Updates in The Management of Ob-Gyn Emergencies: January 2019

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Updates in the Management of Ob-Gyn Emergencies
Chapter · January 2019

DOI: 10.1007/978-3-319-95114-0_33
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Updates in the Management of Ob-Gyn
Emergencies 33
Antonio Ragusa, Alessandro Svelato, Mariarosaria Di
Tommaso, Sara D’Avino, Denise Rinaldo,
and Isabella Maini
33.1 Management of Gynecological

Key Points Emergencies
• Every physician can manage obstetric and gyneco-
logical emergency/urgency effectively following 33.1.1 Ovarian Cysts
the suggestions collected in this chapter.
• Diagnosis is more important than therapy. All The major causes of ovarian cyst complications, frequently
efforts must be employed to find the causes of ill- representing an emergency, are:
ness and so perform an etiological therapy.
• Never postpone an instrumental diagnosis because –– Ovarian torsion
the woman is pregnant. –– Ruptured ovarian cyst (also corpus luteum rupture)
• Never postpone surgery because the woman is preg-
nant, especially if the condition is life-threatening. 33.1.1.1 Ovarian Torsion
• The vast majority of obstetric and gynecological Ovarian torsion refers to the complete or partial rotation of
emergency/urgency needs a multidisciplinary the ovary on its ligamentous supports, resulting in the imped-
approach, so teamwork is the priority. ance of its blood supply. The fallopian tube often twists
• Sometimes it is necessary to perform an empirical along with the ovary; when this occurs, it is referred to as
treatment waiting for the definitive results of exams adnexal torsion [1]. Isolated torsion of the fallopian tube is
that will guide a targeted therapy. less common but may also occur [2].
• To act promptly is the key to solve emergency/
urgency. Epidemiology and Risk Factors
• Simulation and continuous training are mandatory Torsion is one of the most common surgical emergencies,
to improve skills in the management of emergency/ preceded by ectopic pregnancy, corpus luteum rupture with
urgency. hemorrhage, pelvic inflammatory disease, and appendicitis
[3]. Its exact incidence is unknown.
A. Ragusa (*) · A. Svelato · S. D’Avino D. Rinaldo

Department of Obstetrics and Gynecology, Massa Carrara General Department of Obstetrics and Gynecology, “Bolognini” General
Hospital, Massa, Italy Hospital, Bergamo, Italy
M. Di Tommaso I. Maini
Department of Health Science, University of Florence, Florence, Italy Department of Obstetrics and Gynecology, Fondazione MBBM,
e-mail: [email protected] Ospedale S. Gerardo, Monza, Italy
© Springer International Publishing AG, part of Springer Nature 2019 483

P. Aseni et al. (eds.), Operative Techniques and Recent Advances in Acute Care and Emergency Surgery,
https://doi.org/10.1007/978-3-319-95114-0_33
484 A. Ragusa et al.
The primary risk factor is an ovarian mass, particularly a Management

mass that is 5 cm in diameter or larger [4–6]. Torsion is more The mainstay of treatment of ovarian torsion is a swift opera-
likely to occur with benign cysts rather than malignant tive evaluation to preserve ovarian function, avoiding necro-
lesions, possibly because malignant masses are more likely sis that occurs in some hours of vessel occlusion [18]. For
to be fixed [6–8]. Since many of these masses are associated most premenopausal patients with ovarian torsion, detorsion
with functional cysts, the risk of torsion is higher in women and ovarian conservation are recommended. Cystectomy is
of reproductive age, during pregnancy, and in women under- often performed if a benign mass is present. Oophorectomy
going ovulation induction. should be reserved for dead tissue and is reasonable for post-
menopausal women [19] or when ovarian conservation is not
Clinical Presentation technically possible.
Clinical presentation is characterized by the acute onset of Management of torsion in pregnancy is similar to that in
moderate to severe pelvic pain, often with nausea and vomit- nonpregnant patients but may be technically more difficult
ing, in a woman with an adnexal mass. Torsion may also given the size of the gravid uterus [20].
occur in the absence of an adnexal mass [8–10].
33.1.1.2 Ruptured Ovarian Cyst
Diagnosis Rupture of an ovarian cyst is a common occurrence in women
An abdominal and pelvic examination should be performed. of reproductive age. Physiologic cysts, such as a follicular or
Most patients exhibit pelvic and/or abdominal tenderness [5, corpus luteal, or pathologic cysts may rupture. Ovarian cyst
6, 8]. rupture results in a release of cyst fluid or blood that may
A serum human chorionic gonadotropin, hematocrit, irritate the peritoneal cavity [21].
white blood cell count, and electrolyte panel should be taken.
Ultrasound is the imaging study of choice. Epidemiology and Risk Factors
The presence of these findings varies across patients: The incidence of ruptured ovarian cysts is uncertain. Some
data suggest that 4% of women will be admitted to the hos-
–– Rounded and enlarged ovary with heterogeneous stroma pital for an ovarian cyst by the age of 65 [21].
(due to edema and vascular and lymph engorgement),
often abnormally located anterior to the uterus [11, 12] Clinical Presentation
(Fig. 33.1). Rupture of an ovarian cyst is associated with a sudden onset
–– Multiple small peripheral follicles are thought to be due of unilateral lower abdominal pain. The classic presentation
to displacement caused by edema. is the sudden onset of severe focal lower quadrant pain, often
–– The “whirlpool sign” on Doppler grayscale, which repre- following sexual intercourse [22].
sents the twisted vascular pedicle (round hyperechoic
structure with concentric hypoechoic stripes or a tubular Diagnosis
structure with internal heterogeneous echoes) [13, 14]. Sonographic findings contribute to the diagnosis. A finding
–– Decreased or absent Doppler flow within the ovary of a combination of an ovarian cyst and blood or a significant
[15–17]. amount of serous fluid in the pelvis makes the diagnosis
highly likely. An ovarian cyst may or may not be visualized,
a b
Fig. 33.1 A case of adnexal torsion. The ovary is enlarged, the stroma is heterogeneous (a).The swollen salpinx can be seen medial to the ovary
(b). Courtesy of Daniela Giuliani, MD
33 Updates in the Management of Ob-Gyn Emergencies 485
since it may collapse after cyst rupture. Checking human into the endometrial cavity can identify the extent of intra-
chorionic gonadotropin is useful in order to exclude ectopic cavitary fibroids [32].
pregnancy. Ruptured ovarian cysts do occur in pregnant Magnetic resonance imaging (MRI) with gadolinium
women, but ectopic pregnancy is more likely to be life- contrast can provide information on devascularized (degen-
threatening than cyst rupture and should be excluded first. erated) fibroids and the relationship of fibroids to the endo-
metrial and serosal surfaces. This relationship influences the
Management choice among uterine-sparing treatment options [31].
For women with an uncomplicated rupture of an ovarian Possible complications of uterine fibroids include colli-
cyst, the observation rather than surgical intervention is rec- quative necrosis and torsion [32, 33]. Colliquative necrosis
ommended. These patients can usually be managed as outpa- occurs more frequently during pregnancy due to the rapid
tients as long as they are hemodynamically stable without a growth of the fibroid, which makes the blood supply that
significant drop in hematocrit. They should return if increased reaches the fibroid insufficient [32, 33]. The said condition
pain or light-headedness occurs. Oral analgesia is given as can result in intense localized abdominal pain, mild leukocy-
needed. Non-hemorrhagic cyst fluid is usually reabsorbed tosis, and less frequently hyperpyrexia, nausea, and sickness.
within 24 h and symptoms typically resolve within a few The diagnosis becomes suspected on the basis of clinical and
days. Follicular and corpus luteum cysts account for most of ultrasound findings [26, 32]. The latter can show the colli-
these cases. quative necrosis of the fibroid, which has irregular non-vas-
Laparoscopic surgery, rather than laparotomy, is per- cularized hypoechoic areas with regard to myomas, along
formed to control a hemorrhage if the patient’s clinical con- with peripheral vascularization with high impedance
dition is unstable [23]. (pseudo-capsule) and pain caused by the pressure of the
In pregnant women, the rupture of an ovarian cyst is most ultrasound probe [10]. Adnexal torsion, appendix abscess,
likely to occur in the first or early second trimester. and adnexal abscess are to be considered in differential
Conservative management is preferable in pregnancy, as for diagnosis.
nonpregnant patients. If surgery is necessary due to pain or Another possible complication is the torsion of peduncu-
hemorrhage, laparoscopy is a reasonable approach [24]. lated subserous myoma with consequent necrosis. This
causes acute abdominal pain.
The nature of symptoms leads to the choice of therapy.
33.1.2 Uterine Fibroids There is no evidence to support routine treatment of symp-
tomatic fibroids [34].
Uterine myomas are benign growths which originate from The treatment of these conditions is initially conservative
smooth muscle tissue and connective tissue on the walls of and involves the administration of paracetamol or FANS,
the uterus [25]. Their growth is affected by estrogens, growth hydration, and possible antibiotic therapy.
hormones, and progesterone [26]. If this therapy does not solve the problem, surgical
They are the most common benign gynecological pathol- removal of myoma via laparoscopic or laparotomy can be
ogy, with an incidence of between 20 and 77% in premeno- performed.
pausal women, but the real incidence is not known as more
than 50% of these tumors are asymptomatic [27, 28].
Their symptoms can include abnormal bleeding, heavy 33.1.3 Acute Pelvic Inflammatory Disease
menstrual bleeding, pain, a feeling of compression, and uri-
nary symptoms [29, 30]. Pelvic inflammatory disease (PID) is caused by an infection
A bimanual gynecological examination is often used in ascending from the vagina and endocervix, causing endome-
the first instance to verify if the patient has uterine fibroids tritis, salpingitis, parametritis, oophoritis, ovarian tube
[29]. abscesses, and/or pelvic peritonitis [35]. The responsible
Uterine fibroids are often suspected in a premenopausal causal agents are microorganisms that are transmitted sexu-
woman when an enlarged uterus or mass is palpated during a ally, such as Neisseria gonorrhoeae, Chlamydia trachoma-
pelvic examination or when she reports heavy menstrual tis, Mycoplasma genitalium, and other microorganisms that
bleeding [31]. Ultrasonography is the standard confirmatory are present in the vaginal flora (i.e., anaerobic, G. vaginalis,
test because it can easily and inexpensively differentiate a Haemophilus influenzae, E. coli, other enteric gram-negative
fibroid from a pregnant uterus or an adnexal mass [31]. bacteria, Streptococcus agalactiae) [36]. Moreover, cyto-
The need for further imaging depends on the clinical find- megalovirus (CMV), M. hominis, U. urealyticum, and M.
ings in the patient. In women with heavy menstrual bleeding, genitalium could also be associated with some cases of PID,
ultrasonographic examination after the infusion of saline also not transmitted sexually [37–39].
Connected risk factors are [40]: 33.1.3.1 Diagnosis

There is no sensitive and specific anamnestic note, instru-
• Young age mental exam, or lab test for the diagnosis of acute PID [44].
• Multiple partners Additional criteria used to improve the specificity of clin-
• Instrumental interventions on the uterus and pelvis/dis- ical criteria and support a diagnosis of PID are:
ruption of the cervical barrier
• Pregnancy termination—abortion • Vaginal cervical swab for gonorrhea and chlamydia. A
• The insertion of an intrauterine device in the previous 6 positive result supports the diagnosis of PID. Lack of
weeks infection does not exclude PID [45].
• Hysterosalpingography • An increase in white blood cells (WBC) [40] and PCR
• In vitro fertilization support the diagnosis but are not specific and can often be
normal in slight to moderate PID.
There is no real symptom or pathognomonic sign of • A transvaginal scan can highlight fluid collection or tubu-
PID [41]. lar ovarian complexes.
It can often start in asymptomatic form. A diagnostic sus-
pect can be considered in the presence of any of the follow- When there is a diagnostic doubt, laparoscopy may be
ing clinical signs and/or symptoms: useful to exclude other pathologies. It enables to take sam-
ples from the salpinges and Douglas and can provide infor-
• Lower abdominal pain, usually bilateral mation regarding the severity of the condition. It is, however,
• Deep dyspareunia invasive, and pelvic organs may seem normal in mild disease
• Abnormal bleeding: postcoital, intermenstrual, and [46].
menorrhagia An endometrial biopsy should be performed, with Nelaton
• Vaginal discharge related to aspiration syringe and sterile technique, in women
who undergo laparoscopy that does not provide visual evi-
Clinical Signs dence of salpingitis, because endometritis may be the only
sign of PID [44].
• Abdominal pain with possible leg involvement Other image techniques can be used if the clinical diagno-
• Cervical motion tenderness sis is uncertain, in the case of serious illness or those unre-
• Uterine tenderness sponsive to therapy [41].
• Adnexal tenderness
• Oral temperature >101 °F (>38.3 °C) 33.1.3.2 Management
Treatment must provide empirical and broad-spectrum cov-
Complications erage of probable pathogenic agents [44] such as Neisseria
gonorrhoeae (i.e., cephalosporin), Chlamydia trachomatis
• Tubo-ovarian abscess and pelvic peritonitis (i.e., tetracycline, macrolides), and anaerobic bacteria (i.e.,
• Fitz-Hugh-Curtis syndrome with by pain in the right metronidazole) [40].
upper quadrant together with perihepatitis [42]. A delay Cases of light to moderate PID, with suspected clinically
in diagnosis or treatment can increase the risk of long- or microbiologically confirmed, in patients without signs of
term sequelae such as ectopic pregnancy, sterility, and sepsis, hemodynamically stable with pain controlled by
chronic pelvic pain [41] common analgesics, without ovarian tube abscesses, can be
managed as outpatients with oral therapy [47]. The optimal
Differential Diagnosis duration of the treatment is not known, but most of the clini-
cal studies indicate a response after 10–14 days of therapy.
• Extrauterine pregnancy (a pregnancy test is recommended The patients must be reassessed within 72 h. A lack of clini-
for all women with suspected PID) [43]. cal improvement can indicate the need for further investiga-
• Acute appendicitis. tion or hospital treatment.
• Endometriosis: the relationship between the symptoms Hospitalization is indicated in the case of PID during
and the menstrual cycle can be useful [43]. pregnancy, lack of response to oral treatment intolerance to
• Rupture or twist of ovarian cysts. the oral treatment, clinically severe disease (hemodynami-
• Urinary tract infection—often linked to dysuria. cally unstable, pain, nausea, and vomiting, fever, acute abdo-
men), ovarian tube abscess, and impossibility of excluding Meyer suggested another theory regarding metaplasia
emergency surgery. In these cases, parenteral therapy is indi- [56]: endometrium and peritoneum derive from the same
cated [44]. coelomic wall epithelium, which can transform into endome-
Partners of women with PID should undergo screening trial-type glands in response to unknown stimuli; this could
tests for gonorrhea and chlamydia. Abstention from unpro- explain endometriosis in unusual sites and in women who
tected sexual intercourse is recommended until both the part- have undergone total hysterectomy and are not taking estro-
ner and patient have completed the treatment. gen replacement.
Symptoms: the presentation of endometriosis is highly
variable and ranges from debilitating pelvic pain and infertil-
33.1.4 Pelvic Endometriosis ity to no symptoms [57]: pain can include dysmenorrhea,
dyspareunia, and dyschezia, depending on the site involved
Endometriosis can be defined as the presence of endometrial [51, 58]. There is an overlap of symptoms with many condi-
glands and stroma in ectopic locations, primarily the pelvic tions, both gynecological and not.
peritoneum, ovaries, fallopian tubes, vagina, cervix, utero- Sterility is another important consequence of endo-
sacral ligaments, and rectovaginal septum [48] but also in metriosis (20–30% of patients): it can be caused by
extrapelvic sites, i.e., laparotomy scars, pleura, lungs, dia- adherences or by a decreased production of oocytes [59];
phragm, kidneys, spleen, gallbladder, nasal mucosa, spinal periovarian and peritubal adhesions can interfere
canal, stomach, or breast [49]. Ectopic tissues respond to mechanically with ovum transport, peritoneal endome-
normal cyclic hormonal stimulation as they have the same triosis interferes with tubal motility, corpus luteum func-
steroid receptors as normal endometrium. Microscopic inter- tion, and folliculogenesis. Aromatase is believed to raise
nal bleeding, with subsequent inflammatory response, neo- prostaglandin E levels via an increased cyclooxygen-
vascularization, and fibrosis formation is responsible for the ase-2 expression. Endometriosis can also cause a
clinical consequences of this disease [50]. decrease in fertility by binding more sperm to the ampul-
Epidemiology: this condition affects 6–10% of women of lary epithelium and so affecting sperm-endosalpingeal
childbearing age, with a prevalence of 38% in infertile interactions [60].
women and 71–87% of women with chronic pelvic pain Diagnosis: pelvic ultrasonography, MRI, and CT scan-
[51]. The incidence remains stable, although improved rec- ning are usually useful in the case of advanced disease with
ognition may have led to an increased diagnosis rate. endometrial cyst formation or anatomic distortion.
Risk factors include family history, early menarche, short Visualization of endometrial implants is the definitive
menstrual cycles and prolonged flow, heavy bleeding, nulli- method of diagnosis, mainly by laparoscopy.
parity, delayed childbearing, and anatomic alterations [52]. Differential diagnosis can be carried out for appendicitis,
Etiology: the cause of endometriosis is still unclear. diverticulitis, urinary tract infections and cystitis (by urinaly-
Several theories have tried to explain this condition, but none sis and urine culture), chlamydia infections, gonorrhea and
of them have been fully proved [48, 53]. Leading theories pelvic inflammatory disease (by cervical Gram stain and cul-
include metaplastic conversion of coelomic epithelium and tures), ectopic pregnancy, ovarian cyst, and ovarian torsion
hematogenous or lymphatic dispersion of endometrial cells, (by ultrasound).
but it is more likely to be a combination of these [54]. Staging: the American Society for Reproductive Medicine
In 1927, Sampson proposed his theory of retrograde classification of endometriosis is the most widely used stag-
menstruation through the fallopian tubes into the perito- ing system [61] (Figs. 33.2 and 33.3). Point scores are
neal cavity, so causing endometriosis. Later, this was assigned according to the number and size of lesions and
found to be a common physiologic phenomenon that their bilaterality, as well as to the associated adhesion forma-
could not appropriately explain the onset of endometrio- tion. This is a method of recording laparoscopic findings.
sis, although it probably increases the risk of developing This classification does not correlate with pain and other
this condition. symptoms. It can also be used to monitor a patient’s response
More recently, research has focused on the role played by to therapy, although it requires laparoscopic or, less fre-
the immune system in the pathogenesis of endometriosis quently, laparotomic surgery both initially and for
[55]; women with this disorder have increased humoral follow-up.
immune responsiveness and macrophage activation, as well Treatment: as endometriosis depends on a woman’s cyclic
as decreased cell-mediated immunity with diminished T-cell production of menstrual hormones, an improvement in this
and natural killer cell responsiveness. condition can be achieved by suppressing the hormonal
REVISED AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE CLASSIFICATION OF

