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Surgical Emergencies

in Obstetrics & Gynecology


The Surgical Care of Women in Operational Settings

CDR Michael John Hughey, MC, USNR

Bureau of Medicine and Surgery


Department of the Navy
2300 E Street NW
Washington, DC
20372-5300

July 1, 1993

1
This syllabus is designed to provide good advice to surgeons who treat women with
gynecologic problems in isolated settings where gynecologic consultation is not readily
available.

It is not all-inclusive and is not intended to replace good clinical judgment nor in-depth
textbooks which should be consulted whenever appropriate.

As in most areas of medicine, there may be more than one way to deal with any particular
gynecologic problems. For simplicity, one basic approach is usually given here. There are
often other approaches which will give very good or superior results.

Bureau of Medicine and Surgery


Department of the Navy
2300 E Street NW
Washington, DC
20372-5300

2
Contents
Principles of Gynecologic Surgery .............................................................................................4
Surgical Procedures...................................................................................................................5
Repair of Vaginal or Vulvar Lacerations ....................................................................................4
Bladder Lacerations ...................................................................................................................5
Rectal Lacerations .....................................................................................................................5
Other Lacerations.......................................................................................................................5
Vulvar Hematoma ......................................................................................................................6
Bartholin's Abscess ....................................................................................................................6
D&C............................................................................................................................................6
Salpingectomy............................................................................................................................7
Oophorectomy............................................................................................................................8
Ovarian Cystectomy...................................................................................................................8
Hysterectomy .............................................................................................................................9
OB/GYN Illness with Surgical Significance ..............................................................................10
Abortion ....................................................................................................................................10
Threatened Abortion ................................................................................................................10
Incomplete Abortion .................................................................................................................10
Complete Abortion ...................................................................................................................11
Inevitable Abortion ...................................................................................................................11
Septic Abortion .........................................................................................................................12
Second Trimester Abortion ......................................................................................................12
Third Trimester Delivery Complications ...................................................................................12
Cesarean Section.....................................................................................................................12
Manual Removal of the Placenta .............................................................................................12
Immediate Post Partum Hemorrhage ......................................................................................13
Post Partum Hysterectomy ......................................................................................................13
Unruptured Ectopic Pregnancy ................................................................................................13
Ruptured Ectopic Pregnancy ...................................................................................................14
Ruptured Ovarian Cyst.............................................................................................................15
Unruptured Ovarian Cyst .........................................................................................................15
Torsioned Ovarian Cyst ...........................................................................................................15
Pelvic Inflammatory Disease....................................................................................................15
Mild...........................................................................................................................................15
Moderate to Severe..................................................................................................................16
Tubo-Ovarian Abscess.............................................................................................................17
Abnormal Vaginal Bleeding .....................................................................................................17
Overview ..................................................................................................................................17
Mechanical Causes of Abnormal Bleeding ..............................................................................17
Hormonal Causes of Abnormal Bleeding.................................................................................17
What to do first .........................................................................................................................18
Malignancy as a Cause of Abnormal Bleeding ........................................................................18
OB-GYN Consultation ..............................................................................................................18
US Naval Hospitals with OB-GYN Physicians Available for Consultation ...............................19

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Surgical Emergencies
in Obstetrics & Gynecology
The Surgical Care of Women in Operational Settings

CDR Michael John Hughey, MC, USNR


Bureau of Medicine and Surgery
Department of the Navy

The need for gynecologic surgery may


arise in isolated settings, or during Conservation of Ovarian Function.
military operations when consultation is Conserving even a small amount of
restricted and medical support limited. ovarian tissue will result in normal
At such times, surgeons of varying hormonal function. Removing just
experience and training may be required the ovarian cyst and not the entire
to perform gynecologic surgery. ovary will allow continued ovarian
function, even if only 10% of the
ovary remains.

Avoid Damage to Other Important


Principles of Structures. The bowel, bladder and
ureters are very close to the uterus,
Gynecologic Surgery cervix, tubes and ovaries. Damage to
The basic principles of surgery apply to adjacent structures is not uncommon
gynecologic surgery with a few special even when surgery is performed
considerations: competently, by experienced
gynecologic surgeons, in well-
Preservation of Childbearing equipped settings.
Potential. Preserve as much of the
reproductive organs as is reasonable.
The loss of a single ovary or
fallopian tube is preferable to loss of
both. However, leaving the patient's
life in jeopardy to preserve
childbearing potential is ill-advised.

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Surgical Emergencies in Obstetrics & Gynecology

