Shock, Sepsis & Multisystem · Topic 15 of 16

Gynecologic Emergencies & the Pelvic Exam

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Special populations · gynecologic emergencies

Gynecologic Emergencies & the Pelvic Exam

Pelvic pain or bleeding in a patient of reproductive age: test for pregnancy. Unstable ectopic pregnancy and suspected torsion both go straight to surgery.

01 · Unstable ectopicImmediate laparotomy plus shock treatment

02 · Stable, unruptured ectopicMethotrexate 50 mg/m² IM once

03 · Suspected torsionImmediate laparoscopy, even with normal Doppler

Why it happens

Rupture at about 6–16 weeks can cause hemorrhagic shock

Ectopic pregnancy implants outside the uterine lining, most often in the tube

It cannot be carried to term. The structure containing it usually ruptures after about 6–16 weeks; bleeding can be gradual or fast enough for hemorrhagic shock, and later rupture bleeds faster.

Ectopic risk factors

Suspect ectopic whatever the menstrual, contraceptive or sexual history

Tubes and pelvis

Prior ectopic pregnancyPelvic or tubal surgery, including sterilizationTubal damagePID or STI, especially chlamydia

Fertility

Assisted reproductionInfertility

Other

SmokingPregnancy with an IUD in place

What you'll see

Pelvic pain, bleeding, syncope or shock: suspect ectopic first

Pelvic pain or vaginal bleeding in a reproductive-age patient pregnancy test

Unexplained syncope or hemorrhagic shock pregnancy test

Ectopic: classically sudden, localized, constant pain

Ectopic pain varies: dull, sharp or crampy

Ectopic: often vaginal bleeding and a closed os

Ectopic: adnexal mass is inconsistent, exam neither sensitive nor specific

Ectopic rupture typically at about 6–16 weeks surgical emergency

Torsion: sudden, severe pelvic pain, usually with nausea and vomiting

Torsion: often after days of intermittent colicky pain

Torsion: tender unilateral adnexal mass is typical

Torsion usually involves an ovary enlarged over 4 cm

Tubo-ovarian abscess: fever, pain, peritoneal signs, adnexal mass

The pelvic exam

For symptoms or before a procedure, not as required screening

Get consent for each component; the patient may decline any part

Have a chaperone present

Have the patient void first

Bimanual: 2 fingers in the vagina, a hand on the lower abdomen

Bimanual assesses the cervix, uterus and ovaries

Cervical motion, uterine and adnexal tenderness suggest PID

Torsion can also cause cervical motion tenderness

Individualize speculum size to anatomy, age, parity, menopausal status and comfort, and stop if the patient asks. A rectovaginal exam after bimanual palpation can detect an ovarian mass.

Diagnosis & labs

Urine pregnancy test first, then quantitative hCG and pelvic ultrasound

Urine pregnancy test is about 99% sensitive

Positive test: order quantitative hCG and pelvic ultrasound

hCG above ~3,500 mIU/mL: an intrauterine gestational sac should be visible

No sac above that level + adnexal mass or cul-de-sac fluid suggests ectopic

Unconfirmed ectopic, stable patient: repeat serum hCG every 2 days

Viable pregnancy: hCG rises at least 35% in 48 hours

Slower hCG rise or a fall suggests ectopic pregnancy or miscarriage

Torsion ultrasound: enlarged ovary or mass, reduced or absent Doppler flow

Normal Doppler flow does not rule out torsion: it is a surgical diagnosis

Exclude ectopic, appendicitis and PID, but never delay torsion surgery

Older discriminatory zones of 1,000–2,000 mIU/mL still circulate; 3,500 was set to avoid overdiagnosing ectopic and harming desired intrauterine pregnancies. Use the local laboratory level where one is set. No single hCG level excludes an intrauterine pregnancy. Torsion: ACOG Committee Opinion 783 addresses adolescents, and Merck cites it for adnexal torsion generally. In women of all ages, one surgical series of 55 proven torsions found normal Doppler flow in 61% of right-sided and 27% of left-sided cases.