ENDOMETRIOSIS 1985
Patient's Name Date:
Stage I (Minimal) 1-5 Laparoscopy Laparotomy Photography

Stage II (Mild) 6-15 Recommended Treatment
Stage III (Moderate) 16-40
Stage IV (Severe) >40
Total Prognosis
ENDOMETRIOSIS
Peritoneum
< 1 cm < 1 – 3 cm > 3 cm
Superficial 1 2 4
Deep 2 4 6
R Superficial 1 2 4
Deep 4 16 20
Ovary
L Superficial 1 2 4
Deep 4 16 20
POSTERIOR CULDESAC Partial Complete
OBLITERATION 4 40
ADHESIONS < 1/3 Enclosure 1/3-2/3 Enclosure > 2/3 Enclosure
R Filmy 1 2 4
Ovary
Dense 4 8 16
L Filmy 1 2 4
Dense 4 8 16
R Filmy 1 2 4
Dense 4 8 16
Tube
L Filmy 1 2 4
Dense 4* 8* 16
*If the fimbriated end of the fallopian tube is completely enclosed, change the point assignment to 16.
Additional Endometriosis: Associated Pathology:
To be used with normal To be used with abnormal

tubes and ovaries tubes and/or ovaries
Left Right Left Right
Fig. 33.2 American Society for Reproductive Medicine revised classification of endometriosis, 1985 [61]
rhythm. Gonadotropin-releasing hormone (GnRH) agonists, Surgical management of endometriotic lesions usually
androgens, progestins, and oral contraceptive pills can be provides pain relief and an improvement of symptoms [63],
prescribed for this purpose. Nonsteroidal anti-inflammatory with a non-predictable improvement of pregnancy rates.
agents have not been proven to have any benefit in placebo- With conservative surgery, the aim is to remove visible
controlled trials [62]. endometriotic implants and lyse peritubal and periovarian
STAGE I (MINIMAL) STAGE II (MILD) STAGE III (MODERATE)
PERITONEUM PERITONEUM PERITONEUM

Superficial endo – 1–3cm –2 Deep endo – > 3cm –6 Deep endo – > 3cm –6
R OVARY R OVARY CULDESAC
Superficial endo – < 1cm –1 Superficial endo – < 1cm –1 Partial obliteration –4
Filmy adhesions – < 1 –1 Filmy adhesions – < 1 –1 L OVARY
3 4 3 Deep endo – 1–3cm –16
TOTAL POINTS L OVARY
Superficial endo – < 1cm –1 TOTAL POINTS 26
TOTAL POINTS 9
STAGE III (MODERATE) STAGE IV (SEVERE) STAGE IV (SEVERE)
PERITONEUM PERITONEUM PERITONEUM

Superficial endo – >3cm –4 superficial endo – >3cm –4 Deep endo – >3cm –6
R TUBE L OVARY CULDESAC
Filmy adhesions – < 1 –1 Deep endo – 1–3cm –32** Complete obliteration –40
R OVARY 3 Dense adhesions – < 1 –8** R OVARY
Filmy adhesions – < 1 –1 L TUBE 3
Deep endo – 1–3cm –16
3
L TUBE Dense adhesions – < 1 –8** Dense adhesions – < 1 –4
< 1 3 3
Dense adhesions – –16* TOTAL POINTS 52 L TUBE
3 2
L OVARY Dense adhesions – > –16
3
Deep endo – <1cm –4 L OVARY
Dense adhesions – < 1 –4 Deep endo – 1–3cm –16
TOTAL POINTS 3 30 *Point assignment changed to 16 Dense adhesions – > 2 –16
**Point assignment doubled 3 114
TOTAL POINTS
Fig. 33.3 American Society for Reproductive Medicine revised classification of endometriosis, 1985 [61]
adhesions with a laparoscopic approach. Ablation can be 33.1.5 Severe Vaginal Bleeding
performed with laser or electrodiathermy. These techniques
were shown to be effective for relieving pelvic pain in 87% Severe vaginal bleeding is a condition that may be related to
of patients [64]. many etiologies, both functional and structural. It can take
The indication for semiconservative surgery is mainly for place during menstrual flow, as an increased blood loss, or
women who have no desire for future childbearing, are too between two menstrual flows. These situations are, respec-
young for surgical menopause, and are in strong need of pain tively, called menorrhagia and metrorrhagia.
relief. Such surgery consists of hysterectomy and cytoreduc- Munro in 2011 proposed a classification system for
tion of pelvic endometriosis. abnormal uterine bleeding (AUB) in non-gravid women of
Radical surgery includes total hysterectomy with bilateral reproductive age that was officially approved by FIGO
oophorectomy and cytoreduction of visible endometriosis. [65]. This system is called “PALM-COEIN,” as an acro-
Adhesiolysis is performed to recover mobility and normal nym of the nine categories of causes of vaginal bleeding
intrapelvic relationships. (Fig. 33.4):
Polyp Coagulopathy important to consider this cause, as it has been proven that
Adenomyosis Ovulatoru dysfuctions coagulation disorders can often be forgotten in differential
Submucosal
Leiomyoma Endometrial diagnosis of vaginal bleeding [70, 71]. These conditions
Other
Malignancy & hyperplasia latrogenic require a hematologic approach and specific treatment.
Not yet classified Coagulopathy can also be caused by medications; this case
would enter the “Iatrogenic” category, but, since women tak-
ing these drugs usually have a hemostasis disorder, it is still
included in the “Coagulopathy” category [65].
Ovulatory dysfunction: this is a common cause of AUB,
generally manifesting as a combination of unpredictable tim-
ing of bleeding and variable amount of flow. Disorders of
ovulation may be present as a variety of menstrual issues,
Fig. 33.4 A simple way to remember the causes of AUB; the first four from amenorrhea, through light and infrequent spotting, to
(PALM) are structural anomalies; the others are not related to structural
anomalies [65] episodes of extremely heavy menstrual bleeding (HMB),
requiring medical or even surgical intervention. Some ovula-
tory disorders have a clear endocrinological etiology, i.e.,
Polyp hypothyroidism, polycystic ovary syndrome, mental stress,
Adenomyosis hyperprolactinemia, anorexia, obesity, weight loss, or
Leiomyoma extreme exercise. In some cases, the disorder can be iatro-
Malignancy and hyperplasia genic, due to gonadal steroids or phenothiazines and tricyclic
Coagulopathy antidepressants [65].
Ovulatory dysfunction Endometrial: if abnormal bleeding takes place in the con-
Endometrial text of regular menstrual bleeding, characteristic of ovula-
Iatrogenic tory cycles, and if no other causes are identified, the cause is
Not yet classified probably a primary disorder of the endometrium. There
could be a deficit in the endometrial production of vasocon-
Polyps: both endometrial and endocervical. These forma- strictors, such as endothelin 1 and prostaglandin F2α, or an
tions have a variable vascular, glandular, fibromuscular, and accelerated lysis of the endometrial clot for augmented lev-
connective tissue; they are usually asymptomatic but can els of plasminogen activator, with an increased concentration
also bleed [66]. Polyps are usually benign, but a small minor- of molecules promoting vasodilation, i.e., prostaglandin E2
ity may have atypical or malignant features [67]. A therapeu- (PGE2) and prostacyclin (PGI2) [72–74]. Unfortunately, it is
tic approach consists of removal, mostly by hysteroscopy. not possible to measure these abnormalities at present. Other
Adenomyosis: the relationship between AUB and adeno- secondarily disorders can cause endometrial bleeding, such
myosis is still unclear; adenomyosis can be assessed with as inflammation or infection of endometrial tissue, problems
MRI and ultrasonography, but as the latter is more available in the uterine phlogistic response and disorders in local vas-
in common practice, it is proposed that ultrasound criteria culogenesis. The role played by inflammation in uterine
comprise the minimum requirements for inclusion in the bleeding is still not clear: a retrospective evaluation of
PALM-COEIN system. women with chronic endometritis could not assess a correla-
Leiomyoma: this is a benign fibromuscular formation of tion between inflammation and AUB [75, 76], but there is
myometrium, also known as fibroid or myoma. There is a data that supports a relationship between AUB and Chlamydia
high prevalence of this benign tumor worldwide, and it is trachomatis infection [77]. An involvement of endometrium
often asymptomatic. Fibroids can be classified according to as a cause of abnormal uterine bleeding should probably be a
their number, size, and location, but the PALM-COEIN sys- diagnosis of exclusion.
tem just includes the categorization of intramural and subse- Iatrogenic: there are several possible iatrogenic causes of
rosal lesions. They are usually removed, with relief of vaginal bleeding, by intrauterine devices, both medicated or
symptoms, if present [68]. not, and a multitude of drugs. Gonadal steroid therapy is very
Malignancy and hyperplasia: atypical hyperplasia and commonly an agent of AUB, which in this case is called
malignancy are quite uncommon but are a significant cause “breakthrough bleeding (BTB).” Systemically administered
of vaginal bleeding that requires further investigation and steroids, such as progestins, estrogens, and androgens, have
classification according to the WHO and FIGO system [69]. a therapeutic effect on the hypothalamic-pituitary-ovarian
Coagulopathy: this term includes the spectrum of sys- axis and directly affect the endometrium itself. These drugs
temic disorders of hemostasis that may cause vaginal bleed- are used as hormonal contraceptives, and bleeding is usually
ing, i.e., von Willebrand disease (VWD). It is particularly due to their periodic withdrawal. BTB is more frequent in
smokers, because of an enhanced hepatic metabolism that 33.1.6.3 Drainage