Surgical Procedures months until the inflammation has


subsided. During this time, fecal
Repair of Vaginal or Vulvar incontinence will need to be tolerated.
Lacerations
If the rectal sphincter has been torn, it
These lacerations may result from will retract back into the surrounding
childbirth, sexual assault, accidents or tissue, creating a 1-2 cm. "crater."
hostile fire. Identify this crater with your finger, then
grasp the retracted muscle with an
Because this area is quite vascular, instrument and bring it back to the
primary closure is preferred in an acute midline. Suture the edges of the
setting. In cases involving delayed sphincter together, making sure to
treatment (>24 hours after the injury), it include the fibrous capsule of the
may be preferable because of tissue muscle. This will allow proper healing
inflammation and infection to allow and promote subsequent fecal
secondary healing followed, if continence. Failure to close the sphincter
necessary, by a later repair. is not disastrous, but will usually result
in fecal incontinence to some degree and
a later corrective procedure.
Bladder Lacerations
Other Lacerations
Lacerations of the bladder can be
diagnosed with retrograde injection of Other soft tissue lacerations are usually
dye through a Foley catheter. Repair easily repaired with such absorbable
should be in multiple layers, using sutures as 2-0 Vicryl or 0-Chromic. A
absorbable sutures, without tension. A simple running or running locking stitch
very acceptable alternative is simple works well for most of these.
drainage with a Foley or suprapubic
catheter. Many cases of small lacerations When the laceration involves the
will close spontaneously over time with anterior vaginal wall, avoid deep
this type of urinary diversion and those placement of sutures since the bladder
that don't may be closed electively and urethra are usually within a few
weeks to months later. millimeters of the vaginal mucosa.
Placing a Foley catheter in the bladder
prior to suturing will help to outline the
Rectal Lacerations important anterior structures to be
avoided.
Lacerations of the rectum may be closed
primarily with multiple layers of If the laceration involves the posterior
absorbable suture. The need for fecal vaginal wall, remember that the rectum
diversion should be determined by the can be within a few millimeters of the
mechanism and magnitude of the injury. vaginal mucosa. Many gynecologic
If treatment has been delayed or there is surgeons find it advantageous to place
evidence of significant inflammation of the index finger of the non-dominant
the edges of the laceration, surgical hand in the rectum while suturing the
closure should be delayed weeks or posterior vaginal wall.

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Surgical Emergencies in Obstetrics & Gynecology

abscess cavity. Local anesthetic may be


Lacerations involving the lateral vaginal used but is often unnecessary if the skin
walls are best sutured with good is thin and attenuated.
assistance (retraction) and good lighting.
When these lacerations are high in the After drainage of pus from the cavity,
vagina, they are both more difficult loosely pack the cavity with narrow
(because of exposure and lighting gauze (iodoform tape works well for
problems) and more dangerous. The this), primarily to keep the incision open,
ureter courses next to the cervix in the allowing continued drainage over the
parametrial tissues but becomes next few days. The cut edges of the
accessible to accidental vaginal suturing drainage incision may need to be sutured
if the sutures are placed deep and high in for hemostasis but this is usually
the vagina. unnecessary.

Vulvar Hematoma Rest, TID sitz baths, and antibiotics to


cover gram negatives, anaerobes, and
Vulvar hematoma is common following gonococcus are all advisable in the
a "straddle injury." These hematomas are operational setting.
unilateral, painful and can be large (6-8
cm.). Place a Foley catheter in the These draining abscesses usually resolve
bladder and treat the hematoma with ice over the next few days but may return at
packs. Smaller hematomas will resolve a later time. Repeat I&D can be done
without surgery (the larger portion of the multiple times, although a
mass is inflammatory tissue and not marsupialization procedure may
blood clot), but may require several days ultimately be required. It is inadvisable
for the swelling to reduce. Larger to try to surgically remove an entire
hematomas or expanding hematomas abscess on an emergent basis. It is better
will require surgical evacuation of the to simply drain it.
hematoma and primary reclosure. In
about half of these cases, the specific D&C
bleeding point is never identified, but
simple evacuation of the clot and closure In the operational setting, D&C
with sutures solves the problem. (dilatation and curettage) is often
Hemovac drains may be placed if the required to resolve complications of
hematoma bed is still oozing. early pregnancy loss, such as an
incomplete abortion. Rarely would it be
Bartholin's Abscess necessary in a non-pregnant woman with
intractable uterine bleeding.
These painful, unilateral vulvar masses
may be treated conservatively with Under anesthesia, the bladder is
antibiotics if small, but will require catheterized and a pelvic exam
incision and drainage if large or performed so the surgeon can feel the
persistent. For drainage, pick a site on orientation of the uterus. Of particular
the medial aspect of the mass close to importance is noting whether the cervix
the introitus. If the mass is pointing, go leads directly into the uterus or whether
through that area straight into the there is any angulation anterior or

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Surgical Emergencies in Obstetrics & Gynecology

posterior. Equally important is Salpingectomy


determining the size of the uterus as this
will guide the surgeon in inserting the Ectopic pregnancy, ruptured or
instruments. unruptured, will usually require surgical
intervention. Salpingectomy (removal of
The cervix is grasped with a tenaculum the fallopian tube) is uniformly effective,
or a ring forceps on its anterior lip. (This safe, simple, fast, and well within the
works the best for most patients, but the capabilities of an abdominal surgeon. its
posterior lip works better in a women only important disadvantages are that it
whose uterus is tilted posteriorly.) results in the loss of the tube and may be
more surgery than is needed.
The cervix is then dilated by inserting
"dilators" of gradually increasing After opening the abdomen (lower
diameter until the cervix is open about 1- midline incision is fast and gives
2 cm. Fortunately, in the case of excellent exposure), identify the
incomplete abortion, the cervix will fallopian tube containing the ectopic.
already be dilated and no additional Grasp the tube with Babcock clamps and
dilation will be necessary. elevate the tube. This spreads out the
mesosalpinx (the blood supply of the
Polyp forceps or Ring forceps are then tube). Using hemostats, clamp across the
inserted through the cervix into the mesosalpinx, starting at the fimbriated
uterus to grasp and remove any large end and working toward the uterus.
pieces of pregnancy tissue. This is a time Clamp across the tube where it enters the
when gentleness is required because it is uterus. Then remove your specimen and
relatively easy to perforate the soft walls suture the clamped tissue with 0 or 2-0
of the uterus and cause damage to the Vicryl, Chromic or other such material.
surrounding structures (bladder, bowel, Evacuate from the abdomen any large
ureters). Then a curette is gently inserted clots (removal of all free blood from the
and used to scrape any remaining tissue abdomen is both unnecessary and
off the uterine walls. Excessive scraping laborious), and close the abdomen.
at this time can result in too much tissue Surgical drains are usually not
being removed and later infertility. necessary.

