Clinical Diagnosis and Management of Gynecologic Emergencies

Botros Rizk, Mostafa A. Borahay, Abdel Maguid Ramzy, Botros Rizk, Mostafa A. Borahay, Abdel Maguid Ramzy

• Publisher: CRC Press
• Year: 2020
• ISBN:
  9781000281477
• Edition: 1
• Topic: Medicina
• Subtopic: Ginecología, obstetricia y partería

This highly practical text on gynecologic emergencies includes sonographic findings and laparascopic investigations and management for point-of-care assessment. Gynecologists, emergency physicians, and other providers will find this an invaluable resource for information on what to do in a crisis.

1

Gynecologic Emergencies: An Introduction

Dana N. Owens

Introduction

An emergency medical condition manifests itself by acute symptoms of sufficient severity that it is reasonably believed that, in the absence of immediate medical attention, it would result in any of the following: (1) serious jeopardy to the person's health; (2) serious impairment of bodily functions; or (3) serious dysfunction of any bodily organ or part. An urgent medical condition, in contrast, is one that is non–life threatening but requires care within a timely manner, usually within 24 to 48 hours. Any urgent condition may progress to an emergent condition; therefore, accurate triage and evaluation are essential to guide appropriate treatment. Emergencies are unpredictable and can occur at any time, whether in the outpatient or the inpatient setting. Preparation for these emergent situations requires allocation of resources and supplies, planning, and collaboration [1].

Gynecologic emergencies are relatively common and include ectopic pregnancies, adnexal torsion, tubo-ovarian abscess, hemorrhagic ovarian cysts, gynecologic hemorrhage, and vulvovaginal trauma. With the evaluation of gynecologic emergencies, especially in women of reproductive age, a delay in proper diagnosis or improper management of the patient may compromise care, jeopardize future reproductive capabilities, put the patient at risk for sepsis, and/or subject the patient to severe hemorrhage and its associated consequences. Therefore, it is important that the clinician be able to triage the urgent versus emergent condition and to work up, evaluate, and treat the medical condition with a systematic approach. This applies to both the emergency physician who has initial contact with the patient and may need to stabilize the patient and the consultant gynecologist who may be asked to provide additional expertise for the care of the patient. If this is kept in mind, diagnostic failures should not occur, and proper management of similar presenting but less concerning gynecologic urgencies will be enhanced. One way of achieving this is by applying protocols and/or algorithms that allow the provider to distinguish among nongynecologic disorders, emergent and nonemergent gynecologic disorders, which will lead to rapid and efficient intervention. Standardized protocols that have been reviewed and are posted help the entire team or department streamline the workup of the acute patient. Every facility has a method to triage patients and has standard operating procedures which when adhered to that facilitate the safety and care of the patient. Conducting mock simulation drills in the acute care setting with both clinicians and staff will allow issues to be identified related to the physical environment, lack of resources, or common clinical errors made during emergencies [1]. Therefore, simulations may enhance adherence to protocols and allow for needed training.

When providing immediate care to the gynecologic patient, several factors should be considered. The level of care of the treating facility is important in the stabilization and treatment of the gynecologic patient. Emergency departments are categorized into five levels of care. Level I is the highest level with immediate access to all surgical specialists and subspecialties to handle the most severe and complicated conditions. Level II facilities are usually present in medium- to large-sized hospitals with surgeons and anesthesia on 24-hour call with an intensive care unit staffed with emergency medicine physicians. Level III facilities may not have on-call surgeons daily but can handle most surgical problems within 24 hours. These facilities may not be staffed with emergency medicine specialists, but they are equipped to treat and stabilize sicker or more severely injured patients until a higher level of care can be provided. For example, a level III facility may not be equipped to handle the needs of a patient with a ruptured ectopic pregnancy and hemoperitoneum. Level IV and V facilities are found mostly in rural areas and may not have a physician at all times and are intended to stabilize patients for transfer to another facility [2]. That lower-level facility will need to diagnose and stabilize the patient before transfer to a level I or II hospital for emergent intervention. Hence, the level of care of the treating facility may impact the ability to care for certain gynecologic emergent conditions. The ability to acquire the appropriate consultation of specialists is also dependent on the facility and the level of care. Providers at each level should be knowledgeable of resources and protocols, and should have training that prepares them and their staff for possible gynecologic emergencies.