Red flags

Unstable with suspected ruptured ectopic pregnancy laparotomy

Suspected adnexal torsion laparoscopy

Suspected tubo-ovarian abscess rupture, risks septic shock laparoscopy or laparotomy

hCG falls under 15% from day 4 to 7 after methotrexate second dose or operate

Uterine bleeding needing urgent control check for DIC

Methotrexate with rupture, instability or intrauterine pregnancy no methotrexate

Treatment

Stability and rupture decide surgery or methotrexate

Suspected ectopic, in order

Urine pregnancy testpelvic pain, bleeding, syncope or shock

→

Unstable: immediate laparotomyplus hemorrhagic shock treatment

→

Stable: quantitative hCG + ultrasounddiscriminatory zone 3,500 mIU/mL

→

Stable, unruptured tubal: methotrexate50 mg/m² IM once; hCG days 1, 4, 7

Methotrexatestable, unruptured tubal pregnancy

Methotrexate 50 mg/m² IM once

Check hCG on days 1, 4 and 7

Fall under 15% from day 4 to 7: second dose or operate

Rh-negativeevery ectopic pregnancy

Rho(D) immune globulin

Give whether managed with methotrexate or surgery

Torsionsurgical diagnosis

Immediate laparoscopy to detorse and salvage the ovary and tube

Remove only nonviable tissue

Abscesstubo-ovarian, hospitalize

Ceftriaxone 1 g IV q24h Doxycycline 100 mg q12h Metronidazole 500 mg q12h

Observe over 24 hours inpatient

Over 7 cm or incomplete response: consider ultrasound- or CT-guided drainage, percutaneous or transvaginal

Heavy bleedingstabilize, then hormones

Conjugated estrogens 25 mg IV

IV crystalloid and blood products, and exclude pregnancy first

Estrogen every 4–6 hours for 4 doses

Alternativesfor acute uterine bleeding

Tranexamic acid 1.3 g PO Tranexamic acid 10 mg/kg IV (max 600 mg) High-dose combined contraceptives Medroxyprogesterone 20 mg TID

Tranexamic acid, either route, three times daily for 5 days

Urgent controluterine bleeding

Intrauterine balloon tamponade, D&C or uterine artery embolization

Bladder catheter balloon, 30–60 mL. Hysterectomy is the last resort in an unstable patient

Relative contraindications, thrombosis risk, rarer cases

Relative methotrexate contraindications: embryonic cardiac activity on TVUSalso a high initial hCG, an ectopic mass over 4 cm, or refusal of blood products

Surgery, usually laparoscopic salpingectomy, is the methotrexate alternative

High-dose estrogen, progestin and tranexamic acid all raise thrombosis riskselect patients and monitor them

After the acute regimen: daily estrogen-progestin contraceptivetypically continued for a few months

Heterotopic pregnancy: 1 in 10,000–30,000, more often after assisted reproductionotherwise a visible intrauterine pregnancy makes ectopic very unlikely

Cornual and interstitial pregnancies can mimic intrauterine ones

Tubo-ovarian abscess develops in about 15% of patients with salpingitis

After improvement, oral doxycycline and metronidazole complete 14 daysoutpatient PID regimens are on the STI and PID sheet

Methotrexate: absolute contraindications

Any one of these means no methotrexate for ectopic pregnancy

Intrauterine pregnancy, rupture or instability

Methotrexate sensitivity or immunodeficiency

Moderate–severe anemia, leukopenia or thrombocytopenia

Active pulmonary or peptic ulcer disease

Important hepatic or renal dysfunction

Breastfeeding, or no reliable follow-up

Ectopic pregnancy or adnexal torsion?

Both can cause sudden pelvic pain: test for pregnancy first

	Ectopic pregnancy	Adnexal torsion
Pain	Often sudden, localized and constant, often with vaginal bleeding	Sudden and severe with nausea and vomiting, often after intermittent colicky pain
First test	Pregnancy test, then quantitative hCG and pelvic ultrasound	Transvaginal ultrasound with color Doppler
Ultrasound	No intrauterine pregnancy; adnexal mass or cul-de-sac fluid	Enlarged ovary or mass; reduced or absent flow supports it
Treatment	Methotrexate if stable and unruptured; surgery if not	Immediate laparoscopy to detorse and salvage the ovary

Pearl

Pregnancy test first, whatever the history; and normal Doppler flow never clears adnexal torsion.

Sources · Merck Manual Professional: Ectopic Pregnancy · Merck Manual Professional: Adnexal Torsion · Merck Manual Professional: Abnormal Uterine Bleeding · Merck Manual Professional: Vaginal Bleeding · Merck Manual Professional: Pelvic Inflammatory Disease · CDC STI Treatment Guidelines 2021: Pelvic Inflammatory Disease · Merck Manual Professional: Pelvic Examination · Merck Manual Professional: Vaginal Bleeding During Early Pregnancy · ACOG Committee Opinion 783: Adnexal Torsion in Adolescents (2019, reaffirmed 2021) · Grunau et al: Diagnosis of Ovarian Torsion: Is It Time to Forget About Doppler? (JOGC 2018) · Follow your institution's protocols.