Gynaecology emergency cases for GPs: post-coital pain, ruptured haemorrhagic cyst, and mid-cycle bleed — plus AF, SVT and POTS

Part 1 speaker

Chris — obstetrician–gynaecologist (introduces himself as “Chris, obstetrician gynecologist”; surname not given in the recording). Cases from Pindara ED and Gold Coast University Hospital.

Part 2 speaker

Cardiologist / electrophysiologist by role (introduces as doing “heart rhythm things”; works at John Flynn, Pindara and a third hospital ASR’d as “Bella”; not named). No sponsor statement captured for either segment.

Session context

Otter title Medical Case Presentations · id FkbC37gJSWwLXx--Hx2zwf3qFs4 · ~50 min, recorded 21 March 2026 12:17 pm AEST. Technical issues at the start; Chris speaks first (~27 min), then the EP (~27–48 min); closing “speed dating / speed consulting” chatter is not clinical content.

Key messages for GPs

• Always ask cycle timing, LMP, contraception and sexual activity in reproductive-age abdominal pain — even when the story sounds like gastritis or “just had a few drinks”.
• Negative hCG does not fully exclude a ruptured chronic ectopic (uncommon but real, as stated); still keep it on the list if sexually active.
• Pelvic ultrasound is the way to “look inside” for acute gynae differentials — live, detailed, and can escalate care immediately.
• Haemorrhagic ovarian cyst / ruptured follicle can produce haemoperitoneum — Case 1 ~600–800 mL; Case 2 multipack transfusion / return to theatre / oophorectomy pathway as described.
• COCP or depot are the options Chris emphasised to stop ovulation if prevention is desired; LNG-IUD / many POP regimens still allow upstream ovarian cycling.
• Part 2: diagnose AF with ECG; CHA₂DS₂-VASc (woman alone without other risks = 0 for anticoagulation in the speaker’s framing); start anticoagulation early; digoxin useful when BP is low; consider early rhythm strategy in younger patients.

Case 1: 25-year-old post-coital pain (Pindara ED)

Two nights before the talk (relative to the recording), a 25-year-old presented to Pindara ED at ~18:30. Hours earlier she had sex; a moment was “really quite sore”, then settled enough to continue, then lower abdominal pain worsened. She had a midnight flight for a five-week Asia work tour and mainly wanted analgesia to board.

• No bleeding, fevers, urinary or bowel symptoms. Fit, monogamous, no regular meds, surgeries or allergies.
• Obs stable: HR ~70, BP ~110/65, temp ~36.something, RR ~12 (as spoken).
• FBC mentioned (ASR “32” — unclear which parameter); urine dipstick negative; blood hCG negative.
• ED called Chris because of the imaging: ultrasound showed a haemorrhagic cyst on the left ovary with pelvic free fluid extending around the kidneys and toward Morrison’s pouch. She still wanted to fly.

Chris noted airlines are not routinely notified (confidentiality), but if a passenger flies against medical advice and the plane diverts, they can be charged for the diversion — a point he used in counselling. On review she looked worse: mobile but not at rest, abdomen not rigid but not soft, percussion tenderness, unhappy. He took her to theatre.

Findings: about 600–800 mL of blood (including up around the liver); cyst excised and ovary oversewn; some “dental endometriosis” (ASR — likely deep/endometriosis; wording unreliable). Home next day looking well. Guidelines he skimmed suggested waiting about five days before flying rather than one or two.

She was about day 2½–3 of a consistent ~26-day cycle after two months — i.e. not immediately peri-ovulatory in calendar terms for that cycle description as spoken; he still framed the pathophysiology around ovulatory rupture (see below). Treat the exact day-of-cycle wording as somewhat ASR-tangled.