Several principles of medicine are needed for the emergency medicine clinician to be effective in evaluating and treating the emergent gynecologic patient. The first principle is taking a comprehensive medical history. This may be challenging and limited in some cases due to patient condition, need for translation, need for guardianship, and establishment of trust. The time allowed to establish trust is limited and can interfere with obtaining sensitive or personal information that may be needed from the patient. In the acute setting, this may be more apparent in the patient who has experienced sexual abuse or intimate partner abuse. The medical history for the gynecologic patient should include the following: all medical conditions, last menstrual cycle, sexual activity, prior sexually transmitted infection exposure or treatment, prior obstetrical history, recent and past surgical history, use of contraceptives (eg, intrauterine device in the patient with refractory pelvic inflammatory disease or tubo-ovarian abscess), and assessment of mental and emotional health. The latter is most significant in the setting of hemorrhage and spontaneous abortion. The institution should have access to a gynecologist for consultation. This will speed intervention as well as aid in counseling and reassuring the emotionally distraught patient. The ability of the clinician to quickly triage the patient, obtain a comprehensive history, and evaluate the patient while narrowing the differential diagnosis is especially important in the reproductive-age woman. This will help direct the clinician in his or her use of diagnostic testing and allow for a focused exam that may prevent delay in care.

The physician or provider will need to perform a focused yet thorough examination. In most cases, this will allow for correct diagnosis and rapid intervention. For gynecologic “urgencies” and most emergencies, the exam can be done in a timely manner. Certain situations, however, can impede or postpone the exam, and the clinician should consider and be prepared for these situations. Because of the sensitivity of the exam and need to establish trust, consultation with a gynecologist may decrease any distress that may be caused during a gynecologic exam. Due to the nature of the examination, a chaperoned exam is mandatory to protect not only the provider but also the patient. This is especially prudent for the male clinician, who will require a female chaperone to be present during the exam. If a staff member is not available to assist in this role, this can cause a delay in assessment and treatment. The care of the adolescent or pediatric patient is another situation that requires certain guidelines and checks that may impede care. Examples include the ability to obtain consent, confidentiality, and guardianship [3]. It is important to plan for a designated area, the equipment and tools necessary to perform a thorough exam. In addition, the use of a pelvic bed with retractable stirrups and lighted speculums allows for better visualization of the perineum and internal tissues. Availability of appropriate testing swabs, kits, or materials to conduct necessary urine pregnancy tests, cervical cultures, or collection of tissue should be routinely monitored. Having the appropriate instruments to collect specimens may seem trivial, but in the acute setting, it may impact the ability to treat the patient effectively. Using disposable instruments as opposed to reusable instrumentation eliminates the need for processing and mitigates the possibility of contamination and transmission of disease. It also eliminates the need for an additional area for dirty and used supplies and training of staff to safely manage used equipment. With planning and organization, these logistical requirements should not be a hindrance to the evaluation and acute care of the female patient with a gynecologic issue.

