1) The document summarizes various gynecological surgical emergencies including acute vaginal bleeding, pelvic pain, infections, and post-operative complications. 2) It describes ovarian torsion in detail including causes, pathophysiology, signs and symptoms, diagnosis, and management focusing on the importance of detorsion to preserve ovarian tissue. 3) It also outlines the diagnosis and treatment of potentially life-threatening complications like necrotizing fasciitis, emphasizing the need for immediate surgical debridement and broad-spectrum antibiotics to manage this infection.

1. GYNECOLOGICAL SURGICAL
EMERGENCIES

2. Outline
• Active vaginal bleeding
• Pelvic pain
• Infections
• Post-op complications

3. ACUTE VAGINAL BLEEDING IN
THE NON PREGNANT PATIENT

4. Causes of Bleeding by Approximate
Frequency and Age Group
Adolescent Reproductive Perimenopausal Postmenopausal
Anovulation Pregnancy Anovulation
Endometrial lesions,
including cancer (30%)
Pregnancy Anovulation Uterine leiomyomas
Exogenous hormone use
(30%)
Exogenous hormone use Exogenous hormone use
Cervical and endometrial
polyps
Atrophic vaginitis (30%)
Coagulopathy Uterine leiomyomas Thyroid dysfunction
Other tumor—vulvar,
vaginal, cervical (10%)
Cervical and endometrial
polyps
Thyroid dysfunction

5. Management
• Patients who are hemodynamically unstable because of bleeding
must be resuscitated according to standard protocols
• Attempts should be made to localize the source of bleeding. In
women with severe, persistent uterine bleeding, immediate D&C is
usually indicated.
• Uterine packing should be avoided, because it increases the risk of
infection and may hide ongoing blood loss.
• Conjugated estrogens may be used in the ED treatment of life-
threatening hemorrhage that is not caused by pregnancy or tumor
and is not amenable to surgical intervention.

6. Pelvic pain
Ovarian torsion-background
• Torsion involves the twisting of adnexal components
• Most commonly, the ovary and fallopian tube rotate as a single entity
around the broad ligament
• In 50 to 80 percent of cases unilateral ovarian masses are identified
• Adnexal torsion accounts for 3 percent of gynecologic emergencies.
• A disproportionate number of cases of adnexal torsion develop during
pregnancy, and these compose 20 to 25 percent of all torsion cases.

7. Pelvic Pain
Ovarian torsion--pathophysiology
• Adnexal masses with increased mobility have greater torsion rates.
• Pathologically enlarged ovaries with a diameter >6 cm will typically
rise from the true pelvis. Without these bony confines, mobility and
risk of torsion are increased
• highest rates of torsion are found in adnexal masses from 6 to 10 cm
• Torsion of the adnexa more commonly involves the right adnexa,
likely due to limited mobility of the left ovary caused by the sigmoid
colon

8. Pelvic Pain
Ovarian torsion-pathophysiology
• Adnexa are supplied from the respective adnexal branches of both
the uterine and ovarian vessels
• During torsion, one of these, but not the other, may be involved.
• Although low-pressure veins draining the adnexa are compressed by
the twisting pedicle, high-pressure arteries initially resist
compression.
• As a result of this continued inflow but arrested egress of blood, the
adnexa become congested and edematous, but do not infarct
• With continued stromal swelling, however, arteries may become
compressed, leading to adnexal infarction and necrosis and
necessitating adnexectomy.

9. Date of download: 1/16/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Intraoperative photographs of adnexal torsion. A. Twisting of the infundibulopelvic ligament leads to strangulation of ovarian vessels
within it. B. A cyanotic ovary and fallopian tube result and are shown here. Hemorrhage into the tubal walls created this massively
dilated fallopian tube. Dusky fimbria are seen at the end of the tube. (Photographs contributed by Dr. Jason Harn.)
Legend:
From: Chapter 9. Pelvic Mass
Williams Gynecology, 2e, 2012

10. Pelvic Pain
Ovarian torsion—signs and symptoms
• sharp lower abdominal pain with sudden onset that worsens
intermittently over several hours.
• The pain usually is localized to the involved side, with radiation to the
flank, groin, or thigh.
• Low-grade fever suggests adnexal necrosis.
• Nausea and vomiting frequently accompany the pain.

