Medical School · Year 3 · Obgyn · includes a quiz and discussion video

Seminar 20: Gynecologic Emergencies

OB/GYN Clerkship

Learning Objectives

By the end of this seminar, students will be able to:

1. Construct a systematic differential diagnosis for acute pelvic pain in women of reproductive age incorporating both gynecologic and non-gynecologic etiologies
2. Diagnose and manage ruptured ectopic pregnancy as a surgical emergency including resuscitation, operative decision-making, and postoperative care
3. Recognize the clinical presentation of ovarian torsion and apply the principle that normal Doppler flow does not exclude torsion, necessitating surgical exploration based on clinical suspicion
4. Differentiate the management of hemodynamically stable from unstable patients with ruptured ovarian cysts and acute abnormal uterine bleeding
5. Provide trauma-informed care for sexual assault survivors including evidence collection, STI prophylaxis, emergency contraception, and psychological support
6. Apply hemorrhagic shock classification and massive transfusion protocols to gynecologic emergencies requiring resuscitation and emergent surgical intervention

Seminar Outline

Section 1: Approach to Acute Pelvic Pain

Acute pelvic pain in women of reproductive age demands a systematic diagnostic approach because the differential diagnosis encompasses life-threatening surgical emergencies, including ruptured ectopic pregnancy, ovarian torsion, and ruptured tubo-ovarian abscess, as well as common but less urgent conditions. The gynecologic differential includes ectopic pregnancy, ovarian torsion, ruptured ovarian cyst, pelvic inflammatory disease with tubo-ovarian abscess, degenerating uterine leiomyoma, and endometriosis-related pain. Non-gynecologic conditions that may present with acute pelvic pain include appendicitis, which must be considered in any woman with right lower quadrant pain, diverticulitis, nephrolithiasis, urinary tract infection and pyelonephritis, and bowel obstruction. The overlap in symptom presentation between gynecologic and non-gynecologic conditions makes the initial evaluation critically important for directing appropriate management.

The initial assessment of a patient presenting with acute pelvic pain begins with evaluation of hemodynamic stability, as tachycardia, hypotension, or signs of peritoneal irritation may indicate a surgical emergency requiring immediate intervention. A focused history should include the last menstrual period, sexual activity and contraceptive use, pain characteristics including location, onset (sudden versus gradual), quality (sharp, crampy, constant), radiation, and aggravating or alleviating factors. Associated symptoms including nausea, vomiting, vaginal bleeding, fever, urinary symptoms, and bowel changes provide additional diagnostic clues. A pregnancy test with serum beta-hCG is the single most important initial laboratory test in any woman of reproductive age with pelvic pain, as it immediately bifurcates the differential into pregnancy-related and non-pregnancy-related categories and identifies the possibility of ectopic pregnancy.

The physical examination in acute pelvic pain should be thorough and systematic. Abdominal examination assesses for distension, tenderness, guarding, rebound tenderness, and peritoneal signs, with particular attention to the presence of involuntary guarding or rigidity that suggests peritonitis. Speculum examination evaluates for vaginal bleeding, cervical discharge, and visible lesions. Bimanual examination assesses uterine size and tenderness, cervical motion tenderness which is a hallmark of peritoneal inflammation from any cause, and the presence of adnexal masses or tenderness. Cervical motion tenderness is not specific to pelvic inflammatory disease and may be present in ectopic pregnancy, ruptured cyst, torsion, or any condition causing pelvic peritoneal irritation. The rectovaginal examination may identify a mass in the cul-de-sac or tenderness suggesting hemoperitoneum or abscess.

Diagnostic studies complement the clinical assessment and guide definitive management. Beyond the beta-hCG pregnancy test, a complete blood count assesses for anemia suggesting hemorrhage and leukocytosis suggesting infection, though the white blood cell count is nonspecific and may be elevated in many acute conditions. Urinalysis screens for urinary tract infection and hematuria suggesting nephrolithiasis, though mild pyuria can be present in patients with appendicitis or PID due to proximity of the inflamed tissue to the ureter or bladder. Transvaginal ultrasonography is the imaging modality of choice for gynecologic causes of pelvic pain, providing real-time assessment of the uterus, adnexa, and cul-de-sac for free fluid. CT of the abdomen and pelvis is indicated when a non-gynecologic etiology such as appendicitis, diverticulitis, or nephrolithiasis is suspected, as it provides superior visualization of the appendix, bowel, kidneys, and ureters. In the hemodynamically unstable patient, bedside point-of-care ultrasonography can rapidly identify free intraperitoneal fluid indicating hemoperitoneum or abscess rupture.

<image>Panel A: Differential diagnosis framework for acute pelvic pain organized into gynecologic causes (ectopic pregnancy, ovarian torsion, ruptured cyst, PID/TOA, fibroid degeneration) and non-gynecologic causes (appendicitis, diverticulitis, nephrolithiasis, UTI, bowel obstruction) with distinguishing clinical features. Panel B: Initial assessment algorithm showing hemodynamic stability assessment, pregnancy test as first branch point, followed by focused history, physical examination, and directed diagnostic testing based on clinical findings. Panel C: Transvaginal ultrasound images comparing normal adnexa with an adnexal mass containing a yolk sac (ectopic pregnancy), an enlarged ovary with absent flow (torsion), and a complex cystic mass with free fluid (ruptured cyst). Panel D: Physical examination findings diagram showing the locations and characteristics of tenderness patterns in ectopic pregnancy, ovarian torsion, appendicitis, and PID with corresponding peritoneal signs.</image>

Section 2: Ectopic Pregnancy Emergency

Ectopic pregnancy is the implantation of a fertilized ovum outside the endometrial cavity, with the fallopian tube accounting for approximately 95 percent of cases, most commonly in the ampullary segment. Risk factors for ectopic pregnancy include prior ectopic pregnancy, which confers the highest risk of recurrence at approximately 10 to 15 percent, prior tubal surgery including tubal sterilization with subsequent failure, history of pelvic inflammatory disease causing tubal damage and adhesions, current intrauterine device use if pregnancy occurs despite the device, and assisted reproductive technologies, particularly in vitro fertilization. Additional risk factors include cigarette smoking, which impairs tubal motility and ciliary function, endometriosis, and advanced maternal age. Despite the identification of these risk factors, approximately 50 percent of women diagnosed with ectopic pregnancy have no identifiable risk factor.

