Chapter 35 Emergency gynaecology

History includes last normal menstrual period (LMP), past pregnancy history, sexual activity, contraception, pregnancy signs and symptoms, preventative health strategies (PAP smear, breast examination) as well as characteristics of presenting symptoms (commonly pain, abnormal vaginal bleeding plus or minus pregnancy, vaginal discharge, fever).

Management includes excluding pregnancy for every female of reproductive age, and early attention to vital signs, anticipating that certain conditions are associated with immediately life-threatening presentations.

Sensitivity and attention to patient comfort mandates conducting gynaecological history and pelvic examinations in a private area (when the patient’s condition is stable), using a warmed speculum, and offering analgesia early.

Investigations often will involve ultrasound and serum beta human chorionic gonadotrophin (bhCG) estimation (see Table 35.1).

Table 35.1 Interpretation of quantitative serum hCG results

Reference intervals
	Serum hCG (U/L)
Females	< 2.0	Pre-menopausal
	< 10	Post-menopausal
Males	< 2.0
Pregnancy test
	Serum hCG (U/L)	Interpretation
	< 2	Negative (if taken after first missed period)
	2–25	Borderline result (suggest repeat in 48 hours)
	> 25	Consistent with pregnancy
Pregnancy staging
Weeks since LMP	Approximate hCG range (U/L)	Comment
3–4	0–130	Week prior to first missed period
4–5	75–2600	Week after first missed period
5–6	850–20,800
6–7	4000–200,000
7–12	11,500–289,000
12–16	18,300–137,000
16–29	1400–53,000	Second trimester
29–41	940–60,000	Third trimester

LMP, last normal menstrual period

COMMON PRESENTATIONS

Pain

Ruptured ectopic pregnancy

• Incidence of ectopic pregnancy is increasing worldwide, mainly due to the increased incidence of pelvic inflammatory disease (PID) caused by Chlamydia trachomatis.

• History includes abdominal pain (97%), missed period (80%), vaginal bleeding (79%), infertility (15%), use of an intrauterine contraceptive device (IUCD) (14%), previous ectopic pregnancy (11%).

• Presenting signs include abdominal tenderness (91%), adnexal tenderness (54%), less frequently, shoulder tip pain, syncope and hypovolaemic shock (5%).

• Commonly presents between the 5th and 8th week following the LMP.

Diagnosis made by positive bhCG (see Table 35.1), and ultrasound (US) negative for intrauterine pregnancy. (Heterotopic pregnancy—an ectopic pregnancy together with an intrauterine pregnancy—occurs in approx 1 in 30,000 pregnancies.)