases VWF from endothelial stores)
   - Check VWF levels 1 hour after DDAVP to confirm response
   - May need VWF concentrate (Humate-P) if DDAVP response inadequate

**Monitoring:**
- Serial hemoglobin every 6 hours initially
- Pad/tampon counts to quantify bleeding
- Strict intake/output
- Monitor for fluid overload with IV estrogen

**Clinical Course:**

*Day 1:*
- Received 2 units PRBCs, hemoglobin rose to 7.4 g/dL
- IV estrogen and TXA initiated
- DDAVP given with good response (VWF rose to 85%)
- Bleeding significantly reduced within 12 hours

*Day 2:*
- Hemoglobin stable at 7.8 g/dL
- Bleeding controlled, using 2-3 pads per day
- Transitioned to oral OCP (1 tablet every 8 hours)
- IV estrogen discontinued
- Oral TXA started (1.3 grams TID)

*Day 3:*
- Hemoglobin 8.2 g/dL
- Bleeding minimal
- Transitioned to OCP every 12 hours
- Oral iron started (ferrous sulfate 325 mg TID)
- Discharged home

**Discharge Plan:**

1. **Continued OCP taper:**
   - Every 12 hours x 2 days, then daily
   - Continue continuous (no placebo week) for 3 months to allow endometrial healing and iron repletion

2. **Oral Tranexamic Acid:** 1.3 grams PO TID during heavy bleeding

3. **Iron Supplementation:** Ferrous sulfate 325 mg three times daily with vitamin C to enhance absorption; continue for 3-6 months

4. **Hematology Follow-up:**
   - Confirm VWD Type 1 diagnosis
   - Develop bleeding precautions and treatment plan
   - Medical alert bracelet
   - Counsel about surgical/procedural bleeding risk

5. **Gynecology Follow-up:**
   - 2-week appointment to assess response
   - Long-term management with continuous hormonal therapy
   - May consider LNG-IUD when older for long-term management

**Von Willebrand Disease Education:**
- Most common inherited bleeding disorder
- Type 1 is most common (75% of cases) - quantitative deficiency
- Menorrhagia is the most common symptom in affected females
- All adolescents with heavy menstrual bleeding since menarche should be screened
- Treatment options: DDAVP, TXA, VWF concentrates, hormonal management

### Clinical Image
![Intrauterine Balloon Tamponade](image_03.jpg)

**Image Description:** Illustration demonstrating intrauterine balloon tamponade technique for emergency control of uterine hemorrhage. A Foley catheter with a 30-mL balloon is inserted through the cervix and inflated within the uterine cavity, providing mechanical compression of the endometrial surface. This technique can be life-saving as a bridge to definitive treatment in cases of severe acute uterine bleeding.

**Attribution:** Educational illustration of intrauterine balloon tamponade as described in emergency gynecology literature and ACOG management guidelines for acute abnormal uterine bleeding.

---

## Summary of Key Learning Points

1. **Ruptured ectopic pregnancy** is a surgical emergency requiring simultaneous resuscitation and emergent operative intervention; salpingectomy is the procedure of choice for ruptured ectopic in an unstable patient

2. **Ovarian torsion** presents with sudden severe unilateral pain and vomiting; **normal Doppler flow does NOT exclude torsion** - clinical suspicion alone warrants surgery; preserve the ovary whenever possible even if it appears dusky

3. **Acute hemorrhagic uterine bleeding** requires multimodal medical management with IV estrogen, tranexamic acid, and high-dose hormonal therapy; all adolescents with heavy menstrual bleeding since menarche should be screened for bleeding disorders (especially von Willebrand disease)

4. **Hemorrhagic shock classification:**
   - Class I: <15% blood loss - minimal changes
   - Class II: 15-30% - tachycardia, narrowed pulse pressure
   - Class III: 30-40% - hypotension, tachycardia >120, confusion
   - Class IV: >40% - severe hypotension, lethargy

5. **Massive transfusion protocol** should be activated early with balanced 1:1:1 ratio (PRBCs:FFP:platelets); tranexamic acid should be given within 3 hours of hemorrhage onset

6. **Fertility preservation** is paramount in young patients - avoid oophorectomy unless ovary is clearly necrotic; salpingectomy is preferred over salpingostomy in ruptured ectopic to reduce persistent ectopic rates

7. **Risk factors for ectopic pregnancy:** prior ectopic, prior tubal surgery, PID history, IUD use, assisted reproduction, smoking, advanced maternal age