The clinical presentation of ectopic pregnancy varies from asymptomatic early disease detected on routine ultrasound to catastrophic hemodynamic collapse from tubal rupture. The classic triad of amenorrhea, vaginal bleeding, and unilateral pelvic or lower abdominal pain is present in only approximately 50 percent of cases. Vaginal bleeding is typically scant and dark, representing a decidual response rather than the ectopic pregnancy itself. Pain may be dull and intermittent in unruptured ectopic or sudden and severe with rupture. Shoulder pain from diaphragmatic irritation by hemoperitoneum is an important symptom that suggests significant intraperitoneal hemorrhage. Syncope, lightheadedness, and frank hemodynamic shock with hypotension and tachycardia indicate ruptured ectopic pregnancy with substantial blood loss and constitute a surgical emergency.

Ruptured ectopic pregnancy is one of the leading causes of maternal mortality in the first trimester and demands immediate recognition and intervention. The hallmarks of rupture include sudden-onset severe abdominal pain, signs of hypovolemic shock with tachycardia, hypotension, pallor, diaphoresis, and altered sensorium, peritoneal signs with diffuse abdominal tenderness, guarding, and rebound, and abdominal distension from hemoperitoneum. In the acutely unstable patient, bedside point-of-care ultrasonography demonstrating free fluid in the abdomen combined with a positive pregnancy test is sufficient to mandate emergent surgical intervention without further diagnostic delay. A formal transvaginal ultrasound demonstrating an empty uterus with free pelvic fluid or an identifiable adnexal mass in the setting of a positive pregnancy test strongly supports the diagnosis.

Management of ruptured ectopic pregnancy requires simultaneous resuscitation and preparation for emergent surgery. Large-bore intravenous access is established immediately at two sites, and aggressive fluid resuscitation with crystalloid and blood products is initiated. Blood type and crossmatch are sent immediately, and uncrossmatched O-negative blood is used when the clinical situation does not allow time for type-specific blood. The patient is taken to the operating room as quickly as possible for salpingectomy, which is the procedure of choice for ruptured ectopic pregnancy, as salpingostomy in the setting of rupture is technically more difficult and associated with higher persistent ectopic rates. Laparoscopy is preferred when the patient is sufficiently stable to tolerate pneumoperitoneum, though laparotomy may be necessary in the profoundly unstable patient or when laparoscopic access is not feasible due to distension or adhesive disease. Massive transfusion protocol should be activated early when estimated blood loss is significant, using a balanced ratio of 1:1:1 packed red blood cells to fresh frozen plasma to platelets. Rh-negative women require RhoGAM administration.

<image>Panel A: Anatomic diagram showing the locations of ectopic pregnancy implantation with corresponding frequency percentages: ampullary (70 percent), isthmic (12 percent), fimbrial (11 percent), interstitial/cornual (2 to 3 percent), ovarian (1 to 3 percent), and abdominal and cervical (rare). Panel B: Transvaginal ultrasound images showing an adnexal ring sign with yolk sac adjacent to the ovary representing an unruptured ectopic pregnancy, and a second image showing an empty uterus with large-volume free fluid in the cul-de-sac indicating ruptured ectopic with hemoperitoneum. Panel C: Clinical decision pathway for ectopic pregnancy showing the branch point between hemodynamically stable (further workup, consideration of methotrexate versus surgery) and hemodynamically unstable (emergent surgical intervention with salpingectomy). Panel D: Laparoscopic photograph of a ruptured tubal ectopic pregnancy showing the fallopian tube with a ruptured segment and active hemorrhage into the peritoneal cavity with blood clot in the cul-de-sac.</image>

Section 3: Ovarian Torsion

Ovarian torsion occurs when the ovary, often together with the fallopian tube (adnexal torsion), rotates on its vascular pedicle, leading to progressive compromise of venous and lymphatic drainage, followed by arterial occlusion and ultimately ovarian necrosis if not promptly corrected. The mechanism involves twisting of the infundibulopelvic ligament and utero-ovarian ligament, initially occluding the low-pressure venous and lymphatic outflow, causing ovarian edema and enlargement that further increases the propensity for continued torsion. As the torsion tightens, arterial inflow is compromised, leading to hemorrhagic infarction and necrosis. This condition is a true time-sensitive surgical emergency, as delays in detorsion result in irreversible ovarian damage and potential loss of the ovary.

Risk factors for ovarian torsion include the presence of an ovarian mass, with cysts and tumors measuring 5 to 10 centimeters conferring the highest risk, as they create a sufficiently enlarged and mobile ovary to rotate on its pedicle. Pregnancy increases torsion risk due to the presence of an enlarged corpus luteum cyst, particularly in the first trimester. Ovulation induction with gonadotropins produces enlarged, hyperstimulated ovaries that are prone to torsion. Prior ovarian torsion confers risk of recurrence. Polycystic ovary syndrome with bilateral ovarian enlargement is an additional predisposing factor. Interestingly, the right ovary is affected more frequently than the left, possibly because the sigmoid colon limits the mobility of the left adnexa. Torsion can occur at any age, including in children and adolescents, particularly those with mature cystic teratomas (dermoid cysts), which are the most common ovarian neoplasm in young women.