Why a normal ovulation can bleed

Chris sketched the HPO axis and dominant follicle (up to ~3 cm), ovulation, and corpus luteum. At ovulation the follicle ruptures — a breaking point over tissue supplied by the ovarian (gonadal) artery coming off the aorta near renal level (“highest pressure”). Nothing tamponades the ovary’s outer surface in the peritoneal cavity. Sex can knock off clot. Bleed may be acute into a haemorrhagic cyst or a more subacute fill that then ruptures under strain.

Case 2: 18-year-old mid-cycle collapse (GCUH)

An 18-year-old (sometimes spoken as 19) went out Friday night (~three drinks), slept in, then afternoon pain progressed to doubling over. Ambulance gave methoxyflurane (“green whistle”) and fentanyl. Initial ED exam “didn’t feel too bad”; category delayed. History focused on alcohol → differential led by gastritis / possible ulcer; non-urgent CT planned behind major trauma.

Hours later: MET call, HR 140+, writhing; more fentanyl, HR improved, team left. After shift change she went for ultrasound instead: four-quadrant haemoperitoneum. Rushed toward theatre (~15 minutes). Laparoscopy: litres of blood (spoken “two to three litres”); ovary bleeding controlled with diathermy and observed. In recovery she remained on metaraminol. Taken back: oophorectomy / stop the ovarian artery supply as described; still more bleeding and coagulopathy → general surgery laparotomy; minor omental ooze attributed to suction trauma; ICU, then stable.

Missed history: sexually active, no hormonal contraception, mid-cycle. hCG was done (good) and negative. This was mittelschmerz physiology that did not stop bleeding — blood loss approaching circulating volume. Chris’s line: a generation ago she might have died because she ovulated.

History that would have changed the path

• Last period, cycle length, ovulation apps.
• Hormonal contraception / ovarian suppression.
• Prior similar pain, endometriosis history.
• Sexual activity (still consider ectopic even with negative hCG — uncommon ruptured chronic ectopic discussed).
• Think outside the pelvis too (appendicitis, renal stone) — Case 2’s gastritis label was the trap.

Stopping it happening again

Shared decision. Dramatic but uncommon. If she wants pregnancy now, suppressing ovulation blocks that. Prior contraceptive side effects matter. After one event, recurrence is not guaranteed; after two, revisit.

• Best ovulation suppression (as stated): combined oral contraceptive or depot.
• Mirena / many progesterone-only approaches: uterine bleeding pattern changes but “everything above” the uterus — including ovulation — often still happens. Progesterone methods also raise ectopic risk if pregnancy occurs.
• Audience: any COCP that stops ovulation (including lower-dose) can work; choice is negotiation (bleeding vs side effects).
• Chris: ~40+ pills / several progestogens; head-to-head differences often small; cheapest suitable pill may be fine; give 3–6 months before declaring failure (expectation management).
• Personal preference mentioned: estetrol pill “Nextellis” — explicitly “no good reason” / no reps; hippie preference only — not presented as evidence.

Ovary as “testicle”: cyclical trapped pain

If adhesions, infection or endometriosis fix the ovary, physiologic mid-cycle swelling is like squeezing a testis — recurrent unilateral pain building through mid-cycle then easing. Hormonal down-regulation may help without surgery (surgery can worsen adhesions).

Endometriosis, surgery and Four Corners caution

• First private laparoscopy Chris did: ectopic after prior laparoscopy for pain where adhesiolysis likely contributed — post-op photos only, no pre-op photos; reminder to document both.
• Endometriosis awareness is “wonderful” but endo is not the only pelvic-pain cause. Classic delay of 7–12 years to diagnosis (oft-quoted figure he referenced) partly reflected trying conservative care first.
• Surgery indications he stated: pain not responding to appropriate hormones, or infertility — hormones still first-line for pain. Informed consent must include harm from operating (context: contemporary public discussion / Four Corners as mentioned).

Part 2: AF, rate control and ablation

Unnamed EP (John Flynn, Pindara, third site). Prefers lifestyle first (weight, alcohol, sleep apnoea); devices and procedures when needed. Offers Holters, echoes, ECGs, ambulatory BP (white-coat).

