What Are Gynecological Complications?
There are many obstetric and gynecologic complications associated with pregnancy that can lead to severe abdominal pain and blood loss and be life-threatening to the individual. In such situations, the patient requires urgent attention and a quick and accurate decision regarding further management. The treatment will depend on the ability to differentiate between gynecology and gastrointestinal problems, as the absence of vaginal bleeding may make diagnosis difficult in certain cases. Ultrasonography is a valuable tool for detecting the cause and guiding the treatment during emergencies faced by the gynecologist during pregnancy and the early postpartum period.
What Are Some Rare Gynecological Emergencies?
Heterotopic Pregnancy -
Heterotopic pregnancy is an extremely rare condition. It is the presence of multiple embryos, one in the uterus and the other outside the uterus (ectopic pregnancy). The most common site of ectopic pregnancy is the fallopian tube; however, it can also occur in the ovary, cervix, previous C-section scar, or even in the abdomen. The common symptoms of heterotopic pregnancy include lower abdominal pain, vaginal bleeding, and shoulder-tip pain (a sign that the condition is worsening). In severe cases, hypovolemic shock can occur, and its signs include rapid breathing, a rapid pulse, clammy skin, low blood pressure, and unconsciousness.
The emergency management of heterotopic pregnancy is either laparotomy or laparoscopy. It is always performed in situations like suspicion of ectopic pregnancy rupture or in patients with unstable hemodynamic situations. Salpingectomy, salpingostomy, oophorectomy, cornual resection, and even total abdominal hysterectomy are preferred surgical management options for ectopic pregnancy removal. The main benefit of surgical management is the complete removal of the ectopic pregnancy mass. However, there is a higher abortion rate during intrauterine pregnancy.
Incarcerated Uterus -
An uncommon complication occurs when the uterus becomes trapped between the pubic symphysis (a joint present between the left and right pelvic bones) and the sacral promontory (superior surface on the body of the first sacral vertebrae). The signs and symptoms usually occur during 17 weeks of gestation, including nonspecific abdominal pain, back pain, constipation, rectal pressure, a large painful mass prolapsed outside the anus, and overflow incontinence or urinary retention. The diagnosis is made by observing the cervical displacement and the inability to mobilize the uterus on an abdominal-vaginal examination.
The management should be fairly immediate to prevent both spontaneous abortions and deviate urinary retention. It can be performed by placing the patient in the chest-knee position where spontaneous reduction may occur. If it is unsuccessful, the appropriate pressure is applied through the rectum to correct the problem. Sometimes, repositioning can be done under a general or regional anesthetic.
Inversion of Uterus -
An inverted uterus, or uterine inversion, is a rare and life-threatening complication during childbirth. Generally, the placenta detaches from the uterus and comes through the vagina around half an hour after the delivery. But in an inversion of the uterus, the placenta remains attached to the uterus, and when it exits through the vagina, it pulls the uterus inside out.
The treatment should be quick and mainly aim to keep the vitals stable while replacing the uterus to its original position. A professional can manually push the uterus back into its position through the vaginal canal and cervix. If the placement of the uterus is not possible manually, then if there is excess blood loss, surgical intervention (laparotomy) is carried out through an incision into the abdomen to access the pelvic cavity and reposition the uterus.
Ovarian Torsion:
Ovarian torsion is an uncommon event, that occurs when the ovary or fallopian tube twists around the ligaments that hold it in position. This event may compress or cut off the blood supply to the ovary, causing anoxic degeneration of the ovary and eventual gangrenous necrosis. Ovarian torsion can cause sudden severe pain and other symptoms such as nausea and vomiting, fever, and abnormal bleeding because the ovary is not receiving enough blood and oxygen. It is diagnosed by the clinical presentation and physical examination, which reveal a unilateral tender adnexal mass.
The only treatment option for ovarian torsion is surgery; the professional recommends performing the surgery as quickly as possible. Removal of one or both ovaries is called oophorectomy, it can be performed through laparoscopy or laparotomy.
Uterine Rupture:
Uterine rupture during pregnancy is a rare and life-threatening complication with a high maternal and fetal morbidity incidence. It occurs when the wall of the uterus tears open because of the pressure caused by pregnancy. It is commonly seen in people who have had a previous C-section delivery and then try for vaginal birth after cesarean (VBAC) or vaginal delivery. When there is a uterine rupture, a hole is formed in the uterus and abdomen, which is very dangerous, as it can cause severe blood loss. Also, when there is a uterus rupture, the protection layer of the fetus, which is, the uterus, is destroyed, causing the fetus’s heart rate to slow down and reducing oxygen supply. Less oxygen supplied to the fetus can cause brain damage or suffocation.
So the treatment should be quick, aiming to remove the baby and repair the uterus. The ruptured uterine wall is repaired through surgery. Bleeding is more profuse when the uterine tear is longitudinal rather than transverse. If the bleeding is profound, then a hysterectomy will be performed.
Toxic Shock Syndrome -
It is a rare entity occurring in menstruating women. It is caused by exotoxins produced by Staphylococcus aureus (staph) bacteria, but it may also be caused by toxins produced by A streptococcus (strep) bacteria. It is caused by using super-absorbent tampons, menstrual cups, contraceptive sponges, or diaphragms, especially if left behind for a long duration. Tampon use may also damage the cervical and vaginal mucous membranes, which can enhance the absorption of the exotoxin.
The signs and symptoms of toxic shock syndrome include sudden high fever, confusion, low blood pressure, vomiting, diarrhea, headache, seizures, muscle aches, redness of the eyes, mouth, and throat, and rashes resembling sunburn. Treatment involves immediate hospitalization and the removal of any tampons or contraceptive devices from the vagina, if present. Antibiotics, IV fluids, and oxygen are provided to stabilize the patient and treat the infection.
Conclusion
Gynecologic and obstetric complications must require timely diagnosis and abrupt treatment, as they may be not only life-threatening to the mother but also to the baby. A diagnosis is usually made based on signs and symptoms and a physical examination. Also, imaging techniques like ultrasound play a vital role. When the condition is ruled out, emergency treatment will help maintain the mother's and baby's lives.