The clinical presentation of ovarian torsion is characterized by the sudden onset of severe, unilateral lower abdominal or pelvic pain, which is frequently accompanied by nausea and vomiting in up to 70 percent of patients, reflecting the visceral nature of the pain stimulus. A critically important clinical feature is the intermittent nature of symptoms in some patients, as the ovary may undergo partial torsion and spontaneous detorsion, producing episodic attacks of severe pain with symptom-free intervals that may delay diagnosis. Fever is generally a late finding, suggesting ovarian necrosis with secondary inflammation. On examination, a tender adnexal mass may be palpable, and peritoneal signs may develop if necrosis or hemorrhage has occurred. The differential diagnosis includes ruptured ovarian cyst, ectopic pregnancy, appendicitis, and pelvic inflammatory disease, all of which may present with acute unilateral pelvic pain.

The diagnosis of ovarian torsion relies on a high index of clinical suspicion, as no imaging finding definitively confirms or excludes the diagnosis. Transvaginal ultrasonography typically demonstrates an enlarged ovary, often with peripheral follicles displaced by central edema (the "string of pearls" sign), and may show an associated ovarian mass. Color Doppler interrogation may reveal absent or decreased arterial flow, but importantly, the presence of normal Doppler flow does not exclude torsion, as intermittent torsion, dual blood supply, or early-stage torsion with preserved arterial inflow may produce false-negative Doppler studies. Because of these diagnostic limitations, the management principle is that if ovarian torsion is clinically suspected, surgical exploration is warranted regardless of imaging findings. Laparoscopic detorsion is the treatment of choice, and the ovary should be untwisted and preserved whenever possible, even if it appears dusky or edematous, as studies have demonstrated that ovarian function often recovers following detorsion even when the ovary appears nonviable at the time of surgery. Oophoropexy, suturing the ovary to the pelvic sidewall, may be performed to prevent recurrence.

<image>Panel A: Anatomic diagram of ovarian torsion showing the ovary twisted on its vascular pedicle with progressive compromise of venous outflow (early), arterial inflow (late), and resultant hemorrhagic infarction with labeled infundibulopelvic and utero-ovarian ligaments. Panel B: Transvaginal ultrasound image of a torsed ovary demonstrating enlargement to 8 centimeters with peripheral follicles and central stromal edema, alongside a color Doppler image showing absent arterial flow. Panel C: Laparoscopic photographs showing a torsed, dusky-appearing ovary before detorsion and the same ovary after detorsion with restoration of pink coloration indicating return of blood flow. Panel D: Management algorithm for suspected ovarian torsion showing that clinical suspicion alone is sufficient indication for surgical exploration regardless of Doppler findings, with decision points for detorsion versus oophorectomy and oophoropexy consideration.</image>

Section 4: Ruptured Ovarian Cyst

Ovarian cyst rupture is a common cause of acute pelvic pain in premenopausal women, with the clinical severity ranging from mild, self-limited discomfort to life-threatening hemorrhage requiring emergent surgical intervention. Functional ovarian cysts, including follicular cysts and corpus luteum cysts, are the most frequent types to rupture, with follicular cyst rupture typically occurring at mid-cycle during ovulation (mittelschmerz) and corpus luteum rupture during the luteal phase. Corpus luteum cysts are the most clinically significant because they have a thicker, more vascular wall, and rupture can produce substantial intraperitoneal hemorrhage. Hemorrhagic cysts may develop when bleeding into the cyst cavity occurs during formation, and subsequent rupture can release a large volume of blood into the peritoneal cavity. Endometrioma rupture, while less common, causes intense chemical peritonitis from spillage of the thick, tarry endometriotic fluid (chocolate cyst contents) into the pelvis.

The clinical presentation of ruptured ovarian cyst depends on the type of cyst and the volume of fluid or blood released into the peritoneum. Patients typically present with sudden-onset unilateral lower abdominal or pelvic pain, often associated with physical activity, straining, or sexual intercourse. Nausea is common, but vomiting is less prominent than in ovarian torsion. Unlike ectopic pregnancy, significant vaginal bleeding is unusual with isolated cyst rupture, which can be a helpful distinguishing feature. Shoulder pain from diaphragmatic irritation occurs when a significant volume of fluid or blood accumulates in the upper abdomen. In cases of hemorrhagic corpus luteum rupture with substantial hemoperitoneum, patients may present with signs of hypovolemic shock including tachycardia, hypotension, pallor, and altered mental status, mimicking ruptured ectopic pregnancy and requiring emergent surgical evaluation.

Evaluation of a patient with suspected ruptured ovarian cyst centers on transvaginal ultrasonography and hemodynamic assessment. Ultrasound findings may include a collapsed or irregular cyst, free fluid in the cul-de-sac ranging from a small amount consistent with physiologic rupture to large-volume complex echogenic fluid suggesting hemoperitoneum, and the absence of other pathology such as ectopic pregnancy or adnexal mass suggesting torsion. The echogenicity of the free fluid provides prognostic information, as simple anechoic fluid is less concerning than complex echogenic fluid suggesting blood with clot. Serial hemoglobin and hematocrit measurements are important for detecting ongoing hemorrhage, as a single value may not reflect acute blood loss. A pregnancy test is mandatory in all reproductive-age women to exclude ectopic pregnancy, which can present identically and requires fundamentally different management.

Management of ruptured ovarian cyst is guided primarily by hemodynamic status and the volume of intraperitoneal hemorrhage. The majority of patients are hemodynamically stable with minimal free fluid on imaging and can be managed conservatively with analgesics, intravenous hydration, observation with serial vital signs and hemoglobin monitoring, and discharge with close follow-up once pain is controlled and stability is confirmed. Patients with moderate free fluid on imaging who are hemodynamically stable should be admitted for serial observation, with repeat hemoglobin measurement at 4 to 6 hour intervals to detect declining values indicating ongoing hemorrhage. Hemodynamically unstable patients or those with evidence of significant ongoing hemorrhage (falling hemoglobin, increasing tachycardia, persistent pain) require surgical intervention, typically laparoscopic cystectomy or oophorectomy with evacuation of hemoperitoneum and cauterization of the bleeding source. Blood products should be administered as needed, and the surgical team should be prepared for conversion to laparotomy if laparoscopic hemostasis is not achievable.