decreases the levels of circulating steroids [78]. Systemic Incision and drainage are quite a fast and simple procedure that
agents involved in dopamine metabolism can cause uterine provides immediate relief to the patient, with a failure rate of
bleeding, secondary to ovulation problems. Tricyclic antide- 13% [85]. Definite drainage can be carried out by positioning a
pressants, such as amitriptyline and nortriptyline, and pheno- Word catheter for 4–6 weeks, or marsupialization to recreate the
thiazines reduce serotonin uptake and thus interfere with the orifice of the duct, enabling continuous drainage.
dopamine metabolism [79]. Finally, severe vaginal bleeding
is a common side effect of anticoagulant drugs, such as war- 33.1.6.4 Fistulization
farin, heparin, and low molecular weight heparin (LMWH), The technique for creating a new, epithelialized outflow tract
but as previously stated, these cases are included in the for an obstructed Bartholin duct was by placing either a
“Coagulopathy” category. 14-French Foley catheter, a Jacobi ring, or a Word catheter near
Not yet classified: this category comprises many disor- the Bartholin gland duct. The Word catheter is inflated with
ders of the endometrium that may contribute to AUB but 3 mL of saline solution and is left in place for 4–6 weeks. The
which have not been properly studied yet, so their role is still Jacobi ring is a rubber catheter, fashioned into a ring from an
unknown. 8-French T tube threaded over a 2-0 silk suture that enters and
leaves the cyst or abscess through two separate incisions [86].
Recurrence after 6 months ranges from 4 to 17%.
33.1.6 Vulvar Abscesses The most common adverse event is the premature loss of
the Word catheter.
Vulvar abscesses are a common gynecological problem Healing takes place on average after about 3 weeks.
caused by infection of the cute or of the subcutaneous tissue
of the vulva. The most common vulvar abscesses, which 33.1.6.5 Marsupialization
occur in about 2% of women, are Bartholin gland cysts [80]. Incision of the vestibular skin and the cyst wall, emptying the
Recent prevalence estimates and risk factors are difficult to cyst, preserving the new orifice. Suture of the wall of the cyst
define. Data from literature point to bacterial infections in to the edges of the incision of the skin.
57% of cases, with E. coli as the most frequent single agent, Healing takes place on average in less than 2 weeks.
followed by streptococci [81]. Complications: rare hemorrhage (11%).
The patient has severe pain and swelling. On physical Compared to patients treated using incision and drainage,
examination, the abscess looks like a warm and soft mass, those undergoing marsupialization heal more slowly, with-
fluctuating in the lower vestibular area. out any significant difference in recurrence [87].
Rare serious complications can include infections such as
systemic infection, sepsis, and secondary bleeding. 33.1.6.6 Carbon Dioxide Laser
Possibly treatment includes antibiotic therapy selected on With the aim of creating an opening of the orifice of the duct
an empirical basis involving drainage, use of CO2 laser to in the skin of the vulvar area, outpatient treatment of vulvar
carry out ablation of the cyst, fenestration or excision of the abscesses using a CO2 laser was described [88–90].
gland, fistulization to create an opening for a new duct, mar- The cysts and/or abscess is emptied and then vapor-
supialization, or excision of the Bartholin gland. ized [88].
Despite the numerous types of treatment available, recur- Recurrence ranges from 2 to 20%.
rences are frequent [82], and the healing process is prolonged Complications: heavy bleeding (2–8%) after the ablation
and involves the interruption of daily activities, sexual inter- of the gland using a laser [90].
course, as well as discomfort for the female patient.
33.1.6.7 Excision of the Gland
33.1.6.1 Fine-Needle Aspiration The average duration of the procedure is 20–60 min.
Recurrences after 6 months range from 0 to 38%. Compared Recurrences at 2 years range from 0 to 3%.
to alcohol sclerotherapy, this method has been associated Average healing time 11 days.
with about as twice as high frequency of recurrence [83]. Complications: bleeding (2–8%), fever (24%), and dyspa-
reunia (8–16%) [88].
33.1.6.2 Alcohol Sclerotherapy The choice of treatment for Bartholin’s gland cysts
Irrigation with alcohol al 70% for 5 min, after evacuation of remains difficult [81].The ideal treatment is fast and safe,
the cavity of the cyst. Recurrence at 7 months ranges from 8 performed in outpatient regime, using local anesthesia, with
to 10% [84]. Average healing time: 1 week. a low rate of recurrence and fast healing.
Complications: transient hyperthyroidism, hematoma, All therapies described are carried out as outpatient proce-
and tissue necrosis [84]. dure, using local anesthesia or block of the pudendal nerve,
with an average duration of about 20 min. Average healing Clinical assessment must be carried out by expert person-
time is 2 weeks or less. Adverse events are generally rare and nel, and, when possible, the victim must have the possibility
are not life-threatening. Regardless of the treatment, recur- to choose the sex of the examiner.
rences occur in less than 20% of patients, with few exceptions Complete assessment in the case of sexual violence
(the highest percentage is for those after aspiration only). includes [93]:
The best treatment has still not been identified, and in existing
literature, the best intervention among those described previ- –– Consent to clinical examination
ously has not been defined. The operator can, therefore, choose –– Remote and recent medical history, including the descrip-
the suitable treatment on the basis of the patient’s characteristics tion of the events, gynecological obstetric history
(symptoms, age, size of abscess, etc.), the resources of the hospi- –– Physical examination
tal where he/she is working, and his/her experience [81]. –– Detailed examination of the genito-anal apparatus
–– Recording and classification of the identified lesions
–– Collection and preservation of biological samples
33.1.7 Sexual Violence –– Forensic report
33.1.7.1 Definition In women, genital trauma is more easily seen behind the
Violence against women is a major public health and human posterior vulvar commeasure, labia minora, hymen, and/or
rights concern. Sexual violence is defined as, “any sexual fossa navicularis (fossa of vestibule of vagina).
act, attempt to obtain a sexual act, unwanted sexual comments The most frequent types of genital trauma include [91]:
or advances, or acts to traffic women’s sexuality, using coer- Lacerations (Fig. 33.5)
cion, threats of harm or physical force, by any person regard-
less of relationship to the victim, in any setting, including but –– Bruising
not limited to home and work” [91]. –– Abrasions
–– Redness and swelling (Fig. 33.6)
33.1.7.2 Prevalence
Studies show that most victims are female, and that the violence The most frequent non-genital traumas include:
is generally committed by a man, and that many victims know
their tormentor [91]. Global statistics show that between 13 and –– Hematomas and bruises
61% of women 15–49 years old report that an intimate partner –– Lacerations
has physically abused them at least once in their lifetime [92].
There is significant under-reporting of sexual violence. The rea-
sons for nonreporting are complex and multifaceted but typi-
cally include fear of retribution or ridicule and a lack of
confidence in investigators, police, and health workers. Sexual
violence has a significant negative impact on the health of popu-
lations. The main consequences are listed in Table 33.1 [91].
33.1.7.3 Clinical Assessment

The victim must have a safe and protected environment, and
all those involved must have received suitable training with
regard to communicating with victims of sexual violence.
Table 33.1 Consequences of sexual violence [91]

Unwanted pregnancy
Illegal abortion
Sexually transmitted infections (STI), including HIV/AIDS
Sexual dysfunction
Infertility
Pelvic inflammatory disease
Urinary infections
Dangerous sexual practices
Fig. 33.5 Multiple lacerations near the vulvar posterior commissure
Depression, substance abuse, post-traumatic stress disorder (PTSD), (With permission of World Health Organization, Guidelines for med-
and suicide ico-legal care of victims of sexual violence, 2003)
–– Signs of tying the wrists, ankles, and neck

–– Signs of bites, fingers, and belts
–– Anal or rectal trauma
On the basis of the facts and the information provided by

the patient and by investigators, the doctor can decide which
type of samples to take. Ideally, the samples must be taken
within 24 h from the attack. In fact, after 72 h the possibility
of obtaining reliable samples is reduced (Table 33.2) [93].
The presence of semen is confirmed by sampling using a
swab, followed by microscopic examination (Table 33.3).
The swab must be inserted delicately beyond the hymen, tak-
ing care not to touch the external parts (Fig. 33.7). In the case
of suspected ejaculation inside the mouth, since the sperm
Table 33.2 Persistence of biological evidences

Type of assault Persistence of biological evidences
Kissing, licking, biting 48 h or longer
Oral penetration 48 h
Vaginal penetration 7 days
Fig. 33.6 Swelling of the hymen (With permission of World Health
Digital penetratiom 12 h
Organization, Guidelines for medico-legal care of victims of sexual
violence, 2003) Anal penetration 72 h
Table 33.3 Shows the samples that are more frequently taken in the case of sexual violence [91]
Site Material Equipment Sampling instructions Notes
Anus Semen Cotton swabs and Use swab and slides to collect and plate material; lubricate 1
(rectum) microscope slides instruments with water, not lubricant
Lubricant Cotton swab Dry swab after collection
Blood Drugs Appropriate tube Collect 10 mL of venous blood 2
DNA (victim) Appropriate tube Collect 10 mL of blood
Clothing Adherent foreign Paper bags Clothing should be placed in a paper bag(s). Collect paper sheet 3
materials (e.g. semen, or drop cloth. Wet items should be bagged separately
blood, hair, fibres)
Genitalia Semen Cotton swabs and Use separate swabs and slides to collect and plate material 1
microscope slide collected from the external genitalia, vaginal vault and cervix;
lubricate speculum with water not lubricant or collect a blind
vaginal swab (see Fig. 33.11)
Hair Comparison to hair Sterile container Cut approximately 20 hairs and place hair in sterile container 4
found at scene
Mouth Semen Cotton swabs, sterile Swab multiple sites in mouth with one or more swabs (see 1
container (for oral washings) Fig. 33.12). To obtain a sample of oral washings, rinse mouth
or dental flossing with 10 mL water and collect in sterile container
DNA (victim) Cotton swab 5
Nails Skin, blood, fibres, Sterile toothpick or similar Use the toothpick to collect material from under the nails or the 6
etc. (from assailant) or nail scissors/clippers nail(s) can be cut and the clippings collected in a sterile container
Sanitary Foreign material (e.g. Sterile container Collect if used during or after vaginal or oral penetration 7
pads/ semen, blood, hair)
tampons
Skin Semen Cotton swab Swab sites where semen may be present 1
Saliva (e.g. at sites of Cotton swab Dry swab after collection
kissing, biting or
licking), blood
Foreign material (e.g. Swab or tweezers Place material in sterile container (e.g. envelope, bottle)
vegetation, matted
hair or foreign hairs)
Urine Drugs Sterile container Collect 100 mL of urine 2
–– Prevention of sexually transmitted diseases

–– Prevention of HIV/AIDS infection
–– Emergency contraception
–– Psychological and social support [91]
33.2 Management of Ob-Gyn Emergencies
33.2.1 Antepartum Hemorrhage
33.2.1.1 Introduction
Antepartum hemorrhages are defined as a blood loss from
the genitals during the second part of the pregnancy and
complicate 2–5% of pregnancies. They can be divided into
placental abruption hemorrhages (40%), placenta previa
(20%), local causes (10%), vasa previa (0.5%), and uncertain
Fig. 33.7 Vaginal swab (With permission of World Health origin (30%) [94].
Organization, Guidelines for medico-legal care of victims of sexual
violence, 2003) 33.2.1.2 Placenta Previa
Placenta abruption is found in 1% of pregnancies, more fre-
quently during young maternal ages [95, 96].
The most predictive risk factor is abruption in a previous
pregnancy. Other risk factors for placental abruption include:
pre-eclampsia, fetal growth restriction, non-vertex presenta-
tions, polyhydramnios, advanced maternal age, multiparity,
low body mass index (BMI), pregnancy following assisted
reproductive techniques, intrauterine infection, premature
rupture of membranes, abdominal trauma (both accidental
and resulting from domestic violence), smoking and drug
misuse (cocaine and amphetamines) during pregnancy. First
trimester bleeding increases the risk of abruption later in the
pregnancy [97].
The clinical picture is characterized on the basis of the
entity of the bleeding at three levels [95, 96]:
Fig. 33.8 Mouth swab (With permission of World Health Organization,

–– Level 1 characterized by slight vaginal bleeding, mild
Guidelines for medico-legal care of victims of sexual violence, 2003)
uterine contraction and the absence of cardiotocographic
changes;
and semen tend to collect in the spaces between the teeth and –– Level 2 characterized by slight to moderate vaginal bleed-
the edges of the gums, it is important to take samples using a ing, more intense uterine contractions and the presence of
swab placed in the space between the teeth (Fig. 33.8). cardiotocographic changes;
Those who wish to report the assault to the police imme- –– Level 3 characterized by heavy vaginal bleeding, uterine
diately should be encouraged to do so. The wishes of those contractions with the characteristics of from tachysistole
who disclose recent sexual assault but do not wish to report and tetanic, intense abdominal pain and clear pathological
the offense to the police should be respected. They should be CTG, conditions that can lead to the death of the fetus.
offered an examination with collection of DNA and other
evidence, without police involvement. This gives patients the Diagnosis is clinical. Bleeding, which is not present in
opportunity to consider their options and report the assault at 20-30% of cases, is generally dark red. The pain is acute,
a later date [93]. continuous or intermittent, and localization is related to the
position of the placenta. If the placenta is posterior, an acute
33.1.7.4 Treatment and Follow-Up lower lumbar pain may be the only symptom. Uterine con-
Aims of the treatment are: tractile activity is hyperkineticc, or even hypertonic and
tetanic in more serious cases. Nausea e sickness could also intrapartum hemorrhage, hysterectomy, postpartum hemor-
be among the symptoms [98]. rhage, sepsis, and thrombophlebitis. Fetal complications are
A scan used in the diagnosis of placental abruption is not perinatal mortality (4–8%), prematurity, and delayed intra-
a very sensitive technique, even if specific [99]. uterine growth.
Cardiotocography is not always useful in initial phases, but it
becomes increasingly more pathological when the abruption 33.2.1.3 Antepartum Hemorrhage:
involves at least half of the placental bed. The most frequent Management
changes are severe variable decelerations, late decelerations, All patients with blood loss after 20 weeks must be trans-
bradycardia and the reduction in variability [100]. ported to the delivery room. The two primary objectives are
Placental abruption involves a high level of perinatal the hemodynamic evaluation of the mother and the assess-
mortality and morbidity and can cause rare, but serious ment of the well-being of the fetus. Two large venous
maternal and fetal complications [95, 96]. Maternal compli- accesses must be put in place for hematocrit and blood typ-
cations include: mortality (1%), hypovolemic shock (5%), ing sampling. The clinical situation can differ according to
acute renal failure (0.5–1.5%), disseminated intravascular whether or not there is a state of shock. Once the patient has
coagulation (CID) (10%), postpartum hemorrhages (25%) been stabilized and fetal conditions assessed, the cause of the
and recurrence (8–25%). bleeding must be investigated. The clinical situation depends
Placenta previa is a condition in which the placenta is on the extent of the blood loss, on the period of the preg-
positioned in the lower uterine segment and can reach or nancy during which it takes place, and on the degree of
cover, partially or completely, the internal uterine orifice. maternal-fetal compromise.
There is an incidence of 0.3% in single pregnancies [94]. On
the basis of the topography, four possible eventualities can
be highlighted: 33.2.2 Postpartum Hemorrhage
1. Low-lying placenta, ending in the lower uterine

33.2.2.1 Introduction
segment The World Health Organization defines primary postpar-
2. Marginal placenta previa, which reaches or is less than tum hemorrhage (PPH) as blood loss greater than or
2 cm from the edge of internal uterine orifice equal to 500 mL within 24 h of a vaginal delivery. PPH is
3. Partial placenta previa, which partially covers the internal regarded as severe if the blood loss exceeds 1000 mL; in
uterine orifice a cesarean section, blood loss equal to or greater than
4. Central placenta previa, which completely covers the
1000 mL can be defined as anomalous [103]. Secondary
internal uterine orifice PPH is defined as abnormal bleeding from the genital
tract from 24 h after delivery until 12 weeks postpartum
The risk factors for placenta previa are previous placenta [104, 105].
previa, previous cesarean section, previous uterine surgery, PPH is one of the most frequent causes of mortality and
pregnancies using medically assisted procreation techniques, morbidity in the obstetric population globally [103].
twin pregnancies, smoking, cocaine, multiparity, and The causes of PPH can be manifold. In clinical practice,
advanced maternal age [94]. they are summarized as the “4 Ts” [106]:
Patients with placenta previa usually come for a checkup
because of bleeding without pain at about the beginning of • Tone (uterine atony)
the third trimester [101, 102]. On examination, the uterus • Tissue (retained placenta and abnormal placental
appears decontracted, not painful and normal. In the begin- implantation)
ning, the bleeding is bright red and is very light; the onset • Trauma (uterine rupture, cervical laceration, uterine
of symptoms is often slow and insidious and occurs weeks inversion, or birth canal lacerations)
before labor; in one-third of the cases, patients do not have • Thrombin (blood coagulation disorders)
any blood loss until the start of labor. The differential diag-
nosis with placental abruption can be particularly The fundamentals of PPH treatment are:
insidious.
The diagnosis of placenta previa is usually carried out via 1. Maintenance of uterine contractility, obtained by physical
transvaginal scan, which is more precise than a transabdomi- or pharmacologic means
nal scan. 2. Maintenance or support of circulation with proper