• Diagnose AF with ECG; watches (Apple algorithm) useful but confirm.
• Stroke risk: CHA₂DS₂-VASc still used. Score 1 = shared decision; ≥2 anticoagulate if no contraindication. Female sex alone without other risks scores 0 in his framing (not “1”).
• Acute: start anticoagulation; rate-control with beta-blocker if BP allows; digoxin 125 microg useful when BP ~90–100 (doesn’t drop BP); level <1 for toxicity not efficacy; outpatient slow load OK if reviewed in 1–2 weeks; load in hospital if needed.
• Echo to find heart failure / significant valve disease — must-fix group.
• Younger asymptomatic AF: old leave-alone approach aging into cognitive impairment and “leaky valves” from chronic AF — he often aims to restore rhythm within a couple of years. Ablation now ~45 minutes vs old 4–6 hours; older patients sometimes done.
• Public ablation wait spoken as ~3–5 years vs ~1 year privately (no gap fee stated for his patients) — manage medically while waiting.
• Cardioversion stroke risk ~0.7% vs ablation ~≤0.7% (as stated) — sometimes skip “trial cardioversion”. Success: paroxysmal ~85% medium-term with new tech; long-standing persistent ~50–60%; recurrence ~26% spoken in one fragment (veins reconnect / non-vein AF).
• Do not stop anticoagulation just because AF seems gone if CHA₂DS₂-VASc ≥2 — colleague’s patient stroked within six months.

SVT, WPW, ectopics and bradycardia

• SVT: sudden onset/offset; usually symptomatic nuisance unless WPW / accessory pathway — then fix because sudden-death risk higher (spoken roughly 3–4× baseline; absolute still low, e.g. ~1.5% fragment — unverified). Pill-in-pocket; Valsalva; ablation often lifestyle-driven.
• Ventricular ectopy: usually benign; echo if burden high; cardiomyopathy risk if burden >~10–20% (as stated). Low-dose flecainide often used; beta-blockers make young people feel awful.
• Symptomatic bradycardia: fatigue rarely from HR ~50 alone; stress test / stress echo for chronotropic incompetence; pacing example of fit 60-year-old with max HR ~80 restored by pacemaker. Conduction-system / left-bundle-area pacing mentioned with demo ECG.

Inappropriate sinus tachycardia / post-viral tachycardia

• Two groups: post-viral (COVID, flu, gastro) — tend to improve over 12–24 months; and high mental-health / stimulant burden — harder.
• Work-up: bloods, echo (don’t miss rare myocarditis / effusion).
• Ivabradine (ASR “fabricine” / “vavradine” / “Aberdeen”) — speaker uses often; lowers resting and exertional rates enough to enable exercise; expectation management (won’t fix brain fog/bowels). Rare QT issue — check ECG; avoid if planning pregnancy. Visual “green sparkles” in ~3% — not permanent vision loss.
• Hydration, salt, eating; exercise is the long game. Adolescents from ~16–17 seen; many patients 18–21.

GP clinic checklist

1. Reproductive-age abdominal pain: LMP, cycle, contraception, sexual activity, similar prior pain.
2. hCG always — still keep rare hCG-negative ruptured ectopic in mind.
3. Prefer early pelvic ultrasound when gynae differential is live; free fluid to Morrison’s pouch is a red flag.
4. Counsel flying after haemoperitoneum conservatively (~5 days as he read).
5. Prevention talk: COCP/depot if ovulation suppression wanted; IUD/POP ≠ ovarian silence.
6. AF: ECG → anticoagulate by score → rate control → echo → early EP referral for younger patients.
7. Don’t stop anticoagulation solely because AF seems gone.
8. Post-viral inappropriate sinus tachycardia: echo + consider ivabradine with clear expectations.

Transcript caveats

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