<image>Panel A: Diagram showing the types of ovarian cysts prone to rupture with corresponding timing in the menstrual cycle: follicular cyst rupture at mid-cycle, corpus luteum rupture in the luteal phase, and hemorrhagic cyst rupture with timing variable. Panel B: Transvaginal ultrasound image showing a collapsed cyst with adjacent complex echogenic free fluid in the cul-de-sac consistent with hemorrhagic ovarian cyst rupture. Panel C: Management algorithm for ruptured ovarian cyst stratified by hemodynamic status showing conservative management for stable patients with minimal fluid, serial observation for moderate hemorrhage, and emergent surgery for hemodynamically unstable patients. Panel D: Laparoscopic photograph of the pelvis showing blood clot and hemorrhagic fluid from a ruptured corpus luteum cyst with the ovarian rupture site visible on the ovarian surface.</image>

Section 5: Tubo-Ovarian Abscess

Tubo-ovarian abscess represents the most severe acute manifestation of pelvic inflammatory disease, arising when ascending genital tract infection progresses to form an encapsulated collection of purulent material involving the fallopian tube and ovary, often with adherent bowel and omentum. The microbiology of TOA is polymicrobial, reflecting the complex origin of the infection from both sexually transmitted organisms, including Chlamydia trachomatis and Neisseria gonorrhoeae, and endogenous vaginal and cervical flora, including Bacteroides fragilis, Peptostreptococcus species, Escherichia coli, and other anaerobic and aerobic bacteria. Severe or inadequately treated PID creates the conditions for abscess formation when inflammatory exudate becomes walled off by adhesions between the tube, ovary, and surrounding structures. Approximately 25 percent of TOAs are bilateral, reflecting the bilateral nature of the ascending infection.

The clinical presentation of tubo-ovarian abscess is typically more severe than uncomplicated PID, with bilateral pelvic pain of significant intensity, high fever often exceeding 38.5 degrees Celsius, systemic illness with tachycardia, malaise, and a toxic appearance. On bimanual examination, a tender, fixed, complex adnexal mass is palpable, and the patient exhibits significant tenderness with any manipulation of the pelvic organs. Peritoneal signs may be present, particularly if abscess leakage or rupture has occurred. Laboratory findings include marked leukocytosis with left shift, elevated inflammatory markers including C-reactive protein and erythrocyte sedimentation rate, and blood cultures may be positive in patients with bacteremia. The clinical presentation may be less dramatic in immunosuppressed patients, those on antibiotics, or in cases of chronic TOA where systemic inflammatory response is blunted.

Diagnostic imaging confirms the clinical suspicion and guides treatment planning. Transvaginal ultrasonography is the initial imaging study and typically demonstrates a complex, multiloculated adnexal mass with thick walls, internal septations, fluid-debris levels, and surrounding inflammatory changes. CT of the abdomen and pelvis provides additional information regarding the extent of disease, involvement of adjacent structures, and the presence of complications such as abscess rupture, peritonitis, or fistula formation to bowel or bladder. MRI offers superior soft tissue resolution and may be useful in diagnostically challenging cases. Imaging also helps distinguish TOA from other conditions in the differential diagnosis including ovarian neoplasm, endometrioma, periappendiceal abscess, and diverticular abscess, each of which requires different management.

Management of tubo-ovarian abscess requires hospitalization and initiation of broad-spectrum intravenous antibiotics with activity against gram-negative aerobes, gram-positive aerobes, and anaerobic organisms. Standard regimens include cefotetan or cefoxitin combined with doxycycline, or alternatively clindamycin with gentamicin. Metronidazole is often added for enhanced anaerobic coverage. Clinical improvement, indicated by defervescence and decrease in pain, is expected within 48 to 72 hours of antibiotic initiation, and approximately 70 percent of TOAs resolve with antibiotics alone. Patients who fail to improve within 48 to 72 hours require imaging-guided percutaneous drainage, which can be performed via transvaginal or transabdominal routes under ultrasound or CT guidance. Surgical intervention with laparoscopy or laparotomy is indicated for abscess rupture, which is a surgical emergency presenting with acute peritonitis, septic shock, and hemodynamic collapse, requiring emergent exploration, abscess drainage, and often unilateral or bilateral salpingo-oophorectomy. Rupture of a TOA carries significant mortality if not recognized and treated emergently.

<image>Panel A: Transvaginal ultrasound image of a tubo-ovarian abscess demonstrating a complex, multiloculated adnexal mass with thick irregular walls, internal debris and septations, and surrounding echogenic fluid. Panel B: CT scan of the pelvis with contrast showing a bilateral TOA with rim-enhancing pelvic collections, inflammatory fat stranding, and adherent bowel loops. Panel C: Management algorithm for TOA showing initiation of IV antibiotics, 48 to 72 hour reassessment, and decision pathways for clinical improvement (continue antibiotics and transition to oral), no improvement (image-guided drainage), and abscess rupture (emergent surgery). Panel D: Intraoperative photograph of a ruptured tubo-ovarian abscess at laparotomy showing purulent material in the pelvis, inflamed adnexal tissue, and adherent omentum and bowel requiring careful dissection and drainage.</image>

Section 6: Hemorrhagic Emergencies in Gynecology

Acute abnormal uterine bleeding severe enough to cause hemodynamic instability represents a gynecologic emergency that requires rapid assessment and intervention. The most common causes of hemorrhagic gynecologic emergencies include anovulatory bleeding in adolescents and perimenopausal women, uterine leiomyomas causing heavy menstrual or intermenstrual hemorrhage, coagulopathies such as von Willebrand disease and platelet disorders, pregnancy-related bleeding including early pregnancy loss, and endometrial malignancy in postmenopausal women. Anovulatory bleeding is the most frequent cause of severe hemorrhage in young women, as prolonged unopposed estrogen stimulation of the endometrium produces a thick, fragile endometrium that sheds irregularly and copiously when estrogen levels eventually decline. Hereditary bleeding disorders, particularly von Willebrand disease, should be considered in any adolescent presenting with heavy menstrual bleeding from menarche.