The complications connected to placenta previa can be hydration
both maternal and fetal. The maternal complications are 3. Prevention or treatment of the established hemorrhagic
maternal mortality (0.03%), antepartum hemorrhage, coagulopathy
Intervention should be made in the “golden hour” to • Thrombin (in relation to blood coagulation disorders due
increase the chances of survival of the patient [104, 107]. to thrombin dysfunction; any coagulation defects should
be evaluated and corrected with ROTEM/TEG monitor-
33.2.2.2 Medical Management of PPH ing, if available).
The first action to be taken in the case of PPH is to request
the cooperation of other medical and paramedic staff. While The restoration of the circulating volume by giving the
waiting for support, an assessment of the extent of the bleed- least volume of crystalloids (Ringer-lactate/acetate as the
ing through retroplacental bag, gauze, and drapes is advised first line) or colloids [115] until the hypoperfusion is cor-
[108, 109]. rected, based on an evaluation of the clinical and laboratory
Simultaneous with the assessment of blood loss is the variables (sensory state, diuresis, lactates, and deficit base),
need to begin the monitoring of vital signs: blood pressure, and speeding up the request of blood products should be car-
respiratory rate, heart rate, electrocardiography (ECG), pulse ried out only when resolution of the effective hemorrhage is
oximetry, temperature, and diuresis through a urinary cathe- not achieved.
ter. Checking should be carried out initially every 10 min, During massive hemorrhage, fibrinogen is one of the first
according to the clinical evolution, and then every 30 min coagulation factors to decrease beyond critical levels. Several
[108]. At this stage, a request for blood components should recent studies have suggested that fibrinogen is an important
be sent to the transfusion center. predictor of severe PPH [116, 117]. Some guidelines have
Two large venous access points (16 G or, better, 14 G) indicated that fibrinogen concentrate should be the replace-
should also be established; the use of infusion pumps is pref- ment therapy of choice [118].
erable. A urinary catheter also needs to be inserted to empty Transfusion in the presence of the effective PPH is carried
the bladder. out based on clinical indications and not on information
The pharmacologic therapy at this stage includes oxyto- obtained from blood chemistry tests.
cin and tranexamic acid (TXA). There is significant variation Cases that do not respond to the therapies described above
in practice in this regard. However, oxytocin together with require a conservative surgical interventionist approach. In
TXA is to be the first choice (20 IU in 500 mL saline in 2 h) case of non-response to the measures outlined thus far, the
[105]. If no effect is observed after 20 min, a second-line application of partial or total hysterectomy will be
uterotonic may have to be given. necessary.
Evidence supporting the early use of TXA in massive
hemorrhage, at variable dosage of between 1 and 4 g [108– 33.2.2.3 Surgical Management of PPH
113], has been increasing rapidly. Once the peritoneum has been opened, the integrity of the
At the same time, samples regarding blood group have to womb must be checked, carefully examining the uterine
be taken, and repeated blood counts and basic coagulation walls and aiming at obtaining a contraction of the womb uti-
tests should be carried out: prothrombin time, partial throm- lizing a prolonged massage [119]. If this massage has no
boplastin time, fibrinogen, and antithrombin. result, a compressive type of intervention must be carried out
Close monitoring is needed to avoid or correct hypother- (B-Lynch or Hayman technique) which solves the problem
mia and to measure and avoid acidosis (lactates >2 mmol/L) in more than 85% of cases [120–126].
and desaturation. We suggest that an arterial blood gas In the rare cases that B-Lynch or Hayman techniques are
analysis be carried out to obtain a baseline hemoglobin not effective, it is necessary to proceed without further delay
level. with a hysterectomy.
The source of bleeding should be established by applying
the rule of the 4 Ts [106], and the relevant corrective actions B-Lynch
should be determined: The B-Lynch technique is simple to carry out and has excel-
lent results if the indication is correct. In order to carry out
• Tone (bimanual uterine compression, intracavitary uter- the intervention after a vaginal birth, in the absence of hys-
ine tamponade through a hydrostatic balloon catheter, and terotomy, as in the case of a cesarean section, the prevesical
use of uterotonics). In the absence of a hydrostatic bal- peritoneum must be opened, opening the uterine bladder
loon, a latex glove or a condom can be used with good fold of peritoneum and detaching the bladder downward at
results, as suggested by the FIGO 2012 Guidelines [114]. least 2 cm. The lower uterine segment must be cut diago-
It should be emphasized that the use of gauze tamponade nally for 4 cm. The uterus must be exteriorized from the
is now discouraged. laparotomic breach, proceeding using a monofilament
• Tissue (exploration and evacuation of the uterus). thread of at least 120 cm in length with a rounded needle of
• Trauma (vaginal lacerations and cervix and/or uterine more than 48 mm. The anterior part of the uterus is punc-
rupture repair). tured completely on the right side from the dissection of the
bladder at least 15 mm from the hysterotomy. The needle

must come out from the anterior part at least 15 mm above
the hysterotomy, creating the first “handle” puncturing the
posterior segment of the uterus completely by at least 4 cm
from the right uterosacral ligament to the left uterosacral
ligament, thus creating the second “handle” puncturing the
anterior segment of the uterus 15 mm above the hysterotomy
and bringing out the needle 15 mm below the hysterotomy
(Fig. 33.9).
Hayman
This case also involves the creation of handles, from 2 to 4,
which, unlike the B-Lynch, are not connected to each other.
First of all, we proceed, as for B-Lynch, with the detachment
of the bladder. Two stitches are then placed on the lower uter-
ine segment, next to each other, taking care to leave a space
for secretion (Fig. 33.10).
Ligature of the Hypogastric Artery

Ligature of the hypogastric artery, or when indicated, the
uterine artery, is not so useful in solving corporal bleeding,
due to the intense branches of the ovarian artery that take
blood to the uterus. On the other hand, it is considerably Fig. 33.10 Hayman. Two to four stitches are made in the uterus pierc-
ing the lower segment by 15 mm caudal to the real or imagined breach,
going through the uterus from front to back and then tying the threads
on the bottom of the uterus, confirming that the assistant ensures the
volumetric reduction of the uterine size [124, 125] (With permission of
Piccin Editore. From Ragusa A, Crescini C. URGENZE ED
EMERGENZE IN SALA PARTO.Padova 2015: Casa Editrice PICCIN
Nuova Libreria)
u seful in lower uterine segment bleeding, from the cervix

and the vagina, and for broad ligament hematoma. It is also
very useful in cases of uterine rupture to conclude a hyster-
ectomy, otherwise impossible due to the overflow of blood in
the operating area.
The first action to be taken is an incision of the broad
ligament in the part between the round ligament and the
suspensory ligament of the ovary, taking care to remain at
the side, above the iliopsoas muscle, so as not to meet
veins or the lateral uterine anastomosis of the pelvic ves-
sels. If the uterus is to be sacrificed, it is useful to cut and
tie the round ligament. Careful dissection must be per-
formed, leaving the ureter medial, which runs at the back
of the broad ligament, and lateral pelvic vessels, until
identifying the hypogastric artery that should be kept to
the side. At this point, the same hypogastric artery must
Fig. 33.9 B-Lynch. The two ends of the thread must then be tied
slowly using a flat surgical knot, taking care to pull the thread with be followed to the origin of the uterine artery. Proceed
enough force to compress properly the uterus without tearing it [120– from lateral to medial with a curved dissector (right
123]. The assistant must help reduce the size of the uterus by compres- angle), to isolate the artery that is closed with a thread
sion. After having verified that hemorrhage has stopped, the hysterotomy
can be sutured. (With permission of Piccin Editore. From Ragusa A,
passed by means of a right angle, or using a clip, opening
Crescini C. URGENZE ED EMERGENZE IN SALA PARTO, Padova the right angle slightly to be sure to close the artery com-
2015. Casa Editrice PICCIN Nuova Libreria) pletely [126].
The numerous anastomoses between uterine artery, lower 33.2.3 Inversion of the Uterus
bladder, and long vaginal bowels are dramatically reduced,
obtaining a net decrease in the vascularization of the lower Uterine inversion is a rare complication of childbirth and hap-
segment, of the cervix and the upper third of the vagina. The pens when the fundus of the uterus descends abnormally through
risks connected to the closure of the hypogastric artery are the genital tract, thus turning itself inside out [128–132].
gluteal necrosis (if the artery is clamped before the first emi- Four grades of uterine inversion are described (Fig. 33.11):
nence of the rear trunk), ureter injury, and more bleeding in
isolation maneuvers. • Grade 1: fundus inverts down to the cervical canal.
• Grade 2: fundus inverts into the vagina.
Hysterectomy • Grade 3: fundus is visible at the introitus.
Subtotal hysterectomy has lower surgical morbidity and is • Grade 4: complete inversion of both the uterus and vagina.
the operation of choice, unless there is trauma to the cervix Reported incidence ranges from 1/2000 to 1/6400 [128–
or lower segment. 132]. Maternal mortality can be high as 15% if the condi-
If the cervix and paracolpos are not involved as the tion is not promptly diagnosed and corrected. Factors that
source of hemorrhage, subtotal hysterectomy should be ade- have been associated with this condition are summarized
quate to achieve hemostasis, which is the objective of the in (Table 33.4).
intervention. Additionally, the procedure is safer, faster,
easier to carry out, and less likely to cause damage to the
bladder or ureters compared with total hysterectomy [103, 33.2.3.1 Diagnosis
127]. However, if the lower segment and paracolpos are Uterine inversion can be difficult to diagnose, particularly if
involved in the hemorrhage, such as in cases of placenta pre- the fundus is not outside the introitus.
via, total hysterectomy will be necessary for hemostasis Early recognition is important to enable prompt treatment
[103, 127]. and to reduce morbidity and mortality [128–132].
Fig. 33.11 Grades of uterine A A

inversion. (With permission of
Piccin Editore. From Ragusa
A, Crescini C. URGENZE ED
EMERGENZE IN SALA
PARTO, Padova 2015. Casa
Editrice PICCIN Nuova
Libreria)
Grade 1 Grade 2
A
A
Grade 3 Grade 4
Table 33.4 Risk factors for uterine inversion

Excessive traction on umbilical cord
Short umbilical cord
Inappropriate fundal pressure
Abnormally adherent placenta
Previous uterine inversion
Precipitate labor
Uterine abnormalities
Vaginal birth after cesarean (VBAC)
Fibroids
Connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos
syndrome)
Symptoms and signs include:
• Development of sudden maternal shock not proportionate

to blood loss
• Atonic postpartum hemorrhage (present in over 90% of
cases)
• Severe lower abdominal pain in the third stage of labor
• Hypovolemic shock with tachycardia and hypotension
• A mass in the vagina or outside the introitus at vaginal
examination Fig. 33.12 Manual replacement (Johnson maneuver) (With permission
of Piccin Editore. From Ragusa A, Crescini C. URGENZE ED
• Uterine fundus not palpable on abdominal examination (a EMERGENZE IN SALA PARTO, Padova 2015. Casa Editrice PICCIN
dimple may be appreciated in the fundal area) Nuova Libreria)
33.2.3.2 Management • Hydrostatic pressure can be used to correct uterine

The treatment of maternal shock should be addressed immedi- inversion (O’Sullivan technique). Infuse warm saline
ately with standard resuscitation. At the same time, it’s crucial to into the posterior fornix of the vagina via a rubber tube
put the uterus into its anatomical position, in order to resolve held 2 m above the level of the vagina, in order to dis-
neurogenic shock. After 30 min a cervical constriction ring may tend the vagina and push the fundus upward. To increase
develop, thus making uterine repositioning impossible, so the the hydrostatic pressure and prevent saline to overflow,
earlier the restoration, the more likely the success [128–133]. it is possible to seal the vaginal orifice with a hand or a
If the placenta is still attached, no attempts to remove Silastic ventouse cup. Uterine rupture should be ruled
should be done, since they may result in major bleeding. out first.
Placenta should be removed in theater after the uterus has • If replacement is successful, administer uterotonics such
been replaced [133]. as oxytocics, and the attendant should keep his hand in
Interventions are: the uterine cavity for a few minutes, until a firm contrac-
tion occurs to prevent re-inversion.
• Call for senior help. • After successful replacement, a tamponade balloon cath-
• Insert two large-bore intravenous cannulae. eter can be put inside the uterine cavity to maintain uter-
• Give high flow oxygen (10 L/min). ine position [134].
• Collect blood and send for crossmatch (4–6 units), full • If manual replacement fails, transfer the patient to the
blood count and clotting (consider transfusion). operating theater in order to try surgical reduction of the
• Start immediately fluid replacement (at least 1000 mL inverted uterus. Different techniques are described [135].
crystalloids). Laparotomy may be required at this point. Upward gentle
• Continuously monitor blood pressure, pulse, respiratory traction with atraumatic Allis forceps, placed within the
rate, urine output, and O2 saturation. dimple of the inverted uterus may be used to achieve
• Position urinary catheter. replacement to the anatomical position (Huntington’s
• Organize appropriate analgesia. method) (Fig. 33.13). To facilitate this procedure, espe-
• Try manual replacement first (the Johnson maneuver), cially if a cervical ring makes repositioning difficult, is
preferably under general anesthesia, and if possible, use possible to cut vertically the cervical ring posteriorly
tocolytic agents (Fig. 33.12). (where it is less likely to involve the bladder or uterine
Perinatal mortality rate has improved and is currently

estimated to be 10% or less [144, 143]. The explanations for
these better outcomes are the increased availability of cesar-
ean delivery and advances in neonatal resuscitation.
Umbilical cord prolapse primarily occurs in two
settings:
1. When the presenting part does not adequately fill the pel-
vis because of maternal or fetal characteristics
2. When obstetric interventions are performed that dislodge
the presenting part are performed
Fetal and maternal factors that have been associated with

this condition are summarized in Table 33.5.
It is important to avoid amniotomy unless the fetal head is
well-engaged or, if necessary, “needling” the bag for a
slower, more controlled release of fluid.
33.2.4.1 Diagnosis
Early diagnosis is important. A cord prolapsed may be obvi-
ous when there is a loop of cord protruding through the
vulva. However, a prolapsed cord is not always apparent and
may only be found on vaginal examination. It can be sus-
pected when there is an abnormal fetal heart rate pattern in
Fig. 33.13 Surgical correction of uterine inversion with Huntington’s the presence of ruptured membranes, particularly if CTG
method (With permission of Piccin Editore. From Ragusa A, Crescini changes start soon after the rupture [136–142]. In 41–67% of
C. URGENZE ED EMERGENZE IN SALA PARTO, Padova 2015. Casa
Editrice PICCIN Nuova Libreria)
cases, it is associated with severe, sudden decelerations,
often with prolonged bradycardia, or recurrent moderate to
severe variable decelerations.
vessels) to aid replacement of the uterus (Haultain’s tech-
nique). Hysterotomy site is then repaired. 33.2.4.2 Management
• Antibiotics should be given. The approach if the baby is alive and of viable gestation is
• The patients should be monitored closely since re-inver- elevation of the presenting part to relieve compression of the
sion of the uterus is frequent. cord and expedite delivery, usually by cesarean section [145].
Prompt delivery has been shown to improve outcomes.
33.2.4 Prolapsed Umbilical Cord
Cord prolapse is defined as the descent of a loop of umbilical Table 33.5 Risk factors for cord prolapse
cord below the presenting part, in the presence of ruptured Breech presentation
membranes [136–142]. Multiparity
It is an obstetrical emergency and occurs approximately Unstable lie
in 0.1–0.6% of all births, while in breech presentations, its Oblique or transverse lie
incidence can be as high as 1% [136–142]. Polyhydramnios
In cord prolapse, perinatal mortality is due to asphyxia Prematurity
Multiple pregnancy
and is caused by mechanical compression of the cord
Long cord
between the presented part and bony pelvis or by spasm of Low birth weight (<2500 g)
the cord vessels when exposed to cold or manipulations Amniotomy (especially with a high presenting part)
[144, 143]. Sudden rupture of membranes (especially in polyhydramnios)
The interval between diagnosis and birth is significantly Internal podalic version
related to stillbirth and perinatal death [145]. Second twin
–– Call for senior help, including an anesthetist, the theater tive birth are met, ventouse or forceps can be
team, and the neonatal team. considered.
–– Site a wide-bore intravenous cannula and take blood for
group and save and full blood count. Regional anesthesia is possible if fetal conditions permit,
–– Administer intravenous fluids. and the safest method of anesthesia for both the mother and
–– Check vitality of the fetus by ultrasound to visualize fetal fetus should be considered.
movements even with the absence of cord pulsation and Team training exercises have been shown to shorten the
inaudible fetal heart tones. interval between diagnosis and delivery and may lead to
–– Relieve cord compression by elevating the presenting improved neonatal outcomes [146–148].
part. This can be achieved by:
Digital elevation of the presenting part of the fetus above
the pelvic inlet: two fingers or the entire hand should 33.2.5 Acute Abdominal Pain During
be kept in the vagina until the baby is born. Pregnancy
Maternal positioning: such as knee-chest facedown posi-
tion or the exaggerate Sims’ position (left lateral with 33.2.5.1 Introduction
a pillow under the left hip) (Fig. 33.14). Acute abdominal pain during pregnancy has an impact that
ranges from 1:500 to 1:635, and 0.2–1% of these patients
If the cord has prolapsed out from the vagina, an attempt require surgery [149].
to gently replace it back with minimal handling is possible. Table 33.6 shows the possible pathologies in relation to
There is no sufficient evidence to recommend the practice of the seat of the pain.
covering the cord with gauzes soaked in warm saline.
Excessive manipulations of the cord should be avoided. 33.2.5.2 Acute Appendicitis
The insidence of acute appendicitis during pregnancy is 1
–– Continuous electronic fetal monitoring should be per- case every 1500–2000 pregnancies and is the cause of 25%
formed, if possible. of surgery for non-obstetric indications [149, 150].
If the cervix is not fully dilated, a cesarean section should
be performed [145]. Diagnosis
If the cervix is fully dilated and the obstetrician The most common symptom is the pain in the lower right
believes that a vaginal delivery can be performed more quadrant (McBurney point). Associated symptoms include
rapidly than a cesarean section, it is appropriate to pro- anorexia, nausea, and sickness. A perforated appendix should
ceed with vaginal delivery. If prerequisites for opera- be suspected if the pain changes from localized to wide-
a b
Fig. 33.14 Maternal positioning to relieve cord compression: (a) knee-chest facedown position; (b) exaggerate Sims’ position (left lateral with a
pillow under the left hip (With permission of Piccin Editore. From Ragusa A, Crescini C. URGENZE ED EMERGENZE IN SALA PARTO, Padova
2015. Casa Editrice PICCIN Nuova Libreria)
Table 33.6 Location of abdominal pain and possible underlying pathologies

