What are the first line and second line management options for common obstetrics and gynaecology emergencies?

Management of Common Obstetrics and Gynecology Emergencies

First-line and second-line management of common obstetrics and gynecology emergencies should follow a structured approach focused on rapid triage, resuscitation, and appropriate surgical intervention to reduce morbidity and mortality.

Ruptured Ectopic Pregnancy

First-line Management:

• Rapid assessment and resuscitation for hemodynamic stability
• IV fluid resuscitation and blood product transfusion for hemorrhagic shock 1, 2
• Immediate surgical intervention for unstable patients
• Salpingectomy is the most common surgical procedure (performed in 47.8% of acute surgical abdomen cases) 3

Second-line Management:

• Methotrexate treatment for hemodynamically stable patients with unruptured ectopic pregnancy 4
• Serial β-hCG monitoring and follow-up ultrasonography

Obstetric Hemorrhage

First-line Management:

• Activation of multidisciplinary response team (similar to OBCAT alert system) 2
• Aggressive fluid resuscitation and blood product replacement
• Uterotonic medications (oxytocin, methylergonovine, prostaglandins)
• Manual compression and bimanual massage

Second-line Management:

• Surgical interventions including:
  • Damage control packing (required in severe hemorrhage cases) 2
  • Uterine compression sutures
  • Uterine artery ligation
  • Hysterectomy for refractory bleeding

Ovarian Emergencies

First-line Management:

• Pain management
• Ultrasound evaluation
• Surgical intervention for ovarian torsion (7.64% of acute surgical abdomen cases) 3

Second-line Management:

• Laparoscopic detorsion and ovarian conservation when possible
• Oophorectomy if tissue is necrotic

Post-Surgical Complications

First-line Management:

• Rapid assessment for hemorrhage, infection, or visceral injury
• Fluid resuscitation for hemodynamic instability
• Broad-spectrum antibiotics for suspected infection

Second-line Management:

• Surgical re-exploration for:
  • Hemoperitoneum/pyoperitoneum (6.26% of cases following gynecological surgeries) 3
  • Adhesions or intestinal injury (common complications requiring acute care surgical intervention) 2

Septic Abortion

First-line Management:

• Aggressive fluid resuscitation
• Broad-spectrum antibiotics
• Prompt uterine evacuation

Second-line Management:

• Intensive care management for septic shock
• Surgical intervention for uterine perforation or peritonitis

Implementation Considerations

• Triage systems like the Canadian Triage and Acuity Scale improve outcomes by prioritizing care based on severity 1
• Multidisciplinary team approach with immediate access to operating rooms, blood products, and intensive care is essential 1, 2
• Consultant-led teams with specialized training in obstetric and gynecologic emergencies improve patient outcomes 1

Common Pitfalls to Avoid

• Relying on tachycardia alone as an indicator of ruptured ectopic pregnancy (unreliable) 4
• Failing to screen for ectopic pregnancy in women of reproductive age with abdominal pain 4
• Delaying surgical intervention in hemodynamically unstable patients
• Underestimating blood loss in obstetric hemorrhage (average blood loss can reach 6.8±5.5 L requiring massive transfusion) 2

Implementing a structured emergency response system with clear protocols and a multidisciplinary approach has been shown to improve outcomes and patient satisfaction in obstetric and gynecologic emergencies 1.