Assessment of the patient with hemorrhagic gynecologic emergency begins with evaluation of hemodynamic status and quantification of blood loss. Vital signs including heart rate, blood pressure, and orthostatic changes provide immediate information about the degree of hemodynamic compromise. The shock index, calculated as heart rate divided by systolic blood pressure, with a value greater than 1.0 indicating significant hypovolemia, is a useful bedside tool for rapid assessment. Quantification of blood loss through pad counts, clot passage history, and hemoglobin/hematocrit measurement helps gauge severity, though a single hemoglobin value may not reflect acute hemorrhage due to the lag time required for equilibration. Coagulation studies including prothrombin time, partial thromboplastin time, fibrinogen, and platelet count are essential to identify coagulopathy as a contributing factor. A pregnancy test is mandatory in all reproductive-age women to exclude pregnancy-related causes of hemorrhage.

Medical management of acute hemorrhagic uterine bleeding employs a combination of hormonal and non-hormonal agents to achieve hemostasis. Intravenous conjugated equine estrogens, administered at 25 milligrams every 4 to 6 hours for up to 24 hours, rapidly stabilize the endometrium by promoting growth of the endometrial lining over denuded surfaces. High-dose combined oral contraceptive pills, often administered as one pill three times daily with a rapid taper over subsequent days, provide combined estrogenic and progestogenic support to the endometrium. Tranexamic acid, an antifibrinolytic agent, reduces bleeding by inhibiting the breakdown of fibrin clots at the endometrial surface and can be administered intravenously at 1 gram every 8 hours or orally at 1.3 grams three times daily. High-dose oral progestins such as medroxyprogesterone acetate 20 milligrams three times daily can stabilize the endometrium in anovulatory bleeding. Blood product transfusion, including packed red blood cells for severe anemia and fresh frozen plasma and platelets for coagulopathy, is essential for patients with hemodynamic instability or hemoglobin below 7 g/dL.

Procedural and surgical interventions are employed when medical management is insufficient to control hemorrhage. Intrauterine balloon tamponade using a Foley catheter with a 30-mL balloon or a dedicated uterine tamponade balloon provides temporary mechanical compression of the endometrial surface and can be life-saving as a bridge to definitive treatment. Dilation and curettage removes the hemorrhagic, unstable endometrium and provides tissue for histopathologic diagnosis, which is particularly important in perimenopausal and postmenopausal women to exclude endometrial hyperplasia or carcinoma. Uterine artery embolization, performed by interventional radiology, provides a minimally invasive option for controlling hemorrhage from fibroids or other uterine sources in patients who are hemodynamically stable enough to undergo the procedure. Hysterectomy is the definitive surgical treatment for life-threatening uterine hemorrhage that is refractory to all other measures and may be the only option in patients with catastrophic bleeding from endometrial carcinoma, uterine rupture, or massive fibroid hemorrhage.

<image>Panel A: Etiologic classification of acute hemorrhagic uterine bleeding showing anovulatory bleeding, fibroid hemorrhage, coagulopathy, pregnancy-related causes, and malignancy with corresponding patient demographics and distinguishing features. Panel B: Stepwise medical management algorithm showing concurrent administration of IV estrogen, tranexamic acid, and blood products for acute hemorrhage, followed by transition to high-dose OCPs or progestins for maintenance hemostasis. Panel C: Illustration of intrauterine balloon tamponade showing Foley catheter insertion through the cervix with inflated balloon providing direct compression of the endometrial surface for emergency hemorrhage control. Panel D: Angiographic image of uterine artery embolization showing selective catheterization of the uterine artery with microsphere injection to achieve hemostasis in a patient with fibroid-related hemorrhage.</image>

Section 7: First-Trimester Pregnancy Emergencies

First-trimester pregnancy emergencies encompass a spectrum of conditions from threatened abortion with ongoing viability to septic abortion with life-threatening maternal infection. The classification of early pregnancy loss is based on clinical findings: threatened abortion describes vaginal bleeding with a closed cervical os and evidence of ongoing pregnancy viability, inevitable abortion involves bleeding with an open cervical os indicating that passage of the pregnancy is imminent, incomplete abortion describes partial expulsion of the products of conception with retained tissue and ongoing bleeding, and complete abortion indicates complete passage of all pregnancy tissue with cessation of bleeding and a closed os. Missed abortion, in which the embryo has died but tissue has not been expelled, may present with loss of pregnancy symptoms and is diagnosed by ultrasound showing an embryo without cardiac activity or an empty gestational sac exceeding the expected size for gestational age.

Management of incomplete abortion depends on clinical stability and patient preference. Expectant management is appropriate for stable patients with minimal retained tissue, as spontaneous passage of remaining products typically occurs within 1 to 2 weeks. Medical management with misoprostol 800 micrograms administered vaginally is effective for promoting expulsion of retained products in approximately 80 to 90 percent of patients within 48 hours. Surgical management with suction dilation and curettage is indicated for hemodynamically unstable patients with significant hemorrhage, patients with infected retained products, those who fail medical management, and patients who prefer definitive surgical treatment. All Rh-negative women who experience pregnancy loss should receive RhoGAM (anti-D immunoglobulin) at 50 micrograms for losses before 12 weeks or 300 micrograms for losses after 12 weeks to prevent Rh alloimmunization in subsequent pregnancies. Emotional support and acknowledgment of the patient's grief are essential components of care regardless of the management approach chosen.