After an uncomplicated D&C, patients In the face of a large ectopic pregnancy


are advised to rest in bed with bathroom and significant bleeding, this approach
privileges for a day or two and then may of salpingectomy is probably the wisest
return to their normal activities. course. With smaller ectopics, you may
Prophylactic antibiotics may be given conserve some or all of the tube
(particularly in an incomplete abortion performing a "segmental resection" in
situation) as well as ergotamine 0.2 mg which only the middle portion of the
PO TID for 2 days to stimulate uterine tube is removed. This offers the
contractions and reduce blood loss. advantage of conserving some of the
tube for tubal reconstruction at a later
date if necessary.

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Surgical Emergencies in Obstetrics & Gynecology

Another technique which works well for the clamp and suture within the twisted
small ectopic pregnancies (2-3 cm. in pedicle itself and not going too deep
diameter) is the "linear salpingostomy." below the twisted portion.
A scalpel makes a linear incision along
the anti-mesenteric border of the tube, Don't try to untwist the ovary or tube
directly over the ectopic pregnancy. The since you may release clot or cellular
pregnancy is extruded through the toxins into the general circulation. In
incision and the tube observed for operational settings, when ovarian
further bleeding. Often, the bleeding will torsion is encountered, the ovary and all
simply stop. The tube may be reclosed effected tissue should be simply
with very fine absorbable suture or removed.
simply left open (the defect will close
spontaneously.) Drains are not necessary. Watch for
signs of metabolic acidosis during the
While a linear salpingostomy may be recovery as the necrotic tissue may have
preferable in some fully-equipped and released enough tissue toxins to cause
fully-staffed medical facilities, there are this problem.
important drawbacks to its use in
isolated settings, primarily the Ovarian Cystectomy
limitations of diagnostic techniques to
follow these patients over time. Emergency removal of an ovarian cyst is
Surgeons in these isolated settings might usually necessitated because of either
be better advised to perform the severe pain or hemorrhage. In either
definitive therapy (salpingectomy, case, the cyst can often be "shelled out"
partial or complete) which will assure from the ovary allowing ovarian
hemostasis and avoid the possible need conservation. With most cysts, there is a
for reoperation. very nice dissection plane between the
cyst and the ovary that will allow you to
Oophorectomy quickly and easily separate the cyst from
the ovary.
Ovarian torsion is the most common
reason for emergency removal of an After removal of the cyst, close the
ovary. After opening an acute surgical ovary in two layers...a deeper layer to
abdomen, you find the strangulation of assure hemostasis, and a second
one ovary (usually involves the fallopian superficial layer to approximate the
tube as well) due to a twisting of the edges of the ovarian capsule.
blood supply to these structures.
In the case of endometriosis (with
Place a clamp of any appropriate size or "chocolate cysts" and "powder burns" in
type across the twisted pedicle, and the pelvis), surgical dissection planes are
excise the effected ovary and tube. less clear and removal of just the cyst is
Suture the pedicle to secure the blood more difficult. Usually, the chocolate
supply and then close the abdomen. The cyst ruptures while you are trying to
only important structure close to where remove it. Just do the best you can and
you will be clamping and suturing is the remember:
ureter. This may be avoided by keeping

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Surgical Emergencies in Obstetrics & Gynecology

1. You will probably not cure the necessary, be removed electively at a


endometriosis surgically, no later time.
matter how much you remove.
The advantages of this supracervical
2. Take care of the problem you hysterectomy are:
came to fix (hemorrhage, torsion,
etc.) and leave the rest to medical 1. It can be performed more
therapy. easily, particularly by surgeons
with lesser amounts of
Hysterectomy gynecologic surgical training.

It would be a very unusual situation that 2. It is safer in the short run


would require an emergency because it greatly reduces the
hysterectomy. Most bleeding can be chance of inadvertent injury to
controlled with lesser procedures (D&C the bladder, bowel or ureters.
or hormonal management), and most
infections respond to antibiotics. 3. It is faster than a complete
hysterectomy.
Hysterectomy consists of clamping
across the supporting structures of the 4. Because the cervix remains in
uterus and its blood supply followed by place, there is less chance of
removal of the uterus. The most difficult long-term vaginal support
part (and the part which leads to the problems since the supporting
most complications) is removal of the structures (cardinal and
lowest portion of the uterus and cervix. uterosacral ligaments) remain
The reason for this difficulty is the close intact.
proximity of bladder, ureters and bowel.
In an emergency setting, it is very The disadvantages to the supracervical
acceptable to avoid those problems by hysterectomy are several, but relate more
performing a "supracervical to the elective or semi-elective
hysterectomy." hysterectomy setting than the emergency
hysterectomy performed in an
Clamps are placed across the fallopian operational setting. Because the cervix
tubes close to the body of the uterus. remains and may develop cervical
Then working stepwise, the parametrial malignancy at some time in the future,
tissues are clamped (again, very close to the patient has not derived maximum
the body of the uterus.) When the uterus benefit from her surgery. If malignancy
narrows, (above the level of the bladder is present in the uterus, an incomplete
and ureters), a scalpel cuts across the procedure has been performed. Further,
lower uterine segment, resulting in the if infection is present, some infected
removal of the upper portion of the tissue may be left behind.
uterus and the leaving in place of the
lower portion of the uterus (primarily the In the operational arena, none of these
cervix). The raw, cut edge of the cervix disadvantages seem persuasive, and the
and lower uterine segment is sutured for advantages in speed, safety and
hemostasis. This part of the uterus can, if