Location of the pain Organs to be considered Possible causes
Widespread Any intra-abdominal organ Irritation of the initial stage of the visceral peritoneum
Left hypochondria Spleen, pancreas, left splenic flexures of Heat attack, bleeding or rupture of the spleen, colitis
the colon
Epigastrium Stomach, pancreas, aorta, heart Gastritis, pancreatitis, dissection or rupture of the aorta, acute
myocardial infarction
Right hypochondria Liver, kidney, right or hepatic of the colon, Hepatitis, cholecystitis, rupture or hepatic hemorrhage, acute
gallbladder fatty liver of pregnancy (AFLP), HELLP syndrome,
preeclampsia imminent
Right side Right kidney, ascending colon Pyelonephritis, kidney or ureteric stones, inflammatory bowel
disease
Mesogastrium Transverse colon, appendix (visceral pain Appendicitis, gastroenteritis, mesenteric lymphadenitis, acute
in the initial stage), uterus pancreatitis, postpartum placenta, dehiscence or rupture of the
previous uterine scar
Left side Left kidney, descending colon Pyelonephritis, kidney or ureteric stones, inflammatory bowel
disease
Left iliac ditch Sigmoid colon, left fallopian tube and Inflammatory bowel disease, diverticulitis of the sigmoid colon,
ovary ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst,
adnexal torsion
Hypogastrium Bladder, uterus Cystitis, postpartum placenta, dehiscence or breakage of
previous uterine scar
Right iliac ditch Appendicitis, sigmoid colon, right Appendicitis, diverticulitis of the sigmoid colon, ectopic
fallopian tube and ovary pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, adnexal
torsion
spread. A retrocecal appendix can cause symptoms at the carried out where pain is felt most [152, 153]. Care must be
back or side of the patient [150, 151]. taken to avoid excessive uterine traction, thus avoiding irrita-
On physical examination a Rovsing sign may be noted tion to the uterine bowels, with consequent onset of contrac-
[150, 151]. Stiffness and abdominal defense, irritation of the tions. If the appendix is ruptured or there is evidence of
psoas, and rectal and pelvic pain may not be present. peritonitis, a copious intra-abdominal irrigation should be
Leukocytosis is of little use. However, the predominant neu- carried out. The positioning of drainage can be taken into
trophilia (>80%) and an increase in the C-reactive protein consideration to drain the possible abscess. The patient must
may be of help. A scan can identify an inflamed appendix or be administered perioperative antibiotic therapy with sec-
a periappendiceal abscess. The scan should be performed ond-generation cephalosporins, broad-spectrum penicillins,
with the patient in left lateral decubitus position. An abnor- and carbapenems, together with clindamycin or metronida-
mal appendix has a tubular structure, non-compressible, zole [149–153].
showing no peristalsis, with a diameter of more than 6 mm,
which originates from the base of the cecum [150]. 33.2.5.3 Acute Cholecystitis
If the scan is not decisive and diagnostic doubts persist, it Gallbladder pathologies have an incidence that ranges
indicates a magnetic resonance (MR) should be carried out from 1:1600 to 1:10,000 pregnancies and are thus the sec-
[150]. A computed tomography (CT) must be used if there ond most common cause of non-obstetric surgical prob-
are still diagnostic doubts [149, 150]. lems [150, 151]. Ninety percent of the cases are caused by
an obstruction of the cystic duct by biliary stones or sand
Management [150, 151].
Surgical intervention should be carried out immediately
[152, 153]. Active labor is the only indication to postpone Diagnosis
surgery, which will have to be carried out postpartum [152, The symptoms of acute cholecystitis include nausea, sick-
153]. There are no indications to perform a cesarean section, ness, anorexia, intolerance to fatty foods, dyspepsia, and
except in the case of perforated appendix. Surgery may be mesogastric pain in the upper right quadrant, expanding to
carried out via laparoscopy or laparotomy [152, 153]. In the the top of the scapula. The Murphy sign is rare [150, 151].
case of laparotomy performed during the first trimester, the In more serious cases, the patient may have slight jaundice
incision of the skin must be carried out at the McBurney and signs of sepsis [150, 151]. Lab tests can show an
point [141, 153]. The incision may also be longitudinal, increase in direct bilirubin, transaminase, and bilirubin lev-
paramedian or median [152, 153]. The incision can also be els [150, 151].
A scan enables to identify the presence of biliary stones in performing the colonoscopy, surgery is recommended in any
95–98% of cases. Moreover, it is also able to highlight signs of case after delivery due to the high risk (>50%) of recurrences
acute cholecystitis among which edema of the gallbladder with [149, 150, 153].
an increase in wall thickness of more than increase 3 mm, accu-
mulation of peri-cholecystic fluid, biliary stone, and Murphy
sign showing in the scan [149, 154]. Magnetic resonance chol- 33.2.6 Abdominal Trauma During Pregnancy
angiopancreatography (MRCP) can also be used to confirm the
suspicion of biliary stones. Endoscopic retrograde cholangio- 33.2.6.1 Introduction
pancreatography (ERCP) can be used for diagnostic purposes Abdominal trauma during pregnancy is one of the main
or to perform a sphincterotomy to solve possible pancreatitis, causes of maternal death [1]. Most of these traumas are
with minimum exposure to ionizing radiation [149, 154]. caused by domestic violence [155]. Penetrating injuries and
those caused by falling make up the main causes of trauma
Management during pregnancy [156]. The management of traumas during
Symptomatic cholelithiasis is often managed initially pregnancy requires a multidisciplinary approach which
using conservative treatment by means of hydration to involves a trauma surgeon, a specialist in emergency medi-
correct electrolyte, analgesic, anti-inflammatory, and cine, an obstetrician, and a neonatologist [157].
bowel disorders. If there is no improvement after 12–24 h, The management protocol for traumas with regard to a
or there are systemic symptoms, antibiotic treatment must pregnant woman is the same as that for women who are not
be started with third-generation cephalosporins in combi- pregnant. First and foremost, the airways must be managed,
nation with metronidazole. If the conservative treatment bearing in mind that possible intubation could be difficult in
does not result in any improvement, cholecystectomy sur- pregnant women due to the increase in weight and swelling,
gery is indicated via laparoscopic approach. This method characteristic of pregnancy [158]. If the airways are not safe,
can be used in all phases of pregnancy and has been a nasogastric tube should be put in place [159, 160]. The
proven to be safe and well tolerated [154]. patient must be positioned on her left side to increase the
flow of blood to the heart [161, 162].
33.2.5.4 Intestinal Obstruction Priority must be given to the mother’s health over that of
Intestinal obstruction complicates 1 out of 3000 pregnancies the fetus. The patient must be transported to an area with a
and is the third most common cause of for non-obstetric sur- delivery room if her injuries do not endanger the health of
gical problems. Failure to diagnose an intestinal obstruction the mother and if the fetus is ≥23 weeks. If the trauma is
is connected to 6% maternal mortality and 25–40% of fetal severe, or if the fetus is less than 23 weeks, the patient must
death [150, 153]. be managed exclusively by the emergency division [157].
Diagnosis 33.2.6.2 Signs and Symptoms

The most frequent symptoms include acute cramping It is important to bear in mind that a pregnant woman has a
abdominal pain, constipation, nausea, and sickness. The 15% increase in heart rate. Signs of hypovolemic shock may
pregnant abdomen can mask the abdominal distension typi- be delayed due to the increase in blood volume [157]. The
cal of intestinal obstruction [150, 153]. first sign of hypovolemia is that of tachycardia. In these cases
An X-ray of the abdomen can be of help in the diagnosis the fetus should be monitored as soon as possible. Signs of
and should be carried out in supine and upright position. If peritoneal irritation are rare [163]. Uterine pain is a signal of
the X-ray does not give any confirmation, CT or an MR alarm regarding possible placenta detachment. A vaginal
could be performed which allows to identify and treat volvu- examination must be carried out to confirm fetal presenta-
lus [149, 150, 153]. tion, cervical dilation, the length of the cervix, and the level
of the presenting part. It is important to remember that in the
Management case of vaginal bleeding in pregnancy of more than 23 weeks,
Conservative management includes initial intestinal decom- a scan should be carried out before any type of vaginal exam-
pression by means of nasogastric tube, bowel rest, fluid and ination with fingers or speculum, to exclude the possibility of
electrolyte balance, and enemas. If the conservative manage- a placenta previa.
ment is not successful, or if the patient develops fever, tachy-
cardia, or signs of peritonitis, surgical examination is 33.2.6.3 Management
mandatory. Surgery involves an incision median laparotomy, X-rays of the cervical spine, chest, and pelvis should be
lysis of intestinal adhesions, bowel decompression, and, in requested in the case of trauma [162]. The level of radiation
the case of necrotic bowel, bowel resection followed by used is very low [164]. Exposure to levels of radiation above
anastomosis. If the obstruction resolves spontaneously after 5–10 rad can cause deformities before 18 weeks [164, 165].
Nevertheless, investigations should never be delayed. Table 33.7 Risk factors for ectopic pregnancy
Computerized tomography (CT) of the abdomen during the Degree of Odds
third 3-month period causes an absorption of radiation of risk Risk factors ratio
3.5 rad, which is below the limit that could cause fetal dam- High Previous ectopic pregnancy 9.3–4.7
Previous tubal surgery 6.0–11.5
age [166]. The use of gadolinium as a contrast medium is not
Tubal ligation 3.0–13.9
toxic to the fetus and can be used when indicated [167]. Tubal pathology 3.5–25
Lab tests such as complete blood count and coagulation, In utero DES exposure 2.4–13
with particular attention to fibrinogen, should be requested. Current IUD use 1.1–45
In pregnant women, the levels of fibrinogen are higher (circa Moderate Infertility 1.1–28
4 g/L). Levels are below 2 g/L could be a sign of DIC. Previous cervicitis (gonorrhea, 2.8–3.7
A FAST scan is useful in the case of abdominal trauma to chlamydia)
History of pelvic inflammatory disease 2.1–3.0
highlight the presence of fluid in the abdomen, and its pres-
Multiple sexual partners 1.4–4.8
ence is an indication to carry out an abdominal CT. Smoking 2.3–3.9
In pregnancies of more than 23 weeks, the well-being of Low Previous pelvic/abdominal surgery 0.93–3.8
the fetus should be assessed by means of monitoring the fetal Vaginal douching 1.1–3.1
heartbeat [157]. Early age of intercourse (<18 years) 1.1–2.5
In the case in which a separation of the placenta is sus-
pected, fetal monitoring for at least 24 consecutive hours is
advisable [157].
Possible complications of traumas during pregnancy are
feto-maternal hemorrhage, rupture of the uterus, and preterm
delivery [157].
33.2.7 Ectopic Pregnancy and Abdominal

Pregnancy
33.2.7.1 Definition
Ectopic pregnancies are defined as the implantation of blas-
tocyst embryos outside the uterus [168].
33.2.7.2 Epidemiology
The frequency of ectopic pregnancies has increased as a con-
sequence of the increase in risk factors, and thanks to
improved diagnostics, reaching 2% of all pregnancies in the
USA and 1.4% in Italy [168].
In subpopulations at risk, the incidence is 3% in pregnan-
cies with medically assisted procreation and 10% in patients Fig. 33.15 Hyperechoic ring in ectopic pregnancy
with previous ectopic pregnancies.
Ten percent of patients who go to the A&E department 33.2.7.4 Diagnosis
during the first trimester because of bleeding and/or pelvic
pain will be diagnosed with ectopic pregnancy. Transvaginal Scan
Ectopic pregnancy is still the cause of 4–10% of all mater- Ten percent of direct evidence of extrauterine implants (ges-
nal deaths (hemoperitoneum). tational vitreous sac with or without embryo); more fre-
Table 33.7 shows the risk factors for ectopic pregnancy. quently indirect ultrasound signs, empty uterus (lack of
implant endothelium); free liquid in Douglas; and adnexal
33.2.7.3 Clinical hyperechoic ring (Fig. 33.15: “bagel sign”) [168].
Classical clinical presentation (45% of cases): At endometrial level, not tonic, irregular, without the dou-
ble ring, and absence of embryonic echoes [168].
–– Abdominal pain (97%)
–– Vaginal blood loss (79%) Significance of Chorionic Gonadotropin Beta Values
–– Palpable adnexal mass and/or backward mass that fills the (β-hCG)
Douglas (30%), in women with amenorrhea/positive When the scan is not definite, the differential diagnosis is
pregnancy test between early endothelial pregnancy, premature abortion at
an unknown seat, ectopic pregnancy, and vesicular mole: pri- Table 33.8 Precautions to be taken in the case of MTX therapy
mary determinant is the serum dosage of β-hCG [169, 170]. Caveats for physicians and patients regarding the use of methotrexate
(MTX)
–– Early intrauterine pregnancy in regular evolution: in Avoid intercourse until hCG is undetectable
Avoid pelvic exams and ultrasound during surveillance of MTX
48/72 h the level doubles, in ectopic pregnancy this therapy
increase is less, and in vesicular mole the levels are usu- Avoid sun exposure to limit risk of MTX dermatitis
ally much higher. Avoid foods and vitamins containing folic acid
–– Discriminatory area: 2000 UI/L is generally the level Avoid gas-forming foods because they produce pain
above of which, if the pregnancy in the uterus and single, Avoid new conception until hCG is undetectable
the gestational bag with transvaginal probe is shown ASRM Practice Committee. Treatment of ectopic pregnancy. Fertil
(6500 should be seen in transabdominal, while the levels Steril 2008
have not been defined for twin pregnancies yet).
Table 33.9 Treatment and side effects connected to MTX
Effects of the treatment
33.2.7.5 Management Increase in abdominal circumference
Increase in hCG at the beginning of the treatment
–– Waiting conduct (18–33% GEU spontaneous resolution) Vaginal bleeding or spotting
does not affect following fertility [168, 171]. Abdominal pain
–– Criteria: asymptomatic patient, first dosage of Side effects
Epigastric discomfort (heartburn), nausea and sickness
βHCG < 1000 UI/L, with following dosage at 48–72 h with a
Stomatitis
decrease of >15%, paraovarian mass <4 cm, endopelvic dis- Dizziness
charge <100 mL, stability or slow resolution to subsequent Severe neutropenia (rare)
ultrasound checks, and patient’s compliance [168, 171]. Reversible alopecia (rare)
–– Medical therapy (about 50% success) Pulmonary infections (rare)
–– Criteria: symptomatic patient, first dosage of hCG > 1000 UI/L ASRM Practice Committee. Treatment of ectopic pregnancy. Fertil
and <3000 UI/L (3000–5000: risk of failure 5×) even if the Steril 2008
subsequent dosage is stable or reduced, first dosage of
hCG < 1000 UI/L but subsequent dosage at 48–72 h stable/ homolateral ectopic pregnancy, and uncontrolled hemostasis
decreasing <15%/ increase, paraovarian mass <4 cm, BCF [168, 171].
absent, endopelvic discharge <100 mL + stability, or slow If documented trophoblastic peritoneal implants and
resolution to subsequent ultrasound checks [168, 171]. decrease <50% in hCG during the first day compared to pre-
surgery, administration of MTX 50 mgm2 IM single dose
A single dose of methotrexate (MTX) of 50 mg/m2 via [168, 171].
intramuscular injection, followed by weekly monitoring of Perform anti-D immunoprophylaxis in the case of
the hCG and clinical conditions: good response if the Rh-negative blood group.
decrease is >15% between days 4 and 7. If medical therapy Weekly monitoring of βHCG and clinical conditions are
fails (14%): possible new medical therapy, programmed or suggested; serial ultrasound examinations are not useful but
emergency surgery. Table 33.8 shows some precautions to only at hormonal reset and at 4 months from the resetting.
bear in mind during MTX therapy [168, 171]. Avoid possible pregnancies for 6 months from the hormonal
Table 33.9 shows the effects of the treatment and side reset [168, 171].
effects when using MTX.
–– Surgery 33.2.8 Abortion with Hemorrhagic Shock

