EMERGENCIES IN GYNECOLOGY. Abnormal bleeding. Abnormal Bleeding. Prepubertal Age Group Adolescence Reproductive Age Group Postmenopausal Women. Prepubertal Age Group.
EMERGENCIES IN GYNECOLOGY
Vaginal bleeding in the absence of secondary sexual characteristics should be evaluated very carefully.
Foreign body (plastic toy) in the vagina of an 8-year-old girl
(abnormalities in clotting factor production).
(Novak’s Gynaecology 2002)
which are absent in chronic pain states.
Acute pelvic pain !!!
Ectopic pregnancyPelvic inflammatory disease (PID) - Salpingitis- oophoritis - Tuboovarian abscess (TOA) Hemorrhagic ovarian cystOvarian torsionBartholin gland abscess
- ectropic pregnancy = outside the uterus- heterotropic pragnancy = both intrauterine pregnacy (IUP) + ectopic pregnancy, 1 : 30000 pregnancies
- 95% develop in oviducts
- ampullary 79%,- isthmic, fimbrial also cornual
- abdominal - uncommon, - cervical and ovarian are very rare- DGN at 6-8 week
Clinical presentationa. Unruptured ectopic pregnancy- amenorrhea 6-8 weeks- abnormal vaginal bleeding - abdominal pain- adnexal or cervical motion tenderness - adnexal mass - nausea- fatigue- cervix is getting blue
Clinical presentationb. Ruptured ectopic pregnancy- internal bleeding and hypovolemia- tenderness, rebound, or guarding of abdomen- uterine size normal or smaller than expected- echymoses of umbiliculus-Cullen sign- orthostatic blood pressure and pulse changes indicate blood loss
2.Differential diagnosisa. reproductive tract- spontaneous abortion- molar pregnancy- ruptured corpus luteum- acute PID- adnexal torsion
3.Risk factors- Pelvic inflammatory disease (PID)- Previous ectopic pregnancy- Sexually tranmitted diseases (STDs)- Previous surgeries, particulary tubal ligation- Presence of intrauterine device???? (IUD)- User of fertility agents- Cigarettes smoking
4. Diagnostic testsa. B-hCG to confirm pregnancyb. Serum progesterone: a level < 5 ng/ml is highly suggestive of an ectopic pragnancy; a level > 25 ng/ml is highly suggestive of an intrauterine pregnancy
4. Diagnostic testsc. Ultrasonography to look for:- empty uterus- presence of blood in the cul-de-sac- presence of an adnexal mass- presence of echogenic halo around the fallopian tube- presence of fetal heart tones outside the uterus- presence of pseudofolicled. Preoperative laboratory studies: CBC, chemistry panel, PT, APTT, LFTs and blood type and screen.
4. Diagnostic testse. Culdocentesis if ultrasonography is not available: a positive test is aspiration of 0,5 ml of clotting blood with clotts from the posterior cul-de-sac, and is an indication for surgery. A positive test cannot differentiate between a raptured ectopic pregnancy and ruptured corpus luteum cyst. Aspiration of straw-colored fluid is nondiagnostic.
a. Conservative treatment
- blood transfusion if patient is hemodynamically unstable from blood loos.
- check B-hCG in two days and administer methotrexate
- when B-hCG is increaseing- laparoscopy!
b. Operative treatment
- laparoscopy- removal of a ectopic pregnancy, coagulation of vessels and administer methotrexate or 40% hypertonic salt
(≤ 56 days LMP)
(Crenin and Vittinghoff JAMA 272:1190-1195, 1994)
Percent Complete Abortion
Pevic inflamatory disease
Pelvic inflammatory disease (PID) is an inflammatory disorder of the:- uterus,- fallopian tubes,- and adjacent pelvic structures.
= infection of the female genital tract.
PID may occur more frequently in adolescents (ie, 15-19 y), but it can occur in any patients who are sexually active
A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.