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Surgical Emergencies in Obstetrics & Gynecology

simplicity suggest supracervical These patients have moderate to heavy


hysterectomy is preferable when needed. bleeding, uterine cramping, uterine
tenderness and sometimes low-grade
Post-operatively, bedrest with bathroom fever.
privileges for a day or two followed by
steadily increasing ambulation gives If tissue is seen protruding through the
good results. Prophylactic antibiotics cervix, you may grasp is gently with
covering gram negative and anaerobic sponge forceps and ease it the rest of the
bacteria is an excellent idea in the way out of the cervix. The goal of
operational environment. treatment is to convert the "Incomplete
Abortion" to a "Complete Abortion".
Obstetric Illness with
Definitive treatment is D&C (dilatation
Surgical Significance and curettage). If D&C is not available,
bedrest and oxytocin, 20 units (1 amp) in
1 Liter of any crystalloid IV fluid at 125
Threatened Abortion cc/hour may help the uterus contract and
expel the remainder of the pregnancy
Any pregnancy complicated by any form tissue, converting the incomplete
of bleeding from the uterus during the abortion to a complete abortion.
first 20 weeks of pregnancy is
considered a "threatened abortion." Alternatively, ergonovine 0.2 mg P.O. or
The bleeding may be heavy or light, IM three times daily for a few days may
spotting or just brown discharge. It may be effective.
or may not be accompanied by uterine
cramping. If pregnancy tissue is passed, If fever is present, broad-spectrum
it is reclassified as either an incomplete antibiotics are wise, particularly if D&C
or complete abortion. Inevitable abortion is not imminent. Rh negative women
means the cervix has begun to dilate and should ideally receive Rhogam (Rh
bleeding is so heavy that spontaneous immune globulin) within 3 days of a
abortion must occur. completed miscarriage to prevent Rh
sensitization, but it may still be effective
About 1 in every 3 or 4 pregnancies even 7-10 days later.
demonstrates some evidence of bleeding.
The majority of these women will If hemorrhage is present, bedrest, IV
continue the pregnancy uneventfully and fluids, oxygen, and blood transfusion
the remainder will ultimately abort. may all be necessary.
Bedrest will usually slow the bleeding
temporarily, but will not change the final Complete Abortion
outcome of the pregnancy.
A complete abortion is the passage of all
Incomplete Abortion pregnancy tissue from inside the uterus.
Typically, these patients complain of
When some pregnancy tissue has been vaginal bleeding and cramping which
passed, but more remains inside the leads to passage of tissue. Then, the
uterus, this is an "incomplete abortion." bleeding and pain subside.

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Surgical Emergencies in Obstetrics & Gynecology

It is sometimes difficult to know whether safely wait up to six weeks for definitive
the abortion is "complete" or treatment (D&C).
"incomplete." To resolve this issue,
some gynecologists recommend D&C Septic Abortion
for all patients who miscarry, while
others recommend D&C only for those Infection may complicate any abortion.
who obviously have an incomplete Such infections are characterized by
abortion, and those who continue to fever, chills, uterine tenderness and
bleed and cramp. occasionally, peritonitis. The responsible
bacteria are usually a mixed group of
Bedrest for a day or two may be all that strep, coliforms and anaerobic
is necessary to treat a complete abortion. organisms.
Ergonovine 0.2 mg PO TID may be
given for two days to stimulate the Usual treatment consists of bedrest, IV
uterus to contract and reduce bleeding. antibiotics, utero-tonic agents (such as
Some physicians give a broad-spectrum ergotamine or pitocin), and complete
oral antibiotic for a few days to protect evacuation of the uterus. If the patient
against infection. If fever is present, IV does not respond to these simple
broad-spectrum antibiotics are wise, to measures and is deteriorating, surgical
cover the possibility that the removal of the uterus, fallopian tubes
complication of sepsis has developed. If and ovaries may be life-saving.
the fever is high and the uterus tender, If your patient responds well and quickly
septic abortion is probably present and to IV antibiotics and bedrest, you may
you should make preparations for D&C. safely continue your treatment.
Save in formalin any tissue which the Remember, though, that she has the
patient has passed for pathology potential for becoming extremely ill very
examination. quickly and transfer to a definitive care
facility should be considered.
Continuing hemorrhage suggests an
"incomplete abortion" rather than a Evacuation of the uterus can be initiated
"complete abortion" and your treatment with oxytocin, 20 units (1 amp) in 1
should be reconsidered Liter of any crystalloid IV fluid at 125
cc/hour or ergonovine 0.2 mg P.O. or IM
Inevitable Abortion three times daily. If the patient response
is not favorable, D&C is the next step.
An early pregnancy which is destined to IV antibiotics should be started
miscarry or abort is known as an immediately. Reasonable antibiotic
inevitable abortion. choices include (American College of
These pregnancies are complicated by OB-GYN Tech. Bull. #153, 1991):
bleeding and cramping and dilation
(opening) of the cervix at the internal os. Clindamycin 900 mg IV every 8
Such a pregnancy will not survive and hours, plus
can be considered in the same category
as an incomplete abortion. Unless Gentamicin 2.0 mg/kg IV,
hemorrhage is present, patients can followed by 1.5 mg/kg every 8
hours,

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Surgical Emergencies in Obstetrics & Gynecology

more dangerous types of procedures


or because of the relatively large amounts
of placental tissue left inside and the
Metronidazole 500 mg IV every extreme softness of the uterus which
6-8 hours, plus lends itself to perforation and injury.
In the presence of vaginal hemorrhage,
Gentamicin 2.0 mg/kg IV, D&C is indicated immediately, although
followed by 1.5 mg/kg every 8 you might attempt a manual removal of
hours, the placenta. If you can grab a portion of
the placenta (assuming a part of it is
or extruded through the cervix), you
sometimes can tease the rest of the
Cefoxitin 2.0 gm IV every 6 placenta out through the cervix without
hours resorting to D&C.