–– Criteria: severely symptomatic patient, stable or increase
in hCG before or after medical therapy, paraovarian mass The definition of abortion is an interruption of a pregnancy
>4 cm, endopelvic discharge >100 mL, BCF visualiza- prior to the 24 weeks’ of gestation [171].
tion, and unreliable/noncompliant patient [168, 171]. Complications of an abortion are hemorrhagic shock due
to severe bleeding and sepsis. Even without complications,
Conservative (salpingotomy) or demolitive (salpingec- an incomplete abortion can become dangerous if treatment is
tomy) surgery: there is no evidence in literature compared to delayed. An accurate initial assessment of the patient is
different impacts on reproductive performance; conditions therefore necessary.
for salpingectomy: severe impairment of tubal anatomy, seat The possibility of an abortion must be taken into consid-
of the ectopic pregnancy (after evaluation of the anatomy of eration for fertile women with at least two of the three fol-
the contralateral tuba), adnexal mass >5 cm, recurrence of lowing symptoms:
• Vaginal bleeding sutures, a possible laceration of the uterine artery or uterine

• Cramps and/or lower abdominal pains perforation should be taken into consideration.
• History of amenorrhea If there is no evidence of cervical lacerations or uterine
perforation, uterine massage must be performed. At the same
A transvaginal scan, along with BHCG dosage, should be time, uterotonics must be given. The most frequently used
provided. drugs for postabortion hemorrhage are methylergometrine
Tachycardia and hypotension may be signs of severe maleate [175, 176] and misoprostol; oxytocin and prosta-
hemorrhage or septic shock. glandins (carboprost) are used less frequently.
Hemorrhage after an abortion is rare and occurs in less Methylergometrine maleate, in doses of 0.2 mg im, has a
than 1% of cases. The different definitions of postabortion rapid effect (within 5 min) and, if not contraindicated, is the
hemorrhage include “blood loss of more than 250 mL,” first choice of medication. Misoprostol is also effective in
“blood loss of more than 500 mL,” “blood loss requiring hos- cases of postabortion hemorrhage. The recommended dos-
pitalization,” or “blood loss requiring transfusion” [172, ages are 800–1000 μg [174] orally or sublingual with more
173]. rapid peak concentration [177] compared to rectal adminis-
The risk factors regarding postabortion hemorrhage are: tration [178]. Oxytocin is considered as an effective utero-
tonic, but it can be less useful than other types of medication
1. Previous cesarean sections (two or more cesarean
since, during the first and second trimester, the uterus has
sections) fewer receptors for oxytocin.
2. Obesity
3.
Problems regarding coagulation or hemorrhagic Secondary Treatment
diathesis If bleeding continues after the administration of uterotonics
4. Abnormalities of the placenta (placental accretion) and bimanual massage, place further intravenous access and
5. History of previous postpartum hemorrhage alert the anesthetist/resuscitator. Assess for signs of shock
6. Advanced maternal age (heart rate higher than 100 bpm, blood pressure lower than
7. Fibroids and/or other uterine abnormalities 90 mmHg, cold and sweaty skin cute, respiratory rate higher
than 30 per minute, changes in mental condition). Administer
Hemorrhage can be caused by atony (52%), intravascular high oxygen concentrations. Administer fluids and request
coagulopathy (5%), abnormal placenta (17%), or complica- lab tests (blood count, coagulation, cross-tests). If the sus-
tions during surgery such as perforation (7%), cervical lac- pected clinical disseminated intravascular coagulation is
eration (12%), and placental tissue retention [174]. high, a transfusion of red blood cells (RBC) and fresh frozen
Hemorrhage can be one of the most serious and immedi- plasma must be carried out. The results of the lab tests and
ate complications of an abortion. Timely intervention and the clinical assessment of the patient will indicate the need
early recognition of the source/cause of the bleeding can for a transfusion of RBC, FFP, cryoprecipitate, and
reduce the onset of hemorrhagic shock and, therefore, mor- platelets.
bidity and mortality. Revision of the cavity if a scan shows that there is evi-
If bleeding occurs, an assessment of the blood loss must dence of tissue retention or blood reaccumulation.
be carried out, with frequent recording of vital parameters If an atony or bleeding of the lower part of the uterus is
(blood pressure and respiratory rate) along with a venous suspected, a Foley balloon can be put in place, filled with
access. between 30 cc and 80 cc of saline solution, or a Bakri bal-
loon, filled with 120 cc of saline solution [179, 180].
33.2.8.1 Treatment of the Hemorrhage
The first steps to be taken in the case of bleeding include: Following Treatment
In the case of failure of primary and secondary treatment,
1. A physical examination to identify the source/cause of intensive actions such as the embolization of uterine arteries,
the bleeding (vagina, uterus, cervix) laparoscopy, laparotomy, and hysterectomy are necessary.
2. Bimanual examination to evaluate uterine tone If the radiology service is not available, the next step
3. Scan to assess the accumulation of blood or retention of should be laparotomy. Laparoscopy can be useful if per-
tissue formed by expert surgeons, to confirm the suspected perfora-
tion and to repair the continuity of the uterus [180].
Even if not described by literature regarding abortions, it
Primary Treatment could be reasonable to try to control hemorrhages during
In the case of cervical lacerations, carry out surgical repair abortions to perform bilateral uterine artery ligation and/or a
using absorbable sutures. If the bleeding continues after the B-Lynch suture, before carrying out a hysterectomy [180].
In conclusion, consultation with an obstetrician/gynecol- hemorrhage or those who are hemodynamically unstable
ogist is indicated for all patients with a diagnosis of sponta- need immediate consultation and treatment.
neous or incomplete abortions. Patients with severe
Case Scenario D. Abdominal CT

