Surgical Emergencies in Obstetrics and Gynaecology in a Tertiary Care Hospital

Introduction: The management of Obstetrics and Gynaecological Emergency is directed at the preservation of life, health, sexual function and the perpetuation of fertility. Main aim of the study was to access the burden of Surgical Emergency in Obstetrics and Gynaecology and their course of management at BPKIHS. Methods: A total of 314 women presenting at the emergency admission room of Obstetrics and Gynaecology Department of BPKIHS over two years, who required surgical intervention were included in this hospital based descriptive study. Clinical assessment and routine laboratory investigations were performed in all cases. All patients who presented with shock were resuscitated and surgery was done at earliest possible time. Results: The age of patients ranged from 1555 years with approximately 43% in the 25-34 years category. Ninety two percent of them were married. Among the unmarried, 64% came with problems related to unsafe abortion. About 61% of females presenting as acute surgical abdomen had ruptured ectopic pregnancy, 7.64% had twisted ovarian cyst, and 6.26% had haemoperitoneum and pyoperitoneum following vaginal hysterectomies, total abdominal hysterectomies and caesarean section. Almost half (47.8%) of the cases underwent salphingectomy. Conclusions: Women present with wide range of complaints and conditions in the admission room of Obstetrics and Gynecology department of BPKIHS. Skilled clinicians, immediate investigation facilities and experienced specialty Obstetrical and Gynaecological surgeons are the main backbone of the emergency case management and saving lives. Study indicates there is need of some prospective study to establish the causes of rising trend in Ectopic Pregnancies. ________________________________________________________________________________________


INTRODUCTION
The management of women presenting to the emergency department with obstetric or gynecologic complaints is an obvious and expected occurrence in everyday life in emergency. 1Most of the patients present with acute abdomen, abnormal vaginal bleeding or a combination of both.The developments of ultrasonographic imaging, serial biochemical pregnancy tests and minimal invasive surgery have given opportunity for early diagnosis and conservative treatment. 2ynecologic disorders presenting with Acute Abdominopelvic Pain (AAP) may be benign and self-limiting or may negatively affect fertility capacity if not treated.The incidence is calculated as 1.5% of office based visits and 5% of emergency department admissions.The delay in diagnosis and treatment may lead to worse outcomes. 3,4The sufferings of the patients in terms of morbidity, mortality and economy can be reduced to some extent by improving these shortcomings. 5is study was carried out with an objective of evaluating the gravity of emergencies and to highlight various obstetrical and gynaecological problems presenting as acute surgical emergencies and their management at a tertiary care teaching hospital in Eastern Nepal.

METHODS
This is a hospital-based descriptive study, carried out at a tertiary teaching hospital in Sunsari district of east Nepal from April 2010 till March 2012.A total of 314 women were included in the study selected by consecutive method of non-probability sampling technique among the patients who presented to the Obstetrics and Gynaecology emergency room at the hospital during the study period.All cases requiring surgical intervention were included in the study.Cases requiring conservative management were excluded.Immediate resuscitation followed by detailed history taking, physical examinations, lab investigations including ultrasonography for diagnosis and appropriate management were done as per the existing protocol for all patients.Data was collected using semi-structured questionnaire, treatment records and intra-operative findings after taking consent from the patient's closest visitor.This study was conducted after taking ethical clearance from the Institute Ethical Review Board.

RESULTS
Out of a total of 314 patients in the study, the highest number of patients 134 (42.7%) was seen in the 25 to 34 years category which was followed by 104 (33.1%) patients in the 15-24 years category and 60 (19.1%) of the patients were present in the 35-44 years category (Table 1).The most common presenting complaints was pain in abdomen in 238 (75.8%) of the patients followed by bleeding per vagina among 66 (21.0%) of the patients, hemoperitoneum among 34 (10.8%) of the patients and vomiting among 34 (10.8%) of the patients (Figure 1).Among the 25 unmarried cases, who presented at the emergency, 16 (64%) of the cases came with problems related to unsafe abortion.
Out of 314 patients a total of 192 (61.1%) of the patients were diagnosed with ectopic pregnancy followed by ovarian mass 24 (7.6%) (Table 2).

DISCUSSION
A wide variety of cases with surgical emergencies in obstetrics and gynecology are encountered in emergency room starting from young girls to older women at hospitals worldwide.A total of 192 cases of ruptured ectopic pregnancies were seen in this study.A study done for similar duration showed a total of 143 cases of ruptured ectopic pregnancy at BPKIHS. 6The number of ectopic pregnancy in this study is higher in comparison with 174 cases seen in five years in a study done at Tribhuwan University Teaching Hospital (TUTH).][9][10] The reason for greater number of cases at BPKIHS is that it is the only Teaching Hospital in the eastern region with residency program in Obstetrics and Gynecology and is considered as a Regional Hospital with a tertiary care services serving a large number of population from both Nepal and India.This slight increase in number in BPKIHS from the study in 2004 to the current study may be due to increasing number of cases at emergency room of BPKIHS in the present years. 6e most common gynecological and obstetrical emergency encountered in this study was ectopic pregnancy, which is comparable with the findings in a teaching hospital in Nigeria, where ectopic pregnancy was the commonest indication for surgery. 11Another study in Nairobi, Kenya also showed that ectopic pregnancy was the most common cause for emergency laparotomy among women. 12A study however showed that, Pelvic Inflammatory Disease was the most common gynecological emergency in their district hospital at Kasur, Pakistan. 5e age group of patients in our study ranged from 15 to 55 years, similar to the study in Kasur, Pakistan, and different from another study in Lahore, Pakistan where all the patients were in the category of 15 to 35 years. 5,13st common presenting complaint was pain in the abdomen (75.8%) followed by bleeding per vagina (21%) in this study.A study in Turkey also showed that abdomino pelvic pain (59%) was the most common complaint followed by vaginal bleeding (41%). 14out 48% of the patients underwent only Salphingectomy, which is also the most common surgery done for ectopic pregnancy.Nearly 11% patients also underwent salphingectomy with contralateral tubal ligation after taking consent for those wishing for permanent sterilization.
Septic abortion with uterine perforation accounted for 7% of the gynecological emergencies in a study in Nigeria. 11There was a similar finding in this study with almost 5% of unsafe abortion out of the total 314 cases.This number is also worrisome to us as abortion in Nepal has been legalized, and safe abortion is widely promoted.There could be some gaps that have led to this percentage of people to still under go unsafe abortion.

CONCLUSIONS
This study reveals that obstetrical and gynaecological emergencies are common in tertiary care centers like BPKIHS.At the same time it can be observed that some of them could have been avoided with minimal precautions, counseling and pre-conceptual care in time.Obstetricians and gynaecologists can do better management of these cases, if peripheral health institutions refer the patients timely once the diagnosis of AAP is confirmed.
Studies referred in this article as well as this current study are an attempt to highlight the gap between the poor awareness of the local health institutions regarding the acute lower abdomen pain and the availability of the services in a better center for the management of the Obstetrical and gynaecological surgical emergencies.

Figure 1 .*
Figure 1.Distribution of participants as per age group.

Table 1 . Age, marital status, ethnicity and parity status of the patients (n=314).
*Percentages based on multiple responses.___________________________________________________ Total 273 (87%) of patients were from 12 districts in Nepal, with 139 (51%) of total from Sunsari and Jhapa districts.Patients from various states of India also comprised of almost 13%.