Second Trimester Abortion If D&C fails and hemorrhage continues,


hysterectomy may be life-saving.
Middle trimester abortions are
uncommon and usually uncomplicated.
They typically involve a labor-type Third Trimester Delivery
experience for the patient, with delivery
of a non-viable fetus. Complications

After delivery of the fetus, be prepared Cesarean Section


to wait as long as several hours for the
placenta (afterbirth) to separate and be In the face of intractable hemorrhage in
delivered. While waiting, clamp and cut an undelivered patient or totally
the umbilical cord and remove the fetus obstructed labor, emergency cesarean
so as not to distress further the mother. section will probably be life-saving. For
After delivery of the placenta, cramping those abdominal surgeons with lesser
and bleeding usually stop or reduce to a amounts of training in cesarean section,
minimal amount. Pitocin, 10 units IM or a midline lower abdominal incision and
20 units in 1 L of crystalloid at 125 cc/hr midline uterine incision are the wisest.
are helpful in reducing postpartum blood Continue in a midline fashion through
loss. the wall of the uterus until the uterine
cavity is entered. ("low cervical vertical
Pitocin at reduced dosage (same IV Incision) You may extend the uterine
mixture, but at 2-10 drops/minute) can midline incision as high as necessary to
be useful in stimulating the uterus to gain the needed exposure for delivery of
contract in the case of a retained the infant and the placenta. Avoid going
placenta, but has the potential of too low and risking entering the bladder.
overstimulating the uterus. Close the uterus in two or three layers.

If the placenta remains inside longer Manual Removal of the Placenta


than 6 hours, D&C is indicated to
remove it. This surgery is among the After delivery of the infant, the placenta
normally separates within a few minutes.

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Surgical Emergencies in Obstetrics & Gynecology

At this time, if hemorrhage occurs, you ultrasound is not available, then it is best
may need to manually remove the to arrange for MEDEVAC.
placenta. Insert your hand through the Alternative diagnoses which can cause
vagina into the uterus and grasp the similar symptoms include a corpus
placenta. Gently tease it out. luteum ovarian cyst commonly seen in
early pregnancy, or occasionally
Immediate Post Partum Hemorrhage appendicitis. PID is characterized by
bilateral rather than unilateral pain. With
This is generally caused by the uterus a threatened abortion, the pain is central
failing to contract. After manually or suprapubic and the uterus itself may
exploring the uterus to make sure no be tender.
placenta was left inside, manually While awaiting MEDEVAC, the
massage the uterus to encourage it to following are wise precautions:
contract. Give Oxytocin (10-20 units in 1. Keep the patient on strict bedrest. She
1 L crystalloid...run briskly) or is less likely to rupture while lying still.
ergotamine 0.2 mg IM. 2. Keep a large-bore (#16) IV in place. If
she should suddenly rupture and go into
Post Partum Hysterectomy shock, you can respond more quickly.
3. Know her blood type and have a plan
This is performed for uncontrollable for possible transfusion.
hemorrhage. Typically, this is a The vibration during a helicopter ride or
supracervical hysterectomy (subtotal the jostling over rough roads in an
hysterectomy) even in experienced ambulance or truck may provoke the
hands because of the difficulty in easily actual rupture. Try to minimize this risk
identifying the soft, attenuated cervix. and be prepared with IV fluids, oxygen,
By staying well away from the bladder, MAST equipment, etc.
these hysterectomies usually go quite If she develops peritoneal symptoms
well. (right shoulder pain, rigidity, or rebound
tenderness), she may be starting to
Unruptured Ectopic Pregnancy rupture and you should react
appropriately.
A woman with an unruptured ectopic
pregnancy may have the typical Ruptured Ectopic Pregnancy
unilateral pain, vaginal bleeding, and
adnexal mass described in textbooks. Women with a ruptured ectopic
Alternatively, she may have minimal pregnancy will nearly always have pain,
symptoms. The pregnancy test is sometimes unilateral and sometimes
positive. For all practical purposes, a diffuse. Right shoulder pain suggests
negative sensitive pregnancy test rules substantial blood loss. Within a few
out ectopic pregnancy. hours (usually), the abdomen becomes
Patients with a positive pregnancy test rigid, and the patient goes into shock.
and unilateral pelvic pain or tenderness Serum pregnancy tests are positive.
may have an unruptured ectopic Treatment is immediate surgery to stop
pregnancy and should have an the bleeding. If surgery is not an
ultrasound scan to confirm the available option, stabilization and
placement of the pregnancy. If

13
Surgical Emergencies in Obstetrics & Gynecology

medical evacuation should be promptly 5. As she loses blood into the


arranged. While awaiting MEDEVAC: abdomen, she will become
distended. If she becomes so
1. Give oxygen, IV fluids and distended she can't breath, put a
blood according to ATLS chest tube into the abdomen
guidelines. through a small, midline incision
just below the umbilicus to drain
2. Keep the patient at absolute off fluid or blood so she can
rest. breathe.
3. Monitor urine output hourly
with a Foley catheter and take 6. A MAST suit can be very
frequent vital signs to detect helpful in tamponading the
shock. internal bleeding.