A 24-year-old nulliparous woman referred to our emer- We performed transvaginal ultrasound with
gency room for sudden pelvic pain. these results (Fig. 33.16):
She reported a similar, but milder, episode in the previ- –– Rounded and enlarged ovary, with heterogeneous
ous 3 months. She also reported mild nausea, without epi- stroma with multiple small peripheral follicles
sodes of vomiting, and should adjust regularly. –– Decreased Doppler flow within the ovary
Her past medical history was negative. –– Tenderness
Her last period was 1 month before, and her last gyne- –– Free fluid
cological examination was 1 year before without any We suspected an adnexal torsion in a stable
pathological findings. patient without acute abdomen.
Vital parameters at the arrival in ER were normal. 4. Which other US finding is typical of adnexal torsion?
On physical examination we found: A. “Whirlpool” sign
Tenderness at lower abdominal quadrants; Blumberg B. Ground-glass ovarian cyst
sign was negative. C. “Beads-on-a-string” sign
Tenderness of right adnexal region. D. “Cogwheel” sign
5. Which is the correct management of this patient?
1. Which emergency is clinically less likely? A. Laparoscopic detorsion within 24–36 h
A. Appendicitis B. Laparoscopic oophorectomy
B. Ectopic pregnancy C. Laparotomic detorsion and ovarian conservation
C. Adnexal torsion within 24–36 h
D. PID D. Conservative management
2. Which blood test would you perform first?
A. Blood count + CRP + βHCG The patient underwent laparoscopic adnexal detorsion
B. Blood count + βHCG after a few hours.
C. Blood count + hepatic and renal function An elongated utero-ovarian ligament was found dur-
D. Blood count + CRP ing the intervention. The tube was cake on the ovarian
Blood tests showed neutrophil leukocytosis, lining ligament, and this had caused the ischemic phe-
normal hemoglobin, high-level CRP, and negative nomena of the ovary. The next day the woman was dis-
βHCG. missed in good general conditions and postponed to
3. Which imaging would you request? routine outpatient gynecological examination after 3
A. Transvaginal ultrasound weeks.
B. Abdominal ultrasound Please see Chap. 58 for the correct answer.
C. Abdominal X-ray
Fig. 33.16 Case scenario: adnexal torsion. The ovary is enlarged; the stroma is heterogeneous. Medial to the ovary is visible the swollen
salpinx
Acknowledgments We would like to thank Dr. Marta Betti and Dr. 23. Teng SW, Tseng JY, Chang CK, et al. Comparison of laparoscopy
Anna Carli for the collaboration offered in the drafting of this and laparotomy in managing hemodynamically stable patients
chapter. with ruptured corpus luteum with hemoperitoneum. J Am Assoc
Gynecol Laparosc. 2003;10:474.
24. Reif P, Schöll W, Klaritsch P, Lang U. Rupture of endometriotic
ovarian cyst causes acute hemoperitoneum in twin pregnancy.
Fertil Steril. 2011;95:2125.e1.
References 25. Viswanathan M, Hartmann K, McKoy N, Stuart G, Rankins N,
Thieda P, Lux LJ, Lohr KN. Management of uterine fibroids:
1. McWilliams GD, Hill MJ, Dietrich CS III. Gynecologic emergen- an update of the evidence. Evid Rep Technol Assess (Full Rep).
cies. Surg Clin North Am. 2008;88:265. 2007;(154):1–122.
2. Schrager J, Robles G, Platz T. Isolated fallopian tube torsion: a 26. Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treat-
rare entity in a premenarcheal female. Am Surg. 2012;78:118. ment. Am Fam Physician. 2007;75(10):1503–8.
3. Bouguizane S, Bibi H, Farhat Y, et al. [Adnexal torsion: a report of 27. Vollenhoven B. Introduction: the epidemiology of uterine leio-
135 cases]. J Gynecol Obstet Biol Reprod (Paris). 2003;32:535. myomas. Baillieres Clin Obstet Gynaecol. 1998;12(2):169–76.
4. Varras M, Tsikini A, Polyzos D, et al. Uterine adnexal torsion: 28. Greenberg MD, Kazamel TI. Medical and socioeconomic
pathologic and grayscale ultrasonographic findings. Clin Exp impact of uterine fibroids. Obstet Gynecol Clin North Am.
Obstet Gynecol. 2004;31:34. 1995;22(4):625–36.
5. Houry D, Abbott JT. Ovarian torsion: a fifteen year review. Ann 29. Tropeano G, Amoroso S, Scambia G. Non-surgical management
Emerg Med. 2001;38:156. of uterine fibroids. Hum Reprod Update. 2008;14(3):259–74.
6. White M, Stella J. Ovarian torsion: 10 year perspective. Emerg 30. Downes E, Sikirica V, Gilabert-Estelles J, Bolge SC, Dodd
Med Australas. 2005;17:231. SL, Maroulis C, et al. The burden of uterine fibroids in five
7. Oltmann SC, Fischer A, Barber R, et al. Cannot exclude torsion European countries. Eur J Obstet Gynecol Reprod Biol.
a - 15year review. J Pediatr Surg. 2009;44:1212. 2010;152(1):96–102.
8. Tsafrir Z, Hasson J, Levin I, et al. Adnexal torsion: cystectomy 31. Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med.
and ovarian fixation are equally important in preventing recur- 2015;372(17):1646–55.
rence. Eur J Obstet Gynecol Reprod Biol. 2012;162:203. 32. Munro MG, Critchley HO, Fraser IS. The FIGO classification of
9. Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in chil- causes of abnormal uterine bleeding in the reproductive years.
dren. Am J Surg. 2000;180:462. Fertil Steril. 2011;95(7):2204–8.
10. Rousseau V, Massicot R, Darwish AA, et al. Emergency manage- 33. Ouyang DW, Economy KE, Norwitz ER. Obstetric complica-
ment and conservative surgery of ovarian torsion in children: a tions of fibroids. Obstet Gynecol Clin North Am. 2006;33(1):
report of 40 cases. J Pediatr Adolesc Gynecol. 2008;21:201. 153–69.
11. Anthony EY, Caserta MP, Singh J, Chen MY. Adnexal masses in 34. Pérez-López FR, Ornat L, Ceausu I, Depypere H, Erel CT,
female pediatric patients. AJR Am J Roentgenol. 2012;198:W426. Lambrinoudaki I, et al. EMAS position statement: management of
12. Wilkinson C, Sanderson A. Adnexal torsion a multimodality uterine fibroids. Maturitas. 2014;79(1):106–16.
imaging review. Clin Radiol. 2012;67:476. 35. Wiesenfeld HC, Sweet RL, Ness RB, et al. Comparison of acute
13. Valsky DV, EshBroder E, Cohen SM, et al. Added value of the and subclinical pelvic inflammatory disease. Sex Transm Dis.
grayscale whirlpool sign in the diagnosis of adnexal torsion. 2005;32:400–5.
Ultrasound Obstet Gynecol. 2010;36:630. 36. Ness RB, Kip KE, Hillier SL, et al. A cluster analysis of bacterial
14. Vijayaraghavan SB, Senthil S. Isolated torsion of the fallo- vaginosis-associated microflora and pelvic inflammatory disease.
pian tube: the sonographic whirlpool sign. J Ultrasound Med. Am J Epidemiol. 2005;162:585–90.
2009;28:657. 37. Cohen CR, Mugo NR, Astete SG, et al. Detection of Mycoplasma
15. Albayram F, Hamper UM. Ovarian and adnexal torsion: spectrum genitalium in women with laparoscopically diagnosed acute sal-
of sonographic findings with pathologic correlation. J Ultrasound pingitis. Sex Transm Infect. 2005;81:463–6.
Med. 2001;20:1083. 38. Haggerty CL, Totten PA, Astete SG, et al. Mycoplasma geni-
16. BenAmi M, Perlitz Y, Haddad S. The effectiveness of spectral and talium among women with nongonococcal, nonchlamydial
color Doppler in predicting ovarian torsion. A prospective study. pelvic inflammatory disease. Infect Dis Obstet Gynecol.
Eur J Obstet Gynecol Reprod Biol. 2002;104:64. 2006;2006:30184.
17. Lee EJ, Kwon HC, Joo HJ, et al. Diagnosis of ovarian torsion with 39. Jurstrand M, Jensen JS, Magnuson A, et al. A serological study of
color Doppler sonography: depiction of twisted vascular pedicle. the role of Mycoplasma genitalium in pelvic inflammatory disease
J Ultrasound Med. 1998;17:83. and ectopic pregnancy. Sex Transm Infect. 2007;83:319–23.
18. Taskin O, Birincioglu M, Aydin A, et al. The effects of twisted 40. Ross J, Judlin P, Jensen J, International Union Against Sexually
ischaemic adnexa managed by detorsion on ovarian viability and Transmitted Infections. 2012 European guideline for the man-
histology: an ischaemic are perfusion rodent model. Hum Reprod. agement of pelvic inflammatory disease. Int J STD AIDS.
1998;13:2823. 2014;25(1):1–7. https://doi.org/10.1177/0956462413498714..
19. Jones HW, Jones GS. Novak textbook of gynecology. 10th ed. Epub 29 Aug 2013
Baltimore: Wolters Kluwer Lippincott Williams & Wilkins; 1981. 41. Government of Western Australia. Department of Health Benign
p. 471. gynaecology acute pelvic inflammatory disease. Clinical guide-
20. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic man- lines gynaecology 2015.
agement of adnexal masses in pregnancy: a case series. Eur J 42. European Guideline for the Management of Pelvic Inflammatory
Obstet Gynecol Reprod Biol. 2003;108:217. Disease UK National Guideline for the Management of Pelvic
21. Bottomley C, Bourne T. Diagnosis and management of ovarian Inflammatory Disease 2011.
cyst accidents. Best Pract Res Clin Obstet Gynaecol. 2009;23:711. 43. UK National Guideline for the Management of Pelvic
22. Kim JH, Lee SM, Lee JH, et al. Successful conservative manage- Inflammatory Disease 2011.
ment of ruptured ovarian cysts with hemoperitoneum in healthy 44. CDC-Center for Disease Control and Prevention. Sexually trans-
women. PLoS One. 2014;9:e91171. mitted disease treatment guidelines 2015.
45. Workowski KA. Centers for Disease Control and Prevention sexu- bleeding: results regarding the degree of intramural extension.
ally transmitted diseases treatment guidelines. Clin Infect Dis. Obstet Gynecol. 1993;82(5):736–40.
2015;61(Suppl 8):S759–62. https://doi.org/10.1093/cid/civ771. 69. Tavassoli FA, Devilee P. World Health Organization classification
46. Maleckiene L, et al. Comparison of clinical and laparoscopic of tumors: pathology and genetics of tumours of the breast and
diagnoses of pelvic inflammatory disease. Int J Gynaecol Obstet. female genital organs. Lyon: IARC Press; 2003.
2009;104(1):74–17. 70. Dilley A, Drews C, Lally C, Austin H, Barnhart E, Evatt B. A
47. Ness RB, Trautmann G, Richter HE, et al. Effectiveness of treat- survey of gynecologists concerning menorrhagia: perceptions of
ment strategies of some women with pelvic inflammatory disease: bleeding disorders as a possible cause. J Womens Health Gend
a randomized trial. Obstet Gynecol. 2005;106(3):573–80. Based Med. 2002;11(1):39–44.
48. Burney RO, Giudice LC. Pathogenesis and pathophysiology of 71. Byams VR, Anderson BL, Grant AM, Atrash H, Schulkin
endometriosis. Fertil Steril. 2012;98(3):511–9. J. Evaluation of bleeding disorders in women with menorrhagia:
49. Jubanyik KJ, Comite F. Extrapelvic endometriosis. Obstet a survey of obstetrician-gynecologists. Am J Obstet Gynecol.
Gynecol Clin North Am. 1997;24(2):411–40. 2012;207(4):269.e1–5.
50. Avraham S, Seidman DS. Surgery versus pharmacological treat- 72. Gleeson NC. Cyclic changes in endometrial tissue plasminogen
ment for endometriosis. Future Med. 2014;10:161–6. activator and plasminogen activator inhibitor type 1 in women
51. American College of Obstetricians and Gynecologists. Practice with normal menstruation and essential menorrhagia. Am J Obstet
Bulletin 114. Management of Endometriosis. Obstet Gynecol. Gynecol. 1994;171(1):178–83.
2010;116(1):223–36. 73. Smith SK, Abel MH, Kelly RW, Baird DT. Prostaglandin synthe-
52. Viganò P, Parazzini F, Somigliana E, Vercellini P. Endometriosis: sis in the endometrium of women with ovular dysfunctional uter-
epidemiology and aetiological factors. Best Pract Res Clin Obstet ine bleeding. Br J Obstet Gynaecol. 1981;88(4):434–42.
Gynaecol. 2004;18(2):177–200. 74. Smith SK, Abel MH, Kelly RW, Baird DT. A role for prostacy-
53. Nap AW, Groothuis PG, Demir AY, Evers JLH, Dunselman clin (PGi2) in excessive menstrual bleeding. Lancet (London,
GAJ. Pathogenesis of endometriosis. Best Pract Res Clin Obstet England). 1981;1(8219):522–4.
Gynaecol. 2004;18(2):233–44. 75. Heatley MK. The association between clinical and pathological
54. Signorile PG, Baldi A. Endometriosis: new concepts in the patho- features in histologically identified chronic endometritis. J Obstet
genesis. Int J Biochem Cell Biol. 2010;42(6):778–80. Gynaecol. 2004;24(7):801–3.
55. Mathur S, Peress MR, Williamson HO, et al. Autoimmunity to 76. Pitsos M, Skurnick J, Heller D. Association of pathologic diagno-
endometrium and ovary in endometriosis. Clin Exp Immunol. ses with clinical findings in chronic endometritis. J Reprod Med.
1982;50(2):259–66. 2009;54(6):373–7.
56. Suginami H. A reappraisal of the coelomic metaplasia theory by 77. Toth M, Patton DL, Esquenazi B, Shevchuk M, Thaler H, Divon
reviewing endometriosis occurring in unusual sites and instances. M. Association between chlamydia trachomatis and abnormal
Am J Obstet Gynecol. 1991;165(1):214–8. uterine bleeding. Am J Reprod Immunol. 2007;57(5):361–6.
57. Schrager S, Falleroni J, Edgoose J. Evaluation and treatment of 78. Rosenberg MJ, Waugh MS, Stevens CM. Smoking and cycle
endometriosis. Am Fam Physician. 2013;87(2):107–13. control among oral contraceptive users. Am J Obstet Gynecol.
58. Kodaman PH. Current strategies for endometriosis management. 1996;174(2):628–32.
Obstet Gynecol Clin North Am. 2015;42(1):87–101. 79. Meijer WEE, Heerdink ER, Nolen WA, Herings RMC, Leufkens
59. Suzuki T, Izumi SI, Matsubayashi H, Awaji H, Yoshikata K, Makino HGM, Egberts ACG. Association of risk of abnormal bleeding
T. Impact of ovarian endometrioma on oocytes and pregnancy out- with degree of serotonin reuptake inhibition by antidepressants.
come in in vitro fertilization. Fertil Steril. 2005;83(4):908–13. Arch Intern Med. 2004;164(21):2367.
60. Reeve L, Lashen H, Pacey AA. Endometriosis affects sperm- 80. Marzano DA, Haefner HK. The Bartholin gland cyst: past, pres-
endosalpingeal interactions. Hum Reprod. 2005;20(2):448–51. ent, and future. J Low Genit Tract Dis. 2004;8:195.
61. American Fertility Society. Revised American Fertility Society clas- 81. Krissi H, Shmuely A, Aviram A, From A, Edward R, Peled
sification of endometriosis: 1985. Fertil Steril. 1985;43(3):351–2. Y. Acute Bartholin’s abscess: microbial spectrum, patient charac-
62. Allen C, Hopewell S, Prentice A, Gregory D. Nonsteroidal teristics, clinical manifestation, and surgical outcomes. Eur J Clin
anti-inflammatory drugs for pain in women with endometriosis Microbiol Infect Dis. 2016;35(3):443–6.
(Review). 2010;(2). www.cochranelibrary.com. 82. Downs MC, Randall HW Jr. The ambulatory surgical manage-
63. Jacobson T, Duffy JMN, Barlow D, Konincks PR, Garry ment of Bartholin duct cysts. J Emerg Med. 1989;7:623–6.
R. Laparoscopic surgery for pelvic pain associated with endome- 83. Cobellis PL, Stradella L, De Lucia E, et al. Alcohol sclerother-
triosis. Cochrane Libr. 2010;(11):1–21. apy: a new method for Bartholin gland cyst treatment. Minerva
64. Jones KD, Sutton C. Patient satisfaction and changes in pain Ginecol. 2006;58:245–8.
scores after ablative laparoscopic surgery for stage III-IV endome- 84. Kafali H, Yurtseven S, Ozardali I. Aspiration and alcohol sclero-
triosis and endometriotic cysts. Fertil Steril. 2003;79(5):1086–90. therapy: a novel method for management of Bartholin’s cyst or
65. Munro MG, Critchley HOD, Broder MS, Fraser IS. FIGO clas- abscess. Eur J Obstet Gynecol Reprod Biol. 2004;112:98–101.
sification system (PALM-COEIN) for causes of abnormal uterine 85. Cheetham DR. Bartholin’s cyst: marsupialization or aspiration?
bleeding in nongravid women of reproductive age. Int J Gynecol Am J Obstet Gynecol. 1985;152:569–70.
Obstet. 2011;113(1):3–13. 86. Gennis P, Li SF, Provataris J, et al. Jacobi ring catheter treatment
66. Lieng M, Istre O, Sandvik L, Qvigstad E. Prevalence, 1-Year of Bartholin’s abscesses. Am J Emerg Med. 2005;23:414–5.
regression rate, and clinical significance of asymptomatic endo- 87. Andersen PG, Christensen S, Detlefsen GU, et al. Treatment
metrial polyps: cross-sectional study. J Minim Invasive Gynecol. of Bartholin’s abscess. Marsupialization versus incision,
2009;16(4):465–71. curettage and suture under antibiotic cover. A randomized
67. Anastasiadis PG, Koutlaki NG, Skaphida PG, Galazios GC, study with 6 months’ follow up. Acta Obstet Gynecol Scand.
Tsikouras PN, Liberis VA. Endometrial polyps: prevalence, detec- 1992;71:59–62.
tion, and malignant potential in women with abnormal uterine 88. Penna C, Fambrini M, Fallani MG. CO2 laser treatment for
bleeding. Eur J Gynaecol Oncol. 2000;21(2):180–3. Bartholin’s gland cyst. Int J Gynaecol Obstet. 2002;76:79–80.
68. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hys- 89. Benedetti Panici P, Manci N, Bellati F, et al. CO2 laser ther-
teroscopic resection of submucous fibroids for abnormal uterine apy of the Bartholin’s gland cyst: surgical data and functional
short- and long-term results. J Minim Invasive Gynecol. 112. Butwick AJ. Postpartum hemorrhage and low fibrinogen levels:
2007;14:348–51. the past, present and future. Int J Obstet Anesth. 2013;22(2):
90. Fambrini M, Penna C, Pieralli A, et al. Carbon-dioxide laser 87–91.
vaporization of the Bartholin gland cyst: a retrospective analysis 113. Edwards P, Shakur H, Barnetson L, et al. Central and sta-
on 200 cases. J Minim Invasive Gynecol. 2008;15:327–31. tistical data monitoring in the Clinical Randomisation of an
91. World Health Organization. Guidelines for medico-legal care of Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial.
victims of sexual violence, 2003. Clin Trials. 2014;11(3):336–43.
92. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C, 114. Lalonde A, International Federation of Gynecology and

WHO Multi-Country Study on Women’s Health and Domestic Obstetrics. Prevention and treatment of postpartum hem-
Violence Against Women Study Team. Intimate partner violence orrhage in low-resource settings. Int J Gynaecol Obstet.
and women’s physical and mental health in the WHO multicountry 2012;117(2):108–18.
study on women’s health and domestic violence: an observational 115. AIFA. Nota informativa importante concordata con l’EMA
study. Lancet. 2008;371(9619):1165–72. https://doi.org/10.1016/ e l’AIFA: Restrizione d’uso di HES (medicinali contenenti
S0140-6736(08)60522-X. amido idrossietilico). 2013. http://www.agenziafarmaco.gov.
93. UK National Guidelines on the Management of Adult and it/it/content/nota-informativa-importante-sulla-restrizione-
Adolescent Complainants of Sexual Assault; 2011. d%E2%80%99uso-di-hes-medicinali-contenenti-amido-idros.
94. Ragusa A, Crescini C. URGENZE ED EMERGENZE IN SALA Last accessed 06 Jun 2017.
PARTO. Padova: Casa Editrice PICCIN Nuova Libreria; 2015. 116. Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrino-
p. 197–211. gen is an early predictor of the severity of postpartum hemorrhage.
95. Oyelese Y, Ananth CV. Placental Abruptio. Obstet Gynecol. J Thromb Haemost. 2007;5(2):266–73.
2006;108(4):1005–16. 117. Collins PW, Lilley G, Bruynseels D, et al. Fibrin-based clot for-
96. Yeo L, Vintzleos A. Placenta Abruptio. Philadelphia: Lippincott, mation an early and rapidly available biomarker for progression
Williams & Wilkins; 2004. of postpartum hemorrhage: a prospective cohort study. Blood.
97. Royal College of Obstetricians and Gynaecologists. Antepartum 2014;124(11):1727–36.
haemorrhage. RCOG 2011. Green-top guidelines N° 63. 118. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al.
98. Tikkanen M. Etiology, clinical manifestations, and predic- Management of severe perioperative bleeding: guidelines from
tion of placental abruption. Acta Obstet Gynecol Scand. the European Society of Anaesthesiology. Eur J Anaesthesiol.
2010;89(6):732–40. 2013;30(6):270–382.
99. Glantz C, Purnell L. Clinical utility of sonography in the diag- 119. Hofmeyr GJ, Abdel-Aleem H, Abdel-Aleem MA. Uterine mas-
nosis and treatment of placental abruption. J Ultrasound Med. sage for preventing postpartum haemorrhage. Cochrane Database
2002;21(8):837–40. Syst Rev. 2013;(7):CD006431.
100. Usui R, Matsubara S, Ohkuchi A, Kuwata T, Watanabe T, Izumi A, 120. Allam MS, B-Lynch C. The B-Lynch and other uter-