Septic abortion is a life-threatening emergency in which retained products of conception become infected, leading to endometritis, myometritis, parametritis, and potentially overwhelming sepsis. Patients present with fever, uterine tenderness, foul-smelling vaginal discharge, and signs of systemic inflammatory response including tachycardia, tachypnea, hypotension, and altered mental status. Septic abortion may occur spontaneously, following an incomplete miscarriage with retained infected tissue, or as a complication of an unsafe termination procedure. The causative organisms are typically polymicrobial, including Escherichia coli, group B Streptococcus, anaerobic bacteria, and occasionally Clostridium species, which can cause rapidly progressive gas gangrene and toxic shock. Management requires emergent broad-spectrum intravenous antibiotics covering gram-positive, gram-negative, and anaerobic organisms, along with urgent uterine evacuation by suction curettage to remove the infectious source. Hemodynamic resuscitation with crystalloids, vasopressors, and blood products as needed follows standard sepsis management protocols. Delayed uterine evacuation in septic abortion carries significant mortality risk.

Molar pregnancy (gestational trophoblastic disease) can present with emergent complications requiring immediate intervention. Complete hydatidiform mole classically presents in the first trimester with vaginal bleeding, a uterus larger than expected for gestational age, markedly elevated beta-hCG (often exceeding 100,000 mIU/mL), and ultrasound showing a "snowstorm" pattern without fetal tissue. Emergent complications include hemorrhage requiring suction curettage for evacuation, thyroid storm from cross-reactivity of the alpha-subunit of hCG with the TSH receptor causing hyperthyroidism, respiratory distress from trophoblastic embolization to the pulmonary vasculature, and preeclampsia developing before 20 weeks of gestation, which is essentially pathognomonic for molar pregnancy. Management of the mole itself involves suction dilation and curettage with careful attention to hemorrhage control, uterine perforation risk due to the distended uterus, and the potential need for blood products. Following evacuation, serial beta-hCG monitoring is essential to detect persistent gestational trophoblastic neoplasia.

<image>Panel A: Ultrasound images comparing normal intrauterine pregnancy with threatened abortion (subchorionic hematoma), incomplete abortion (irregular intrauterine contents with open cervical os), and complete hydatidiform mole (snowstorm pattern). Panel B: Management algorithm for first-trimester pregnancy loss showing expectant, medical (misoprostol), and surgical (D&C) options with indications for each approach and decision points based on hemodynamic stability and patient preference. Panel C: Clinical presentation comparison of septic abortion versus uncomplicated incomplete abortion showing distinguishing features including fever, uterine tenderness, foul discharge, and systemic inflammatory response. Panel D: Serial beta-hCG monitoring curve following molar pregnancy evacuation showing normal declining trajectory versus plateau or rise indicating persistent gestational trophoblastic neoplasia requiring chemotherapy.</image>

Section 8: Post-Procedural Emergencies

Post-hysterectomy hemorrhage is the most common serious complication following gynecologic surgery and may arise from several sources. Vaginal cuff bleeding occurs when sutures at the vaginal apex become disrupted, producing visible vaginal bleeding that can range from minor spotting to brisk hemorrhage, managed initially with direct pressure and vaginal packing and definitively with resuturing of the vaginal cuff. Pedicle hemorrhage from the uterine artery, ovarian vessel, or vaginal branch pedicles may present as expanding pelvic hematoma, hemodynamic instability, or falling hemoglobin without visible external bleeding, requiring return to the operating room for exploration and hemostasis. Retroperitoneal hematoma may develop insidiously, with flank or back pain, unexplained tachycardia, or falling hemoglobin alerting the clinician to occult hemorrhage. Disseminated intravascular coagulation can complicate massive hemorrhage from any source, requiring aggressive correction with blood products including fresh frozen plasma, cryoprecipitate, and platelets guided by coagulation studies.

Ureteral injury is a feared complication of gynecologic surgery, occurring in approximately 0.5 to 2 percent of hysterectomies, with higher rates during radical hysterectomy, surgery for endometriosis, or procedures complicated by distorted anatomy. When recognized intraoperatively, ureteral injury can be repaired immediately, often with primary ureteroneocystostomy or placement of a ureteral stent, yielding excellent outcomes. Unrecognized ureteral injury presents in the postoperative period with flank pain, fever, costovertebral angle tenderness, persistent watery vaginal drainage suggesting ureterovaginal fistula, rising serum creatinine, or development of urinoma or hydronephrosis. Diagnosis is confirmed by CT urogram demonstrating contrast extravasation, ureteral obstruction, or hydronephrosis, or by cystoscopy with retrograde pyelography. Delayed recognition requires multidisciplinary management involving urology, and treatment options include ureteral stent placement for partial injuries or surgical repair for complete transection or delayed presentation with fistula formation.

Bowel injury during gynecologic surgery may occur during entry into the abdomen, during adhesiolysis, or during dissection in the cul-de-sac, particularly in the setting of endometriosis, prior pelvic radiation, or extensive adhesive disease. Intraoperative recognition allows immediate repair, with serosal injuries requiring simple imbrication, partial-thickness injuries requiring layered closure, and full-thickness injuries requiring primary repair or resection with anastomosis or diversion depending on the extent and location of injury. Unrecognized bowel injury presents in the postoperative period with prolonged ileus, increasing abdominal distension and pain, fever, tachycardia, leukocytosis, and eventually peritonitis and sepsis. CT of the abdomen with oral and intravenous contrast may demonstrate free air, free fluid, bowel wall thickening, or contrast extravasation. The threshold for surgical re-exploration should be low when bowel injury is suspected, as delayed recognition is associated with significant morbidity and mortality.

Complications following dilation and curettage include uterine perforation, infection, incomplete evacuation, and the delayed complication of Asherman syndrome. Uterine perforation occurs when the uterine sound, dilator, or curette passes through the myometrium, with the fundus being the most common site. Management depends on the instrument involved and whether there is concern for intra-abdominal injury: perforation with a blunt instrument such as a sound or suction cannula in an otherwise uncomplicated patient may be managed with observation, serial vital signs, and monitoring for signs of intraperitoneal hemorrhage. Perforation during sharp curettage or when electrosurgical energy has been applied raises concern for bowel or vascular injury and necessitates laparoscopic evaluation. Post-procedural infection presents with fever, pelvic pain, and foul-smelling discharge within days of the procedure and requires broad-spectrum antibiotics. Asherman syndrome, the formation of intrauterine adhesions, is a late complication that presents with amenorrhea, hypomenorrhea, or infertility and is diagnosed by hysteroscopy demonstrating intrauterine synechiae.