4. Consider MAST trousers. 7. She may require as many as 15


or 20 units of blood.
If abdominal surgery is not an available
option, the outlook for a patient with a Ovarian Cyst
ruptured ectopic pregnancy is not totally
bleak. Aggressive fluid and blood These cysts are common and generally
replacement, oxygen and complete cause no trouble. Each time a woman
bedrest will result in about a 50/50 ovulates, she forms a small ovarian cyst
chance of survival. If this approach is (3.0 cm. in diameter or less). Depending
necessary: on where she is in her menstrual cycle,
you may find a small ovarian cyst. Large
1. Maintain the urine output cysts (>7.0 cm.) are less common and
between 30 and 60 ml. /hour. should be followed clinically or with
ultrasound.
2. If the pulse is >100 or urine Occasionally, ovarian cysts may cause a
output <30, she needs more fluid. problem by:

3. If she becomes short of breath Delaying menstruation


and the lung sounds become Rupturing
"crackly," slow down the fluids Twisting
as she probably is becoming fluid Causing pain
overloaded. (Central monitoring Bleeding
is helpful if available.)

4. If she becomes short of breath 95% of ovarian cysts disappear


and the lungs sound dry, increase spontaneously, usually after the next
the fluids and give blood as she menstrual flow. Those that remain and
is probably anemic and in need those causing problems are often
of more oxygen carrying removed surgically.
capacity.

14
Surgical Emergencies in Obstetrics & Gynecology

Ruptured Ovarian Cyst Patients with this problem complain of


severe unilateral pain with signs of
This cyst has ruptured and spilled its peritonitis (rebound tenderness, rigidity).
contents into the abdominal cavity. If the This problem is often indistinguishable
cyst is small, its rupture usually occurs clinically from a pelvic abscess or
unnoticed. If large, or if there is appendicitis, although an ultrasound
associated bleeding from the torn edges scan can be helpful.
of the cyst, then cyst rupture can be
accompanied by pain. The pain is Treatment is surgery to remove the
initially one-sided and then spreads to necrotic adnexa. If surgery is
the entire pelvis. If there is a large unavailable, then bedrest, IV fluids and
enough spill of fluid or blood, the patient pain medication may result in a
will complain of right shoulder pain. satisfactory, though prolonged, recovery.
Symptoms should resolve with rest In this suboptimal, non-surgical setting,
alone. Rarely, surgery is necessary to metabolic acidosis resulting from the
stop continuing bleeding. tissue necrosis may be the most serious
threat to the patient.
Unruptured Ovarian Cyst
Other surgical conditions which may
While most of these cysts are without resemble a twisted ovarian cyst (such as
symptoms, they can cause pain, bowel obstruction, appendicitis, ectopic
particularly with strenuous physical pregnancy) may not have a good
activity or intercourse. Treatment is outcome if surgery is delayed. For this
symptomatic with rest for those with reason, patients thought to have a
significant pain. The cyst is expected to torsioned ovarian cyst should be moved
rupture, usually within one month. Once to a definitive care setting where surgery
it ruptures, symptoms will gradually is available.
subside and no further treatment is
necessary. PID

If it doesn't rupture spontaneously, Pelvic Inflammatory Disease (PID) is a


surgery is sometimes performed to bacterial inflammation of the fallopian
remove it. This will relieve the tubes, ovaries, uterus and cervix.
symptoms and prevent torsion. This Initial infections are caused by single-
surgery is done electively. agent STDs, such as gonorrhea or
chlamydia. Subsequent infections are
Torsioned Ovarian Cyst often caused by multiple non-STD
organisms (E. Coli, Bacteroides, etc.).
A torsioned or twisted ovarian cyst
occurs when the cyst twists on its Mild PID
vascular stalk, disrupting its blood
supply. The cyst and ovary (and often a Gradual onset of mild bilateral pelvic
portion of the fallopian tube) die and pain with purulent vaginal discharge is
necrose. the typical complaint. Fever <100.4 and
deep dysparunia are common.

15
Surgical Emergencies in Obstetrics & Gynecology

Moderate pain on motion of the cervix Gram-negative diplococci in cervical


and uterus with purulent or discharge or positive chlamydia culture
mucopurulent cervical discharge is may or may not be present. WBC and
found on examination. Gram-negative ESR are elevated.
diplococci or positive chlamydia culture
may or may not be present. WBC may Treatment consists of bedrest, IV fluids,
be minimally elevated or normal. IV antibiotics, and NG suction if ileus is
present. Since surgery may be required,
Treatment consists of: transfer to a definitive surgical facility
should be considered.
Doxycycline 100 mg PO BID x
10-14 days, plus one of these: ANTIBIOTIC REGIMEN: (Center for
Disease Control, 1989)
Cefoxitin 2.0 gm IM with
probenecid 1.0 gm PO, Doxycycline 100 mg PO or IV
every 12 hours, plus either:
or Cefoxitin, 2.0 gm IV every 6
hours,
Ceftriaxone 250 mg IM
Or
or
Cefotetan, 2.0 gm IV every 12
Equivalent cephalosporin hours.