1. Symptoms may include:
- Acute onset of bilateral lower abdominal or pelvic pain
- General malaise
- Vaginal discharge and bleeding
- Pain on ambulation (due to peritoneal irritation)
- Right upper quadrant (RUQ) pain, in some patients with Fitz-Hugh-Curtis syndrome (PID+ perihepatitis)
2. Physical examination findings may include:- classic triad: lower abdominal tenderness, - cervical motion tenderness, and bilateral adnexal tenderness- Cervical discharge, bleeding, and irritation- Fever - Tachycardia - Adnexal tenderness usually is present with no masses palpated
Differential diagnosis:a. Reproductive tract disorders- adnexal torsion- ectopic pregnancy- bleeding corpus luteumb. GI tract disorders- appendicitis- diverticulitis c. Urinary tract disorders - cystourethritis- pyelonephritis
appendicitisa. Symptoms may include:- abdominal pain beginning around the umbilicus, - migrating to the right lower quadrant (RLQ) and localizing to McBurney’s point- pain that procedes vomiting- diarrea- high fever, marked leukocytosib. Physical examination findings may include- muscular rigidity- Blumberg sign- Iliopsoas sign- Obturator sign- Rovsing sign
3. Diagnostic testsa. Complete blood count (CBC) to look for leukocytosis and granulocyte shiftb. Cervical cultures to isolate causative organismc. Gram stain to look for white blood cells (WBCs)d. Blood cultures if patient is febrilee. Ultrasonography if tuboovarian abscess (TOA) is suspectedf. Screening for other STDs
4. Treatmenta). Antibiotics: - ceftriaxone 125-250 mg IM once and- doxycycline 100mg twice a day for 10-14 days. azithromycin 1g orally once may be substituted for doxycycline if patient compliance is a problemb). STD counsellingc). Removal of infected foreign body if present
5. Dispositiona. Most patients can be discharged with outpatient follow-up within 48 hours. HIV testing should be done at follow-up visit.b. Inpatient admission include:- uncertain diagnosis- suspected TOA- fever >39 C - failure of outpatient therapy- pregnancy- first episode in a nulligravida- inability to tolerate oral intake- inability to follow up in 48 hours- immunosuppression
Are considered to be post-inflammatory scar tissues that are formed after abdominal surgery, endometriosis and intra-abdominal infections. Adhesions may also be a severe and sometimes life-thereatning complication. Although no universal nomenclature exists, they can be described as dense or filmy, thick or thin, opaque or trasluscent and vascular or avascular.
- Is an acute infection involving the fallopian tube, ovary, board ligament, bowel, or omentum, resulting in a pelvic mass.- Usual causes are anaerobes, particulary Bacteroides spp.
1.Clinical featuresa) Symptoms may include:-severe pelvic and lower abdominal pain- severe back pain- rectal painb). Physical examination findings may include:-an acutely ill- appearing patient- fever- tachycardia- hypotension- vaginal discharge, adnexal tenderness, and presence of a mass revealed on pelvic examinationTrauma - mass revealed on rectal examination- abdominal guarding and tenderness
3.Treatmenta. IV hydrationb. IV antibiotics ( cefoxitin + doxycycline or gentamycin + clindamycin)c. Emergency laparotomy if TOA has ruptured
- Patients with TOA should be admitted to the ob/gyn service for operative menagment.
Hamorrhagic ovarian cyst1.Clinical featuresa. Symptoms may include:- sudden onset of sharp lower abdominal pain- symtoms of hypotension: lightheadness, syncope, weaknessb. Physical examination findings may include:- abnormal vital signs (tachycardia with or without hypotension)- lower abdominal tenderness with or without rebound- adnexal mass
2.Diagnostic testa. B-hCG to look for pregnancyb. Preoperative laboratory studies: CBC, chemistry panel, PT, APTT, and type and crossmatchc. Ultrasonography to look for free fluid in the cul-de-sac
4. Dispositiona. Most patients can be discharget home with outpatient foolow-up.b. Any patient with significant bleeding should be admitted to the ob/gyn service for further management.
Ovarian torsion- An ovary may twist on its vascular pedicle, compromising its blood supply and precipitating ischemia and peritonitis.- Infarction of the ovary may result without immediate intervention.
1.Risk factorsa. Size of the mass (the larger the mass, the more likely it is to twist). Presence of cysts or tumors within the ovary increases this risk.b. Lenght of the pedicle ( a longer pedicle has more mobility).c. The right ovary is 2 or 3 times more likely to develop torsion than the left one.
2. Clinical featuresa. Symptoms may include:- Sudden onset of unilateral colicky pain that radiates from the groin to the flank:” reverse renal colic”- nausea and vomiting- lower abdominal pain (may be intermittent)- history of ovarian cystsb. Physical examination findings may include:- lower abdominal tenderness with rebound- cervical motion tenderness- tender adnexal mass
3.Diagnostic testsa. B-hCG to look for pregnancyb. Preoperative laboratory studies: CBC, chemistry panel, PT, APTT, and type and screen.c. Ultrasonography with Doppler to look for:- enlarged cystic ovaries with small central cystic spaces resulting from hemorrhage. Torsion is unusual with „normal size” ovaries.- Blood flow. A twisted ovary will have decreased blood flow === necrosis.
4. Treatment- Treatment is emergency laparotomy!5. Dispositiona. Patient with suspected ovarian torsion should be admitted to the hospital.b. Patients with an adnexal mass but without evidence of torsion may be discharged with outpatient follow-up, although many patients with large masses are admitted for further work-up.
1. Clinical featuresa. Symptoms may include:- vulvar mass - drainage- pain- difficulty ambulatingb. Physical examination findings may iclude:- fluctuant mass at introitus
2. Diagnostic tests- No specific diagnostic tests are necessary.- Diagnostic aspiration to determine whether there is an abscess (or a cyst) may be performed by introducing an 18-gauge needle into the mass to look for fluid and pus.
3. Treatmenta. For small abscess (<2cm): antibiotics (cephalexin) [250-500mg orally 4 times a day for 7 days (adults) or 25-50 mg/kg/day (children)] and warm soaks.B. For large abscess: incision and drainage or placement of a Word’s catheter.
4. Dispositiona. Patients can be discharged home with outpatient follow-up.b. Patients with recurrent abscesses should be referred for marsupialization.