<image>Panel A: Diagram of potential sources of post-hysterectomy hemorrhage showing the vaginal cuff, uterine artery pedicle, ovarian vessel pedicle, and retroperitoneal space with corresponding clinical presentations and management approaches. Panel B: CT urogram images demonstrating ureteral obstruction with proximal hydronephrosis following gynecologic surgery compared with normal postoperative appearance, with annotation of the common sites of ureteral injury during hysterectomy. Panel C: Intraoperative photograph of a recognized bowel injury during gynecologic surgery showing a full-thickness enterotomy being repaired in layers with absorbable suture. Panel D: Hysteroscopic image of Asherman syndrome showing intrauterine adhesions obscuring the endometrial cavity, with a comparison image of normal hysteroscopic appearance for reference.</image>

Section 9: Sexual Assault Management

The management of a patient presenting after sexual assault requires a patient-centered, trauma-informed approach that prioritizes the physical and emotional well-being of the patient while fulfilling medicolegal obligations for evidence collection and reporting. The first priority is addressing any acute medical injuries, which may include genital lacerations, abrasions, and contusions, as well as non-genital injuries to the face, extremities, and torso. A trauma-informed approach recognizes the profound psychological impact of sexual violence and ensures that the patient maintains control of the encounter to the greatest extent possible, with all examinations and procedures performed only with informed consent, in a private and secure setting, and at a pace dictated by the patient. Documentation should be thorough and objective, recording findings using precise descriptive language without interpretive conclusions about consent or the nature of the assault.

The medical evaluation proceeds with a detailed history limited to information clinically necessary for medical care and evidence collection, avoiding unnecessary repetition that can re-traumatize the patient. Physical examination should be comprehensive, documenting all injuries using body diagrams and photography with patient consent. The forensic evidence collection, ideally performed by a Sexual Assault Nurse Examiner using a standardized sexual assault evidence collection kit, includes swabs from the vagina, cervix, anus, and mouth as appropriate, collection of the patient's clothing, combing of pubic hair for foreign hair and debris, collection of fingernail scrapings, and blood and urine samples for toxicology if drug-facilitated assault is suspected. Chain of custody must be maintained throughout the evidence collection process to ensure its admissibility in legal proceedings. The examination should be performed within 72 to 120 hours of the assault, though evidence may still be collected beyond this window in some circumstances.

STI prophylaxis is a critical component of sexual assault management and should be offered empirically to all patients regardless of the assailant's STI status, which is typically unknown. The recommended prophylactic regimen includes ceftriaxone 500 milligrams intramuscularly for gonorrhea prevention, doxycycline 100 milligrams orally twice daily for 7 days (or azithromycin 1 gram orally if doxycycline is not tolerated) for chlamydia prevention, and metronidazole 2 grams orally as a single dose for trichomoniasis prevention. HIV post-exposure prophylaxis with a 28-day course of antiretroviral medication should be offered when the assault poses a significant risk of HIV transmission, such as when the assailant is known to be HIV-positive, the assault involved receptive anal intercourse, or the victim has mucosal trauma. Hepatitis B vaccination should be administered if the patient is not already immune. Baseline testing for HIV, syphilis, hepatitis B, hepatitis C, chlamydia, and gonorrhea is performed at the initial visit, with follow-up testing at 2 weeks, 6 weeks, 3 months, and 6 months to detect seroconversion.

Emergency contraception should be offered to all sexual assault survivors at risk for pregnancy. The copper intrauterine device is the most effective form of emergency contraception, preventing pregnancy in more than 99 percent of cases when placed within 120 hours (5 days) of unprotected intercourse, and has the additional benefit of providing ongoing highly effective contraception. Ulipristal acetate 30 milligrams orally is the most effective oral emergency contraceptive, maintaining efficacy up to 120 hours after intercourse without significant decline in effectiveness over that interval. Levonorgestrel 1.5 milligrams orally is available over the counter and is most effective when taken within 72 hours, with declining efficacy thereafter. All options should be presented to the patient, and the decision should be made based on patient preference, timing since assault, and clinical circumstances. Psychological support, including immediate crisis counseling, information about normal psychological responses to trauma, and referral to specialized sexual assault advocacy services and follow-up mental health care, is an essential component of comprehensive management that should not be overlooked in the acute setting.

<image>Panel A: Flowchart of the trauma-informed approach to sexual assault care showing the sequence from initial triage and medical stabilization through consent and history, forensic evidence collection, STI prophylaxis, emergency contraception, and psychological support with patient autonomy emphasized at each decision point. Panel B: Sexual assault evidence collection kit contents including swabs, envelopes for clothing and debris, pubic hair comb, fingernail collection materials, blood and urine toxicology tubes, and chain of custody documentation forms. Panel C: Emergency contraception comparison showing copper IUD (more than 99 percent effective, up to 120 hours), ulipristal (95 percent effective, up to 120 hours), and levonorgestrel (89 percent effective, best within 72 hours) with mechanism of action and clinical considerations for each. Panel D: Follow-up testing timeline showing baseline STI testing at initial visit, with repeat testing intervals at 2 weeks, 6 weeks, 3 months, and 6 months for HIV, syphilis, hepatitis B, hepatitis C, chlamydia, and gonorrhea seroconversion.</image>

Section 10: Resuscitation Principles in Gynecologic Emergencies

The initial stabilization of a patient presenting with a gynecologic emergency follows the ABCDE framework of trauma resuscitation: airway assessment and management, breathing evaluation with supplemental oxygen administration, circulatory assessment with establishment of vascular access and fluid resuscitation, disability assessment including mental status evaluation, and exposure with complete physical examination. In gynecologic emergencies, circulatory compromise from hemorrhage is the most common life-threatening presentation, and establishing two large-bore peripheral intravenous lines (16-gauge or larger) is a critical early step. Crystalloid resuscitation with normal saline or lactated Ringer solution is initiated immediately, though current evidence supports early transition to blood products in patients with significant hemorrhage rather than large-volume crystalloid resuscitation, which can exacerbate dilutional coagulopathy, hypothermia, and acidosis.