et al. Fetal heart pattern reflecting the severity of placental abrup- ine compression suture techniques. Int J Gynecol Obstet.
tion. Arch Gynecol Obstet. 2008;277(3):249–53. 2005;89(3):236–41.
101. Oyelese Y, Smulian JC. Placenta previa, placenta accreta and vasa 121. B-Lynch C, Coker A, Lawal AH, Abu J, Cowen MJ. The B-Lynch
previa. Obstet Gynecol. 2006;107(4):927–41. surgical technique for the control of massive postpartum haemor-
102. Royal College of Obstetricians and Gynaecologists. Placenta rhage: an alternative to hysterectomy? Five cases reported. Br J
praevia, placenta praevia accreta and vasa praevia: diagnosis and Obstet Gynaecol. 1997;104(3):372–5.
management. RCOG 2011. Green-top guidelines N° 27. 122. Baskett TF. Uterine compression sutures for postpartum hemor-
103. WHO recommendations for the prevention and treatment of rhage: efficacy, morbidity, and subsequent pregnancy. Obstet
postpartum haemorrhage. 2012. http://apps.who.int/iris/bitstr Gynecol. 2007;110(1):68–71.
eam/10665/75411/1/9789241548502_eng.pdf. Last accessed 06 123. Price N, B-Lynch C. Technical description of the B-Lynch
Jun 2017. brace suture for treatment of massive postpartum hemorrhage
104. Royal College of Obstetricians and Gynaecologists (RCOG). and review of the published cases. Int J Fertil Womens Med.
Prevention and management of postpartum haemorrhage. Green- 2005;50(4):148–63.
top Guideline N. 52. 2009. https://www.rcog.org.uk/en/guidelines- 124. Hayman RG, Arulkumaran S, Steer PJ. Uterine compression
research-services/guidelines/gtg52/. Last accessed 06 Jun 2017. sutures: surgical management of postpartum hemorrhage. Obstet
105. Mousa HA, Blum J, Abou El Senoun G, Shakur H, Alfirevic Gynecol. 2002;99(3):502–6.
Z. Treatment for primary postpartum haemorrhage. Cochrane 125. Ghezzi F, Cromi A, Uccella S, Raio L, Bolis P, Surbek D. The
Database Syst Rev. 2014;(2):CD003249. Hayman technique: a simple method to treat postpartum haemor-
106. Mukherjee S, Sabaratnam A. Post-partum haemorrhage. Obstet rhage. BJOG. 2007;114(3):362–5.
Gynaecol Reprod Med. 2009;19:121–16. 126. Joshi VM, Otiv SR, Majumder R, Nikam YA, Shirivastava
107. Meir JY, Natale N, Arisi E, et al. Emorragia post-partum: linee guida M. Internal iliac artery ligation for arresting postpartum haemor-
per la prevenzione, Diagnosi e il trattamento. Linee guida AOGOI. I rhage. BJOG. 2007;114(3):356–61.
libri dell’AOGOI. Cento, Ferrara: Editeam; 2009. p. 23–49 127. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal
108. Abdul-Kadir R, McLintock C, Ducloy AS, et al. Evaluation and hysterectomy for benign gynaecological conditions. Cochrane
management of postpartum hemorrhage: consensus from an inter- Database Syst Rev. 2012;(4):CD004993.
national expert panel. Transfusion. 2014;54(7):1756–68. 128. Grady K, Howell C, Cox C. Uterine inversion - chapter23. In:
109. Pavord S, Maybury H. How I treat postpartum hemorrhage. Blood. The MOET coursemanual: managing obstetric emergencies and
2015;125(18):2759–70. trauma. 2nd ed. London: RCOG Press; 2007.
110. Ducloy-Bouthors AS, Jude B, Duhamel A, et al. High-dose 129. Loeffler F. Postpartum haemorrhge and abnormalities of the
tranexamic acid reduces blood loss in postpartum haemorrhage. third stage of labour. In: Chamberlain G, editor. Turnbull’s
Crit Care. 2011;15(2):R117. obstetrics. 2nd ed. Edinburgh: Churchill Livingstone; 1995.
111. Sentilhes L, Deneux-Tharaux C. Prophylactic tranexamic acid in p. 729–34.
addition to uterotonics may prevent blood loss for vaginal and cae- 130. O’Sullivan J. Acute inversion of the uterus. Br Med J. 1945;2:
sarean deliveries. Evid Based Med. 2016;21(3):97. 282–3.
131. Ragusa A, Crescini C, et al. Uterine inversion- Chapter 11. In: 155. Kuhlmann RS, Cruikshank DP. Maternal trauma during preg-
Manuale di urgenze ed emergenze in sala parto. 2nd ed. Padova: nancy. Clin Obstet Gynecol. 1994;37(2):274–93.
Piccin Press; 2016. 156. Petrone P, Talving P, Browder T, Teixeira PG, Fisher O, Lozornio
132. Shah-Hosseini R, Evrard JR. Puerperal uterine inversion. Obstet A, et al. Abdominal injuries in pregnancy: a 155-month study at
Gynecol. 1989;73(4):567–70. two level 1 trauma centers. Injury. 2011;42(1):47–9.
133. Watson P, Besch N, Bowes WA Jr. Management of acute and 157. Vikram K, Parul G, Ranjana K, Umamaheshwar K. Trauma
subacute puerperal inversion of the uterus. Obstet Gynecol. in pregnancy - a review. Adv Res Gastroenterol Hepatol.
1980;55(1):12–6. 2016;2(1):555580.
134. Soleymani Majd H, Pilsniak A, Reginald PW. Recurrent uterine 158. Suresh MS, Wali A. Failed intubation in obstetrics: airway man-
inversion: a novel treatment approach using SOS Bakri balloon. agement strategies. Anesthesiol Clin North Am. 1998;16:477–98.
BJOG. 2009;116(7):999–1001. 159. Ramsay G, Paglia M, Bourjeily G. When the heart stops: a
135. Huntington JL, Irving FC, Kellog FS. Abdominal reposition in review of cardiac arrest in pregnancy. J Intensive Care Med.
acute inversion of the puerperal uterus. Am J Obstet Gynecol. 2013;28(4):204–14.
1928;15:34–40. 160. Lockey DJ, Crewdson K, Lossius HM. Pre-hospital anaesthesia:
136. Boyle JJ, Katz VL. Umbilical cord prolapse in current obstetric the same but different. Br J Anaesth. 2014;113(2):211–9.
practice. J Reprod Med. 2005;50(5):303–6. 161. Pearlman M, Faro S. Obstetric septic shock: a pathophysiologic
137. Draycott T, Winter C, Crofts J, et al., editors. Module 8. Cord pro- basis for management. Clin Obstet Gynecol. 1990;33(3):482–92.
lapse in: PROMPT: practical obstetric multi professional training 162. American College of Surgeons Committee: on Trauma. Trauma
course manual. London: RCOG Press; 2008. p. 117–24. in women. In: Advanced trauma life support for doctors: student
138. Goswami K. Umbilical cord prolapse. In: Grady K, Howell C, Cox course manual. 9th ed. Chicago, Surgeons. 2012;9:259–68.
C, editors. Managing obstetric emergencies and trauma. The MOET 163. Epstein FB. Acute abdominal pain in pregnancy. Emerg Med Clin
course manual. 2nd ed. London: RCOG Press; 2007. p. 233–7. North Am. 1994;12(1):151–65.
139. Koonings PP, Paul RH, Campbell K. Umbilical cord prolapse. A 164. Puri A, Khadem P, Ahmed S, Yadav P, Al-Dulaimy K. Imaging
contemporary look. J Reprod Med. 1990;35(7):690–2. of trauma in a pregnant patient. Semin Ultrasound CT MR.
140. Panter KR, Hannah ME. Umbilical cord prolapse: so far so good? 2012;33(1):37–45.
Lancet. 1996;347(8994):74. Royal College of Obstetricians and 165. Donnelly EH, Smith JM, Farfán EB, Ozcan I. Prenatal radiation
Gynaecologists. Umbilical cord prolapse. Green-top Guideline exposure: background material for counseling pregnant patients
No.50; April 2008. following exposure to radiation. Disaster Med Public Health Prep.
141. Siassakos D, Crofts JF, Winter C, Weiner CP, Draycott TJ. The 2011;5(1):62–8.
active components of effective training in obstetric emergencies. 166. De Santis M, Di Gianantonio E, Straface G, Cavaliere AF, Caruso
BJOG. 2009;116(8):1028–32. A, Schiavon F, et al. Ionizing radiations in pregnancy and terato-
142. Usta IM, Mercer BM, Sibai BM. Current obstetrical prac- genesis: a review of literature. Reprod Toxicol. 2005;20(3):323–9.
tice and umbilical cord prolapse. Am J Perinatol. 1999;16(9): 167. Patel SJ, Reede DL, Katz DS, Subramaniam R, Amorosa
479–84. JK. Imaging the pregnant patient for nonobstetric conditions:
143. Murphy DJ, MacKenzie IZ. The mortality and morbidity asso- algorithms and radiation dose considerations. Radiographics.
ciated with umbilical cord prolapse. Br J Obstet Gynaecol. 2007;27(6):1705–22.
1995;102(10):826–30. 168. Ray JG, Schull MJ, Urquia ML, You JJ, Guttmann A, Vermeulen
144. Lin MG. Umbilical cord prolapse. Obstet Gynecol Surv. MJ, Franco EL, Academic Editor. Major radiodiagnostic imaging
2006;61(4):269–77. in pregnancy and the risk of childhood malignancy: a population-
145. Katz Z, Shoham Z, Lancet M, Blickstein I, Mogilner BM, Zalel based cohort study in Ontario. PLoS Med. 2010;7(9):e1000337.
Y. Management of labor with umbilical cord prolapse: a 5-year Published online 7 Sept 2010. https://doi.org/10.1371/journal.
study. Obstet Gynecol. 1988;72(2):278–81. pmed.1000337.
146. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande 169. Sagiv R, Debby A, Feit H, Cohen-Sacher B, Keidar R,

VA. Change in knowledge of midwives and obstetricians follow- Golan A. The optimal cutoff serum level of human chori-
ing obstetric emergency training: a randomized controlled trial of onic gonadotropin for efficacy of methotrexate treatment in
local hospital, simulation centre and teamwork training. BJOG. women with extrauterine pregnancy. Int J Gynaecol Obstet.
2007;114(12):1534–41. 2012;116(2):101–4.
147. Siassakos D, Fox R, Draycott TJ. Umbilical cord prolapse [Green- 170. Abe T, Akira S, Negishi Y, Ichikawa M, Nakai A, Takeshita
top guideline no. 50]. London: RCOG Press; 2008. T. Relevance of declines in serum human chorionic gonadotropin
148. Siassakos D, Hasafa Z, Sibanda T, Fox R, Donald F, Winter C, levels to the management of persistent ectopic pregnancy. J Obstet
et al. Retrospective cohort study of diagnosis-delivery interval Gynaecol Res. 2009;35(5):961–6.
with umbilical cord prolapse: the effect of team training. BJOG. 171. Hajenius PJ, Mol F, Mol BW, Bossuyt PM, Ankum WM, van
2009;116(8):1089–96. der Veen F. Interventions for tubal ectopic pregnancy. Cochrane
149. Khandelwal A, Fasih N, Kielar A. Imaging of acute abdomen in Database Syst Rev. 2007.
pregnancy. Radiol Clin North Am. 2013;51:1005–22. 172. Diagnosis and management of ectopic pregnancy. Green‐top guide-
150. Germain A, Brunaud L. Visceral surgery and pregnancy. J Visc line no. 21. 2016;123(13):e15–55. https://doi.org/10.1111/1471-
Surg. 2010;147:e129–35. 0528.14189. First published: 3 Nov 2016.
151. Gilo NB, Amini D, Landy HJ. Appendicitis and cholecystitis in 173. Choudhary N, Saha SC, Gopalan S. Abortion procedures in a
pregnancy. Clin Obstet Gynecol. 2009;52:586–96. tertiary care institution in India. Int J Gynaecol Obstet. 2005;91:
152. ACOG Committee on Obstetric Practice. ACOG Committee 81–6.
Opinion No. 474: Non obstetric surgery during pregnancy. Obstet 174. Steinauer JE, Diedrich JT, Wilson MW, Darney PD, Vargas JE,
Gynecol. 2011;117:420–1. Drey EA. Uterine artery embolization in postabortion hemor-
153. Evans SR, Sarani B, Bhanot P, Feldman E. Surgery in pregnancy. rhage. Obstet Gynecol. 2008;111:881–9.
Curr Probl Surg. 2012;49:333–88. 175. O’Connell K, Jones H, Simon M, Saporta V, Paul M, Lichtenberg
154. Knab LM, Boller AM, Mahvi DM. Cholecystitis. Surg Clin North E. First-trimester surgical abortion practices: a survey of National
Am. 2014;94:455–70. Abortion Federation members. Contraception. 2009;79:385–92.
176. O’Connell K, Jones HE, Lichtenberg ES, Paul M. Second- 179. Frick AC, Drey EA, Diedrich JT, Steinauer JE. Effect of prior
trimester surgical abortion practices: a survey of National Abortion cesarean delivery on risk of second-trimester surgical abortion
Federation members. Contraception. 2008;78:492–9. complications. Obstet Gynecol. 2010;115:760.
177. Tang O, Schweer H, Seyberth H, Lee S, Ho P. Pharmacokinetics 180. Olamijulo J, Doufekas K. Intrauterine balloon tamponade for
of different routes of administration of misoprostol. Hum Reprod. uncontrollable bleeding during first trimester surgical termination
2002;17:332–6. of pregnancy. J Obstet Gynaecol. 2007;27:440–1.
178. Meckstroth K, Whitaker A, Bertisch S, Goldberg A, Darney
P. Misoprostol administered by epithelial routes: drug absorption
and uterine response. Obstet Gynecol. 2006;108:582–90.
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Updates in the Management of Ob-Gyn Emergencies

Chapter · January 2019

Antonio Ragusa Alessandro Svelato

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Mariarosaria Di Tommaso Sara D'Avino

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33.1 Management of Gynecological

A. Ragusa (*) · A. Svelato · S. D’Avino D. Rinaldo

© Springer International Publishing AG, part of Springer Nature 2019 483

The primary risk factor is an ovarian mass, particularly a Management

Connected risk factors are [40]: 33.1.3.1 Diagnosis

REVISED AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE CLASSIFICATION OF

Stage I (Minimal) 1-5 Laparoscopy Laparotomy Photography

< 1 cm < 1 – 3 cm > 3 cm

To be used with normal To be used with abnormal

Left Right Left Right

STAGE I (MINIMAL) STAGE II (MILD) STAGE III (MODERATE)

PERITONEUM PERITONEUM PERITONEUM

STAGE III (MODERATE) STAGE IV (SEVERE) STAGE IV (SEVERE)

PERITONEUM PERITONEUM PERITONEUM

smokers, because of an enhanced hepatic metabolism that 33.1.6.3 Drainage

33.1.7.3 Clinical Assessment

Table 33.1 Consequences of sexual violence [91]

–– Signs of tying the wrists, ankles, and neck

On the basis of the facts and the information provided by

Table 33.2 Persistence of biological evidences

–– Prevention of sexually transmitted diseases

33.2 Management of Ob-Gyn Emergencies

33.2.1 Antepartum Hemorrhage

Fig. 33.8 Mouth swab (With permission of World Health Organization,

1. Low-lying placenta, ending in the lower uterine

bladder at least 15 mm from the hysterotomy. The needle

Ligature of the Hypogastric Artery

u­ seful in lower uterine segment bleeding, from the cervix

Fig. 33.11 Grades of uterine A A

Table 33.4 Risk factors for uterine inversion

Symptoms and signs include:

• Development of sudden maternal shock not proportionate

33.2.3.2 Management • Hydrostatic pressure can be used to correct uterine

Perinatal mortality rate has improved and is currently

Fetal and maternal factors that have been associated with

33.2.4 Prolapsed Umbilical Cord

Table 33.6 Location of abdominal pain and possible underlying pathologies

Diagnosis 33.2.6.2 Signs and Symptoms

33.2.7 Ectopic Pregnancy and Abdominal

–– Surgery 33.2.8 Abortion with Hemorrhagic Shock

• Vaginal bleeding sutures, a possible laceration of the uterine artery or uterine

Case Scenario D. Abdominal CT

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33.1 Management of Gynecological

Connected risk factors are [40]: 33.1.3.1 Diagnosis

smokers, because of an enhanced hepatic metabolism that 33.1.6.3 Drainage

33.1.7.3 Clinical Assessment

33.2 Management of Ob-Gyn Emergencies

33.2.1 Antepartum Hemorrhage

u seful in lower uterine segment bleeding, from the cervix

33.2.3.2 Management • Hydrostatic pressure can be used to correct uterine

33.2.4 Prolapsed Umbilical Cord

Diagnosis 33.2.6.2 Signs and Symptoms

33.2.7 Ectopic Pregnancy and Abdominal

–– Surgery 33.2.8 Abortion with Hemorrhagic Shock