11. Pelvic Pain
Ovarian Torsion--diagnosis
• Sonography plays an essential role in evaluation.
• Sonographic findings can vary widely depending on
• the degree of vascular compromise,
• the characteristics of any associated intraovarian or intratubal mass, and
• the presence or absence of adnexal hemorrhage.
• Sonographically, torsion may mimic
• ectopic pregnancy,
• tuboovarian abscess,
• hemorrhagic ovarian cyst, and endometrioma.
• Accordingly, rates of correct sonographic diagnosis range from 50 to
75 percent

12. Date of download: 1/16/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Whirlpool sign of ovarian torsion seen with transvaginal sonography. A. Conventional transabdominal sonography. White arrows
point to torsion of ovarian vessels. BL = bladder. B. Transvaginal color Doppler shows twisting of the vessels. (Vijayaraghavan,
2004, with permission.)
Legend:
From: Chapter 9. Pelvic Mass
Williams Gynecology, 2e, 2012

13. Pelvic Pain
Ovarian Torsion--management
• De-torsion is key
• Within minutes following detorsion, congestion is relieved, and
ovarian volume and cyanosis typically diminish.
• A persistently black-bluish ovary, is NOT pathognomonic for necrosis,
and the ovary may still recover.

14. Cohen SB, Oelsner G, Seidman DS, et al: Laparoscopic detorsion allows sparing of the twisted
ischemic adnexa. J Am Assoc Gynecol Laparosc 6(2):139, 1999
• Reviewed 54 cases in which adnexa were preserved regardless of
their appearance following detorsion
• Reported functional integrity and successful subsequent pregnancy in
almost 95 percent.

15. • 50 patients with 53 cases of ovarian torsion treated between January 1989
and March 2012
• 22 cases ovaries were removed, and in 31 cases the torsion was relieved
and the ovaries left in the abdominal cavity
• In 20 girls with ovaries left behind…long term clinical and ultrasound data
obtained
• 17 of the 20 had multifollicular ovaries
• 2 of the other 3 had sonographically detected ovarian function(at least a few follicles
seen)
• Only one had no ovarian material detectable by ultrasound
• None of the girls had thromboembolism or peritonitis, and no malignant
tumors were found in the operated ovaries.
Geimanaite L, Trainavicius K. Ovarian torsion in children: management and outcomes.
J Pediatr Surg. 2013 Sep;48(9):1946-53.

16. Bar-On S, Mashiach R, Stockheim D, Soriano D, Goldenberg M, Schiff E,
Seidman DS.
Emergency laparoscopy for suspected ovarian torsion:
are we too hasty to operate? Fertil Steril. 2010 Apr;93(6):2012-5

17. Post-op complications
Fascial dehiscence
• Disruption of the deep fascial planes.
• Dehiscence is caused by inadequate closure or intrinsic host factors,
such as malnutrition, glucocorticoid use, or diabetes.
• Dehiscence of abdominal incisions has the potential for evisceration
• Early recognition is key
• IF NO EVISCERATION
• Can manage conservatively with abdominal binders
• If there is any uncertainty about the extent of dehiscence, operative
exploration is indicated.
• Consider broad spectrum antibiotics

18. Post-op complications
Fascial dehiscence
• Management of evisceration
• An abdominal binder with sterile towels soaked in saline to replace abdominal
contents and temporize the situation.
• Broad spectrum antibiotics
• Final goal of treatment is closure
• For critically ill patients with significant edema—maintain abdominal wall integrity until pt
stable enough to take to OR
• Before correcting dehiscence, debride necrotic and infected tissue.