This is continued for at least 48 hours


after clinical improvement. The
Moderate to Severe PID doxycycline is continued orally for 10-
14 days.
With moderate to severe PID, there is a
gradual onset of moderate to severe ALTERNATIVE ANTIBIOTIC
bilateral pelvic pain with purulent REGIMEN: (Center for Disease Control,
vaginal discharge, fever >100.4 (38.0), 1989)
lassitude, and headache. Symptoms more
often occur shortly after the onset or Clindamycin 900 mg IV every 8
completion of menses. hours,

Excruciating pain on movement of the Plus


cervix and uterus is characteristic of this
condition. Hypoactive bowel sounds, Gentamicin, 2.0 mg/kg IV
purulent cervical discharge, and followed by 1.5 mg/kg IV every
abdominal distension are often present. 8 hours
Pelvic and abdominal tenderness is
always bilateral except in the presence of This is continued for at least 48 hours
an IUD. after clinical improvement. After IV
therapy is completed, doxycycline 100

16
Surgical Emergencies in Obstetrics & Gynecology

mg PO BID is given orally for 10-14 bleeding lesion, or bleeding from the
days. surface of the cervix due to cervicitis.
Much more commonly, abnormal
Tubo-Ovarian Abscess bleeding arises from inside the uterus.
There are really only three reasons for
These patients are very ill, with severe abnormal uterine bleeding:
PID. In addition, they have palpable
pelvic masses from dilated, abscessed Pregnancy-related problems
fallopian tubes. Mechanical Problems
Hormonal Problems
An initial course of IV antibiotic therapy
is warranted even if surgery ultimately is The limited number of possibilities
necessary. With the antibiotics, the makes caring for these patients very
patient will either improve and stabilize, simple. First, obtain a pregnancy test.
allowing definitive surgery at a later, Next, obtain a blood count and assess the
more elective time, or they will not rate of blood loss to determine how
stabilize and instead follow a downward much margin of safety you have.
clinical course. These failing patients Someone with a good blood count
require laparotomy. (hematocrit) and minimal rate of blood
loss (less than a heavy period), can
At surgery, removal of the abscessed tolerate this rate of loss for many days to
fallopian tubes is necessary, along with weeks before the bleeding itself becomes
all affected tissue. This typically a threat.
includes the ovaries and the uterus. This
surgery may be difficult because the Mechanical Causes of Abnormal
considerable inflammation will obscure Bleeding
anatomic landmarks and the edematous
tissues will be friable and difficult to Uterine fibroids or endometrial polyps
manipulate. In such a setting, are examples of mechanical problems
supracervical hysterectomy may be a inside the uterus which may cause
wise course even considering the leaving abnormal bleeding. Since mechanical
behind of a possibly infected cervix. problems have mechanical solutions,
After removal of the affected tissues, these patients will need surgery of some
locally irrigate with crystalloid and place sort (D&C, Hysterectomy,
multiple surgical drains.
Myomectomy) to resolve their problem.
Once the infected tissues are removed, In the meantime, have them lie still and
recovery is usually brisk, although return the bleeding will improve or temporarily
of GI function may be prolonged. go away. Giving hormones (BCPs) to try
to stop the bleeding will not help this
Abnormal Vaginal Bleeding condition, but neither will it be harmful.

Overview Hormonal Causes of Abnormal


Bleeding
Occasionally, abnormal bleeding will be
due to a laceration of the vagina, a

17
Surgical Emergencies in Obstetrics & Gynecology

Hormonal causes include anovulation With bedrest and hormonal treatment,


leading to an unstable uterine lining, bleeding should be substantially
breakthrough bleeding associated with improved within 24 hours. It should
birth control pills, and spotting at continue to improve with additional days
midcycle associated with ovulation. The of treatment. If hormonal control is not
solution to all of these problems is to succeeding, then a D&C will be
take control of the patient hormonally necessary. Pregnant women should not
and insist (through the use of BCPs) that receive BCPs, and pregnant women of
she have normal, regular periods. more than 20 weeks gestation should be
examined vaginally only in a setting in
If the bleeding is light and her blood which you are prepared to do an
count good, simply start BCPs (low- immediate cesarean section should you
dose, monophasic, such as LoOvral or discover an unsuspected placenta previa.
OrthoNovum 1+35 or Ovcon 35, etc.) at
the next convenient time. After a month Malignancy as a Cause of Abnormal
or two, her bleeding should be well Bleeding
under control.
Abnormal bleeding can be a symptom of
If the bleeding is heavy or her blood malignancy, from the vagina, cervix or
count low, then it is best to have her lie uterus.
still while you treat with birth control
pills. Some gynecologists have used 4 Cancer of the vagina is extraordinarily
OCPs per day initially to stop the rare and will demonstrate a palpable,
bleeding, and then taper down after bleeding lesion. Cancer of the cervix is
several days to three a day, then two a more common but a normal Pap smear
day, and then one a day. If you abruptly and normal exam will effectively rule
drop the dosage, you may provoke a that out. Should you find a bleeding
menstrual flow, the very thing you didn't lesion in either the vagina or on the
want. Giving iron supplements is a good cervix, these should be biopsied.
idea (FeSO4 325 mg TID PO or its Cancer of the uterus (endometrial
equivalent) for anyone who is bleeding carcinoma) occurs most often in the
heavily. older population (post-menopausal) and
is virtually unknown in patients under
What to do First age 35. For those women with abnormal
bleeding over age 40, an endometrial
Since most (90%) of the non-pregnancy biopsy is a wise precaution during the
bleeding is caused by hormonal factors, evaluation and treatment of abnormal
your best bet is to: bleeding.