Imaging and laboratory diagnostics are essential components in the evaluation of the gynecologic patient. Providers should be aware of what imaging diagnostics (eg, computed tomography [CT], magnetic resonance imaging [MRI], or ultrasonography) are available in their facility because this may impact the care that can be administered in that facility. Ultrasonography is the imaging modality of choice for the obstetrician-gynecologist. Like surgery, ultrasonography is an operator-dependent technology. Having sonographers who are competent and trained in the performance of obstetrical and gynecologic exams can only be achieved by supervised experience with a large variety of normal and abnormal examinations [4]. Gynecologic sonography has multiple uses, including evaluation of menstrual cycle and endometrial thickness and follicular development, determination of intrauterine pregnancy, localization of an intrauterine device, assessment of an adnexal or pelvic mass, evaluation for sequelae of pelvic infection, and identification of congenital uterine anomalies [4]. For most gynecologic emergencies, if the patient is stable, there is time to perform formal imaging to aid in diagnosis. If an obstetrician-gynecologist is immediately available for consultation, depending on their experience, they may perform a bedside rapid scan, which can provide more details and a diagnosis. Quick scans, or limited exams, can be performed by the emergency medicine physician to address specific focused questions when immediate impact on management is anticipated and when time or other constraints make performance of a standard examination impractical or unnecessary. An example would be a reproductive-aged woman who presents with hypotension, tachycardia, and peritoneal signs. A quick scan can identify free fluid and possible adnexal mass with no intrauterine pregnancy. Other imaging modalities such as CT and MRI are used frequently and help to narrow the differential diagnosis in the female patient because many symptoms may overlap between disease processes. When evaluating the pediatric or adolescent female, using MRI instead of CT has the advantage of decreased exposure to ionizing radiation [5]. Having a relationship with the radiology department is beneficial, especially in the acute setting. Interventional radiologists are a key group to work closely with because they are very familiar with normal pelvic arterial anatomy and have experience with embolization for pelvic trauma, in addition to experience with uterine fibroid embolization (UFE) [6]. In the setting of acute hemorrhage, if available, emergent embolization may be performed in the angiography suite and can stabilize the patient until further intervention can be obtained. Gynecologic conditions that may present emergently and may benefit from interventional radiology procedures include cervical ectopic pregnancies, uterine arteriovenous malformations, and large uterine fibroids [6].

In most cases, laboratory diagnostics are necessary to narrow down the differential diagnosis. A clear example is having the ability to perform a pregnancy test on a reproductive-aged female patient, which can exclude multiple diagnoses. It is essential for providers to know the capabilities of their facilities. Depending on the facility, immediate access to lab testing may not be available. Limiting factors for obtaining and processing lab data include the following: availability of staff to draw blood for testing, transportation of specimens (either by hand or tube system), capacity of the lab for processing specimens, and location of lab facilities. Not all hospitals have on-site laboratories; in some cases, the lab may be off campus or located in another city, which may interfere with collection and time to review the results. This can put the clinician and patient in a precarious position and can impact the care of the emergent patient. Although this is an extreme case, delays in testing or release of results can also occur in larger facilities due to high volume. These delays can have severe consequences for the reproductive-aged patient who may have a ruptured ovarian cyst versus a ruptured ectopic pregnancy, because not having access to pregnancy test results may change the type of intervention that takes place. To bypass this potential hazard, the ability to use point-of-care (POC) testing in the acute care setting can give rapid results that can guide diagnosis and initiation of treatment protocols without delaying care. Routine training of staff and maintenance of control testing for POC should be instituted and monitored. The ability to accurately interpret lab data and imaging studies in a timely manner will impact the timely care of the gynecologic patient.

In emergent situations, communication and the exchange or handoff of information needs to be done in a clear and concise manner to help ensure expedient care. Communication and handoff failures are both common and hazardous and have been identified by The Joint Commission and the Department of Defense as a contributing cause of approximately two out of every three sentinel events—serious, often fatal preventable adverse events in hospitals [7]. The exchange of information may be in the form of a verbal or written handoff system during transitions of care. Transitions of care between providers occur during emergent situations where critical clinical information is transmitted. Poor transitions, especially in the emergent situation, lead to uncertainty during clinical decision making, which can then lead to harm (near misses) or serious clinical consequences [8]. The use of a standardized language or communication protocol during the verbal handoff of care helps to ensure transmission of consistent information and allows for questioning. SBAR (Situation, Background, Assessment, Recommendation) is a standardized communication tool that can be used to facilitate information transfer [8]. Use of another communication tool, the I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) tool, has been researched and validated, and I-PASS is the only model associated with improved patient care. The use of these tools combined with a check back (closed loop communication strategy to verify and validate the information exchanged) or call out (strategy ...