19. Fascial dehiscence
Management cont’d
• Interrupted mass closure using permanent suture typically recommended
• If primary closure is under tension, may need to use mesh bridge
• If the subcutaneous wound is left open, wet-to-dry dressing changes may be
performed until the decision has been made to proceed with a delayed primary
closure or allow secondary intention to compete the process

20. Post-op complications
Fascial dehiscence
• Tilou et al, 2003, Am Surg
• Looked at 55 trauma patients with FD
• 71% of FD patients had intraabdominal infection (compared to 4.6%
of all trauma laparotomies)
• No clinical or laboratory factors help to predict which FD patients
have intra-abdominal infection
• Recommendation from the study:
• FD should be viewed as sign of possible underlying infection
• Before you manage the dehisced fascia—image or directly visualize the entire
abdominal cavity

21. POST-OP COMPLICATIONS
NECROTIZING FACIITIS

22. Post-operative complications
Necrotizing fasciitis
• Arguably the most feared complication
• Etiology: direct contamination of the wound with group A streptococci
or S. aureus.
• Risk factors include diabetes mellitus, alcoholism,
immunosuppression, and peripheral vascular disease,

23. Necrotizing fasciitis—Three types based on
etiology
• Type 1: a mixed infection from aerobic and anaerobic bacteria,
including group A [beta]-hemolytic streptococci, Staphylococcus
aureus, Escherichia coli, Clostridium and Bacteroides species
• Type 2: is caused by group A [beta]-hemolytic streptococci, possibly
with a coinfection by S aureus, and primarily affects the extremities
• Type 3: NF is associated with Vibrio vulnificus, which enters the
subcutaneous tissues via puncture wounds from fish or marine insects
• When NF is present in genitalia/perineum it’s called : Fournier’s
gangrene

24. Necrotizing fasciitis--Diagnosis
• The diagnosis is clinical—the condition has a rapidly progressive course
• Hallmarks of fasciitis are
• The presence of marked systemic toxicity
• Pain out of proportion to local findings.
• Early in the course of infection, findings of cellulitis (erythema, edema, and pain) may
predominate, making the early diagnosis difficult or impossible
• X-ray is poor screening tool
• CT is more sensitive (80%) and can demonstrate fascial thickening and edema, deep
tissue collections, and gas formation
• IV contrast provides no additional benefits
• MRI most sensitive but would impose delays to treatment
• WBC>14,000 and serum sodium less than 135 a good predictor of necrotizing infection
• Rapid strep screen can identify Group A beta hemolytic strep

25. Date of download: 1/19/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Necrotizing soft tissue infection. Large cutaneous bullae are seen on the leg of this patient with necrotizing fasciitis. Note the dark
purple fluid in the bullae. (Photo contributed by Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L,
Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.)
Legend:
From: Soft Tissue Infections
Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 2011

26. Post-operative complications
Necrotizing fasciitis
• Treatment:
1. Avoid vasoconstrictors
2. Should include antibiotics –
• The tissue ischemia produced in necrotizing soft tissue infections impedes immune system
destruction of bacteria and prevents adequate delivery of antibiotics.
• Antibiotics alone RARELY effective
3. immediate surgical debridement—cornerstone of management.
4. Tetanus prophylaxis as indicated
5. Mortality skyrockets if treatment delayed>24hrs
• The mortality rate remains 25% to 35%
• Bacteremia is a strong predictor of mortality

27. Necrotizing fasciitis—antibiotic considerations
• Common regimen:
• combination of
• penicillin for gram-positive cocci, an
• aminoglycoside for gram-negative aerobes,
• a third-generation cephalosporin,
• and clindamycin or metronidazole for anaerobes.
• Clindamycin suppresses the production of both streptococcal toxin and M protein
• Vancomycin is added when methicillin-resistant S aureus is suspected
or penicillin allergy present.
• In immunocompromised patients, cover for pseudomonas