Urgent care in gynaecology: Resuscitation and management of sepsis and acute blood loss

A Framework Proposal for Quality and Safety Measurement in Gynecologic Emergency Care

Potentially life-threatening gynecologic emergencies are high-risk conditions that may serve as a useful framework to improve quality and safety in emergency care.

OBJECTIVE:

To define and assess the prevalence of potentially life-threatening gynecologic emergencies among women presenting for acute pelvic pain for the purpose of developing measures to audit quality of care in emergency departments.

METHODS:

We conducted a mixed-methods multicenter study at gynecologic emergency departments in France and Belgium. A modified Delphi procedure was first conducted in 2014 among health care professionals to define relevant combinations of potentially life-threatening conditions and near misses in the field of gynecologic emergency care. A prospective case–cohort study in the spring of 2015 then assessed the prevalence of these potentially life-threatening emergencies and near misses among women of reproductive age presenting for acute pelvic pain. Women in the case group were identified at 21 participating centers. The control group consisted of a sample of women hospitalized for acute pelvic pain not caused by a potentially life-threatening condition and a 10% random sample of outpatients.

RESULTS:

Eight gynecologic emergencies and 17 criteria for near misses were identified using the Delphi procedure. Among the 3,825 women who presented for acute pelvic pain, 130 (3%) were considered to have a potentially life-threatening condition. The most common diagnoses were ectopic pregnancies with severe bleeding (n=54; 42%), complex pelvic inflammatory disease (n=30; 23%), adnexal torsion (n=20; 15%), hemorrhagic miscarriage (n=15; 12%), and severe appendicitis (n=6; 5%). The control group comprised 225 hospitalized women and 381 outpatients. Diagnostic errors occurred more frequently among women with potentially life-threatening emergencies than among either hospitalized (odds ratio [OR] 1.7, 95% CI 1.1–2.7) or outpatient (OR 14.7, 95% CI 8.1–26.8) women in the control group. Of the women with potentially life-threatening conditions, 26 met near-miss criteria compared with six with not potentially life-threatening conditions (OR 25.6, 95% CI 10.9–70.7).

CONCLUSIONS:

Potentially life-threatening gynecologic emergencies are high-risk conditions that may serve as a useful framework to improve quality and safety in emergency care.

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy

BACKGROUND/AIMS

Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity.

METHODS

A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status.

RESULTS

There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP.

CONCLUSION

Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

Non-invasive tools for the diagnosis of potentially life-threatening gynaecological emergencies: a systematic review

OBJECTIVE

To identify non-invasive tools for diagnosis of the major potentially life-threatening gynaecological emergencies (G-PLEs) reported in previous studies, and to assess their diagnostic accuracy.

METHODS

MEDLINE; EMBASE; Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched to identify all eligible studies published in English or French between January 1990 and December 2012. Studies were considered eligible if they were primary diagnostic studies of any designs, with a gold standard and with sufficient information for construction of a 2 × 2 contingency table, concerning at least one of the following G-PLEs: complicated ectopic pregnancy, complicated pelvic inflammatory disease, adnexal torsion and haemoperitoneum of any gynaecological origin. Extraction of data and assessment of study quality were conducted by two independent reviewers. We set the thresholds for the diagnostic value of signs retrieved at Sensibility ≥ 95% and LR-≤ 0.25, or Specificity ≥ 90% and LR+ ≥ 4.

RESULTS

We identified 8288 reports of diagnostic studies for the selected G-PLEs, 45 of which met the inclusion criteria. The methodological quality of the included studies was generally low. The most common diagnostic tools evaluated were transvaginal ultrasound (20/45), followed by medical history (18/45), clinical examination (15/45) and laboratory tests (14/45). Standardised questioning about symptoms, systolic blood pressure<110 mmHg, shock index>0.85, identification of a mass by abdominal palpation or vaginal examination, haemoglobin concentration <10 g/dl and six ultrasound and Doppler signs presented high performances for the diagnosis of G-PLEs. Transvaginal ultrasound was the diagnostic tool with the best individual performance for the diagnosis of all G-PLEs.

CONCLUSION

This systematic review suggests that blood pressure measurement, haemoglobin tests and transvaginal ultrasound are cornerstone examinations for the diagnosis of G-PLEs that should be available in all gynaecological emergency care services. Standardised questioning about symptoms could be used for triage of patients.

Obstetrical and Gynecological-Related Infections

The vast majority of pregnancies occur amongst a generally healthy patient population, i.e. females from the teenage years in to the 40s. In most cases, the pregnancy is uneventful and where infections do arise, these are often relatively minor and easily treatable, e.g. urinary tract infection and vaginal thrush. However, sepsis is now the leading cause of maternal deaths in the UK accounting for 26 deaths between 2006 and 2008 and there has been an increase in death due to community-acquired Group A streptococcal (GAS) (also known as Streptococcus pyogenes) disease [1]. A literature review of 55 pregnancies with symptomatic Groups A streptococcal infection since 1966 recorded early onset septic shock in 91 % with a maternal mortality rate of 58 % but the mortality has improved to 32 % in recent years [2]. Furthermore, when toxic shock syndrome due to Group A streptococci (can also be caused by Staphylococcus aureus) occurs during pregnant, it can have devasting consequences with multi-organ failure and a mortality of over 50 % in reported cases [3]. A recent review from the UK covers many of the important issues associated with GAS in the obstetrical setting including the its diverse manifestations, the need to manage puerperal sepsis caused by GAS quickly, suggested initial antibiotic therapy (e.g. cefuroxime and metronidazole until confirmed), and issues such as prophylaxis for contacts and the possible role of intravenous immunoglobulins [4].

Operative laparoscopy as the mainstay method in management of hemodynamically unstable patients with ectopic pregnancy

STUDY OBJECTIVE

To determine the safety and sustainability of operative laparoscopy in hemodynamically unstable women with ectopic pregnancy according to the effect of operator experience on success rates, whether the volume of hemoperitoneum affects the operative method used, and requirements for admission to the intensive care unit (ICU) and administration of blood transfusion.

DESIGN

Prospective cohort study (Canadian Task Force classification II-A).

SETTING

University hospital.

PATIENTS

Between January 2003 and February 2010, 505 women with ectopic pregnancy (55 tubal, 4 ovarian, 7 cornual, and 1 in the cesarean scar) were seen, including 124 women with hemoperitoneum greater than 500 mL, of whom 67 were hemodynamically unstable.

INTERVENTIONS

Operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

The greater the volume of hemoperitoneum, the greater the likelihood of hemodynamic instability. The odds of hemodynamic instability were greater in nontubal ectopic pregnancies. The overall operative laparoscopy rate in hemodynamically unstable patients was 85%, compared with 95% in hemodynamically stable women. The volume of hemoperitoneum did not affect the operative method used. Experienced operators had a 100% success rate at operative laparoscopy in hemodynamically unstable women, compared with a 72% success rate with confident operators. A small number of women required admission to the ICU. Although the laparoscopy group required more blood transfusions, they had a shorter length of hospital stay compared with the laparotomy group.

CONCLUSION

Operative laparoscopy is safe and sustainable in most women with hemodynamic instability. Women who undergo operative laparoscopy do no worse than those who undergo laparotomy, and even those who require ICU admission still benefit from the advantages of operative laparoscopy.