1. Obtain a pregnancy test. Consultation


2. Obtain a blood count.
3. Examine the patient. Before embarking on a course of
4. Put the patient to bed if the surgical treatment of gynecologic
bleeding is heavy. disease, it is wise to consult, whenever
5. Begin BCPs and iron. possible and by whatever means are
possible, with a fully-qualified

18
Surgical Emergencies in Obstetrics & Gynecology

gynecologic surgeon. Even if such (may be OB-GYN or Family


consultation is by phone or Practice MO or Resident)
radiotelephone, it will be helpful to you. Ask DSN operator to ring hospital's
(**)
Such a consultation will help confirm commercial number.
your clinical opinions, give you Beaufort, South
Naval Hospital
confidence, and serve to guide you in Carolina
your clinical approach to the patient. Hospital -24 (C) 803-525- (DSN) 832-
hour number 5600 5600
Your Command is able to contact the (C) 803-525- (DSN) 832-
Labor Deck
5571 5571
appropriate Force Medical Officers
National Naval
should you desire to consult with them. Bethesda,
Medical
In addition, the phone numbers for those Maryland
Center
Navy Hospitals having OB-GYN Hospital -24 (C) 301-295- (DSN) 295-
physicians available are provided here. hour number 4611 4611
(C) 301-295- (DSN) 295-
For each hospital, the main (24-hour) Labor Deck*
4170 4170
DSN and commercial phone numbers Bremerton,
Naval Hospital
are listed. Some overseas (OUTCONUS) Washington
hospital numbers require a Navy Switch Hospital -24 (C) 360-475- (DSN) 494-
prefix and these are indicated. hour number 4232 4232
With or without such a consultation, re- Labor Deck*
(C) 360-475- (DSN) 439-
reading the appropriate portion of the 4227 4227
standard textbooks should give you Camp Lejeune,
Naval Hospital
detailed understanding of the clinical North Carolina
task you are soon to undertake. Last, Hospital -24 (C) 910-451- (DSN) 484-
there may be other physicians or support hour number 4300 4300
personnel in your command with (C) 910-451- (DSN) 484-
Labor Deck
4280 4280
experience in gynecologic issues from
whose experience you can benefit. Camp
Pendleton, Naval Hospital
California
Important Phone Numbers
Hospital -24 (C) 760-725- (DSN) 365-
hour number 1288 1288
These phone numbers may prove helpful (C) 760-725- (DSN) 365-
to you in dealing with various women's Labor Deck
1509 1509
health issues. Consultation with an OB- Cherry Point Naval Hospital
GYN physician can be obtained at any Hospital -24 (C) 919-466- (DSN) 582-
time, day or night. hour number 0266 0266
US Naval Hospitals with OB-GYN (C) 919-466- (DSN) 582-
Physicians Available for Consultation Labor Deck
0460/0459 0460/0459
Symbol Meaning Jacksonville,
Naval Hospital
(C) Commercial telephone number Florida
(DSN) DSN telephone number Hospital -24 (C) 904-777- (DSN) 942-
Navy Switch Required. First dial (C) hour number 7301 7301
703-695-0441, then give the (C) 904-777- (DSN) 942-
(NS) Labor Deck*
operator the DSN number you wish 7704 7704
to reach. Pensacola,
(*) Physician on-board 24-hours a day Naval Hospital
Florida

19
Surgical Emergencies in Obstetrics & Gynecology

Hospital -24 (C) 904-505- (DSN) 534- 081-811-6404 629-6404


hour number 6601 6601 Okinawa,
(C) 904-505- (DSN) 534- Naval Hospital
Labor Deck* Japan
6298 6782 (DSN)
Hospital -24 (C) 011-81-
Portsmouth, Naval Medical (NS)643-
hour number 611-743-7555
Virginia Center 7555
Hospital -24 (C) 757-953- (DSN) 564- (C) 011-81- (DSN) (NS)
Labor Deck*
hour number 5009 5009** 611-743-7597 643-7597
(C) 757-953- (DSN) 564- Roosevelt
Labor Deck*
5284 5284** Roads, Puerto Naval Hospital
San Diego, Naval Medical Rico
California Center Hospital -24 (DSN) (NS)
(C) 787-865-
Hospital -24 (C) 619-532- (DSN) 522- hour number 831-
5767/5997
hour number 6400 6400 (ER) 5767/5997
(C) 619-532- (DSN) 522- (C) 787-865- (DSN) (NS)
Labor Deck* ISPU
8865 8865 5911/5912 831-5948
Twentynine Rota, Spain Naval Hospital
Palms, Naval Hospital Hospital -24 (C) 011-3456- (DSN) (NS)
California hour number 82-3305 727-3305
Hospital - (C) 011-3456- (DSN) (NS)
(C) 760-830- (DSN) 957- Labor Deck
24 hour 82-3655 727-3655
2190 2190
number Naval
Labor (C) 760-830- (DSN) 957- Sigonella, Sicily
Hospital
Deck* 2533/2534/2535 2533/2534/2535 Hospital - 24 (C) 011-39- (DSN) (NS)
OUTCONUS hour number 95-56-4842 624-4842
Guam, Mariana (C) 011-39- (DSN) (NS)
Naval Hospital Labor Deck
Islands 95-56-4765 624-4765
Hospital -24 (C) 011-671- (DSN) (NS) Yokosuka,
hour number 344-9340 344-9340 Naval Hospital
Japan
(C) 011-850- (DSN) (NS) Hospital -24 (C) 011-81- (DSN) (NS)
Labor Deck 505- 534- hour number 311-734-7144 243-7144
6782/6789 6782/6789
(DSN) (NS)
Guantanamo (C) 011-81-
Naval Hospital Labor Deck 234-
Bay, Cuba 311-734-5311
5311/7315
Hospital -24
(C) 011-539- (DSN) 464-
hour number
97-2690 2690
(ER)
(C) 011-539- (DSN) 464-
Labor Deck
97-2063 2063
Keflavic,
Naval Hospital
Iceland
Hospital -24 (C) 011-354- (DSN) (NS)
hour number 25-3300/3310 450-3201
24-hour OB
watch
Naples, Italy Naval Hospital
Hospital -24 (C) 011-39- (DSN) (NS)
hour number 81-724-4872 625-4872
Labor Deck (C) 011-39- (DSN) (NS)

20