Ovarian Torsions and Other Gynecologic Emergencies A Clinician’s Guide to Managing Ob/Gyn Emergencies World Health Special Focus on Haiti Ambereen Sleemi, MD,MPH No Disclosures Torsion and other gyn emergencies • Ovarian torsion

• Gynecologic cancers

• Cervical cancer

• endometrial cancer

• ovarian cancer Ovarian Torsion

• What is ovarian torsion?

• Why is is an emergency?

• How is it treated? Ovarian Torsion

• A twisting of the ovary around its support and cutting off of the blood supply

• cutting off the blood supply causes severe abdominal pain and death of the tissue

• treated as a surgical emergency Ovarian Torsion The blood supply to the ovary is cut off by the twisting of an enlarged, usually cystic ovary Ovarian Torsion

• An ovarian torsion presents with classic findings of severe onset of intermittent abdominal pain, that may wax and wane (over 90%)

• it may be associated with nausea and vomiting (over 80%)

• 60% occur on right side

• risk factors are pregnancy, reproductive age (can be pre or post menopausal also) Torsion and untwisted Signs and Symptoms

• Vague complaints of lower abdominal pain

• Classic- sitting or sleeping and sudden severe pain that disappears and reappears

• Nausea and vomiting

• Often a delay in diagnosis Findings

• Unilateral adnexal mass or tumor usually seen

• lower abdominal pain

• Pelvic exam- palpate a unilateral, tender mass

• Pregnancy associated with up to 20% of torsion cases

• Ultrasound with adnexal mass, low or no blood flow Management

• Pregnant or not, management same

• Surgical treatment is needed

• Ovary is untwisted and observed for signs of necrosis and tissue damage

• If ovary appears viable, may remove the cyst only

• If ovary is necrotic, need to remove

• Ovarian salvage possible if treated without delay Gynecologic Cancer

• Cervical cancer

• Haiti has highest rate in Western Hemisphere

• 13x higher than US

• #1 cause of cancer deaths in women in Haiti

• Screening is possible - cytology or visual inspection

• Not widely used Haiti cancer mortality World Health Organization - Cancer Country Profiles, 2014 Risk factors

• Human Papilloma virus

• Smoking

• Multiple sexual partners

• Immunocompromised/HIV

• More kids

• Long term OCP use-indirect Signs and symptoms

• Abnormal vaginal bleeding

• Pelvic pain

• Flank pain- advanced cases

• Signs of spread

• Lesion on cervix

Cervix cancer

• Grows slowly

• Can be diagnosed in early pre-cancer stages

• Pap test

• VIA

• If caught early, treatment and cure likely

• Late stages, poorer prognosis

Staging and Treatment

• Spread is locally

• Treatment depends on stage

• Excision

• Surgery

• Radiation

• Chemotherapy Prevention of Cervix Cancer

• Screening with Pap test or VIA pap testing- needs pathology

• VIA- vinegar and inspection- teachable, affordable

• HPV vaccine Other Considerations

• Endometrial cancer

• Abnormal vaginal bleeding in older patients

• Postmenopausal risk factors

• Ovarian- older patients

• Few signs early on, often diagnosed in late stages Contact Information

Ambereen Sleemi, MD, MPH Surgical Director International Medical Response www.internationalmedicalresponse.org

@globalgyno @IMR_MedResponse

@internationalmedicalresponse

Email [email protected]