Hemorrhagic shock in gynecologic emergencies is classified by the estimated volume of blood loss and corresponding physiologic responses. Class I shock involves less than 15 percent blood volume loss (up to 750 mL) and presents with minimal hemodynamic changes including normal blood pressure and mild anxiety. Class II shock involves 15 to 30 percent loss (750 to 1,500 mL) with tachycardia, narrowed pulse pressure, and anxiety. Class III shock involves 30 to 40 percent loss (1,500 to 2,000 mL) with hypotension, tachycardia above 120, confusion, and decreased urine output. Class IV shock involves greater than 40 percent blood volume loss with severe hypotension, marked tachycardia, lethargy or obtundation, and negligible urine output. The shock index, calculated as heart rate divided by systolic blood pressure, provides a rapid bedside assessment tool, with a value greater than 1.0 indicating significant hemorrhagic shock and a value greater than 1.5 indicating severe shock with high mortality risk.

Resuscitation of hemorrhagic shock in gynecologic emergencies emphasizes the damage control resuscitation paradigm, which prioritizes early blood product administration, permissive hypotension (targeting systolic blood pressure of 80 to 90 mmHg until surgical hemostasis is achieved), and prevention of the lethal triad of hypothermia, acidosis, and coagulopathy. Massive transfusion protocols should be activated early, defined as the anticipated need for 10 or more units of packed red blood cells within 24 hours or 4 or more units within 1 hour. The balanced transfusion ratio of 1:1:1 (packed red blood cells to fresh frozen plasma to platelet units) mimics whole blood composition and reduces dilutional coagulopathy compared with crystalloid-heavy resuscitation. Tranexamic acid should be administered early, within 3 hours of hemorrhage onset, at a dose of 1 gram intravenously over 10 minutes followed by a second gram over 8 hours, as it has been demonstrated to reduce mortality in hemorrhaging patients. Point-of-care coagulation testing with thromboelastography or rotational thromboelastometry, where available, enables goal-directed transfusion to correct specific coagulation deficits.

Surgical decision-making in the hemorrhaging gynecologic patient must be timely and decisive, as delays in achieving surgical hemostasis significantly increase mortality. The key indications for immediate operative intervention include hemodynamic instability that does not respond to initial resuscitation, peritoneal signs suggesting intra-abdominal hemorrhage or visceral injury, and clinical scenarios where the source of hemorrhage can only be controlled surgically, such as ruptured ectopic pregnancy, ruptured tubo-ovarian abscess, or post-surgical hemorrhage. Damage control surgery principles may apply in the most critically ill patients, focusing on rapid hemorrhage control and contamination management with temporary abdominal closure and planned return to the operating room for definitive repair once the patient has been physiologically stabilized in the intensive care unit. Communication between the surgical team, anesthesia, nursing, blood bank, and intensive care unit is essential for coordinated management of the critically ill gynecologic patient, and early activation of the institutional massive transfusion protocol ensures that blood products are available without delay.

<image>Panel A: ABCDE assessment framework for gynecologic emergencies showing airway, breathing, circulation (with emphasis on IV access and fluid resuscitation), disability (mental status), and exposure (complete examination) with gynecology-specific considerations at each step. Panel B: Hemorrhagic shock classification diagram showing Classes I through IV with corresponding estimated blood loss, heart rate, blood pressure, mental status, and urine output at each level with the shock index calculation. Panel C: Massive transfusion protocol activation flowchart showing triggers for activation, the 1:1:1 balanced transfusion ratio, TXA administration timing, point-of-care coagulation testing, and goal-directed component therapy adjustments. Panel D: Damage control surgery decision algorithm showing the pathway from initial assessment through resuscitation to the decision between definitive surgery in stable patients versus abbreviated damage control surgery in critically ill patients with planned ICU resuscitation and staged return to OR.</image>

Summary

• Acute pelvic pain evaluation requires a pregnancy test in all reproductive-age women to bifurcate the differential, with transvaginal ultrasound as the imaging modality of choice for gynecologic causes
• Ruptured ectopic pregnancy is a surgical emergency presenting with amenorrhea, vaginal bleeding, pain, and hemodynamic instability, requiring emergent salpingectomy and simultaneous resuscitation
• Ovarian torsion presents with sudden unilateral pain and nausea, and normal Doppler flow does not exclude the diagnosis; clinical suspicion alone warrants surgical exploration with laparoscopic detorsion
• Ruptured ovarian cyst management is guided by hemodynamic status, with conservative observation for stable patients and surgical intervention for hemodynamic instability or ongoing hemorrhage
• Tubo-ovarian abscess requires hospitalization with IV antibiotics, with imaging-guided drainage for non-responders within 48 to 72 hours and emergent surgery for rupture
• Acute hemorrhagic AUB is managed with IV estrogen, tranexamic acid, and high-dose hormonal therapy, escalating to balloon tamponade, D&C, uterine artery embolization, or hysterectomy as needed
• Septic abortion requires broad-spectrum IV antibiotics and urgent uterine evacuation, with delay in treatment carrying significant mortality risk
• Post-procedural emergencies including hemorrhage, ureteral injury, and bowel injury require prompt recognition, with a low threshold for surgical re-exploration
• Sexual assault management follows a trauma-informed approach with STI prophylaxis (ceftriaxone, doxycycline, metronidazole), emergency contraception (copper IUD most effective), and comprehensive follow-up
• Hemorrhagic shock management uses damage control resuscitation with early blood products, 1:1:1 balanced transfusion, TXA within 3 hours, and surgical source control as the definitive treatment

Key Terms

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