Emergencies in gynecology
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EMERGENCIES IN GYNECOLOGY. Abnormal bleeding. Abnormal Bleeding. Prepubertal Age Group Adolescence Reproductive Age Group Postmenopausal Women. Prepubertal Age Group.

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EMERGENCIES IN GYNECOLOGY

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EMERGENCIES IN GYNECOLOGY


Abnormal bleeding


Abnormal Bleeding

  • Prepubertal Age Group

    • Adolescence

  • Reproductive Age Group

  • Postmenopausal Women


Prepubertal Age Group

  • Slight vaginal bleeding can occur within the first few days of life because of withdrawal from the high level of maternal estrogens.

  • inform new mothers of female infants of this possibility


Vaginal bleeding in the absence of secondary sexual characteristics should be evaluated very carefully.


Prepubertal Age Group

  • The causes of bleeding range from the medically mundane to malignancies that may be life-threatening.

  • The source - sometimes difficult to identify, and parents who observe blood in a child's diapers or panties may be unsure of the source.

  • Pediatricians - look for urinary causes, and gastrointestinal factors.


Causes of Vaginal Bleeding in Prepubertal Girls

  • Vulvar Lesions

    • Vulvar irritation

    • maceration of the vulvar skin,

    • or fissures can bleed.


Foreign Body

  • A foreign body in the vagina is a common cause of vaginal discharge, which may appear purulent or bloody. Young children explore all orifices and may place all varieties of small objects inside their vaginas

Foreign body (plastic toy) in the vagina of an 8-year-old girl


Precocious Puberty

  • Precocious puberty occasionally is marked by vaginal bleeding in the absence of other secondary sexual characteristics,

  • it is more common for the onset of breast budding or pubic hair growth to occur before vaginal bleeding.


Trauma

  • A careful history should be obtained from

    • one or both parents or

    • caretakers

    • and the child herself,

  • because trauma caused by sexual abuse is often not recognized.

  • There is a mandatory legal obligation to report suspected child physical abuse


Other Causes

  • Other serious but rare causes of true vaginal bleeding include vaginal tumors.

    • rhabdomyosarcoma (sarcoma botryoides) is associated with bleeding.

  • Other forms of vaginal tumor are also rare but should be ruled out if no other obvious source of bleeding is found externally


Adolescence

  • To assess vaginal bleeding during adolescence, it is necessary to have an understanding of the range of normal menstrual cycles.

  • During the first 2 years after menarche, most cycles are anovulatory. Despite this, they are somewhat regular, within a range of approximately 21 to 40 days.


Normal Menses

  • The mean duration of menses is 4.7 days; 89% of cycles last <7 days. The average blood loss per cycle is 35 ml, and the major component of menstrual discharge is endometrial tissue.

  • Recurrent bleeding in excess of 80 ml/cycle results in anemia.


Abormal bleeding

  • Cycles > 42 days,

  • < 21 days,

  • Bleeding > 7 days

  • during adolescence greater irregularity is acceptable if significant anemia or hemorrhage is not present.

  • consideration should be given to girls whose cycles are consistently outside normal ranges or whose cycles were previously regular and become irregular


Hormonally active ovarian tumors

  • lead to endometrial proliferation and bleeding.

  • Exogenously administered estrogens can result in bleeding.


Anovulatory bleeding

  • The physiology - failure of the feedback mechanism

  • In anovulatory cycles, estrogen secretion continues, resulting in endometrial proliferation with subsequent unstable growth and incomplete shedding.

  • The clinical result is: irregular, prolonged, and heavy bleeding.


Exogenous Hormones

  • Oral contraceptive use is associated with breakthrough bleeding, which occurs in as many as 30% to 40% of individuals during the first cycle of combination pill use.

  • In addition, irregular bleeding can result from missed pills


Hematologic Abnormalities

  • Idiopathic Thrombocytopenic Purpura (ITP),

  • von Willebrand's disease.

  • leukemia

  • Thrombocytopenia, etc.

  • Adolescents who have severe menorrhagia, especially at menarche, should be screened for coagulation abnormalities, including von Willebrand's disease.


Infections

  • Irregular or postcoital bleeding can be associated with chlamydial cervicitis.

  • and screening for chlamydia should be performed routinely among sexually active teens


STD / STI

  • Menorrhagia can be the initial sign for patients infected with sexually transmissible organisms.

  • Adolescents have the highest rates of pelvic inflammatory disease (PID) of any age group when only sexually experienced individuals are considered.


Endometritis

  • PID (endometritis, salpingitis, oophoritis). Occasionally, chronic endometritis will be diagnosed when an endometrial biopsy is obtained for evaluation of abnormal bleeding in a patient without specific risk factors for PID.


Endocrine or Systemic Problems

  • Thyroid dysfunction.

    • hypothyroidism

    • and hyperthyroidism

  • Hepatic dysfunction

    (abnormalities in clotting factor production).


  • Reproductive Age Group

    • Beyond the first 1 to 2 years after menarche, menstrual cycles generally conform to a cycle length of 21 to 35 days, with a duration of less than 7 days of menstrual flow.

    • As a woman approaches menopause, cycle length becomes more irregular as more cycles become anovulatory.


    Reproductive Age Group

    • Although the most frequent cause of irregular bleeding is hormonal disorder

    • Pregnancy-related bleeding (spontaneous abortion, ectopic pregnancy) should always be considered.

    • pregnancy test !!!!


    Anatomic Causes

    • Anatomic causes of abnormal bleeding in women of reproductive age occur more frequently than in women in other age groups.

    • Uterine leiomyomas occur in as many as one-half of all women older than 35 years of age and are the most common tumors of the genital tract


    Neoplasia

    • Abnormal bleeding is the most frequent symptom of women with invasive cervical cancer.

    • Any obvious cervical lesion should be evaluated by biopsy!!!


    TREATMENT


    Nonsurgical Management

    • Most bleeding problems, including anovulatory bleeding can be managed nonsurgically.

    • Treatment with NSAIDs such as ibuprofen and mefenamic acid has been shown to decrease menstrual flow by 30% to 50%

      (Novak’s Gynaecology 2002)


    Hormonal management

    • frequently can control excessive or irregular bleeding.

    • Although there is a paucity of randomized controlled trials demonstrating the effectiveness of oral contraceptives in reducing menstrual flow, oral contraceptives have long been used clinically to decrease menstrual flow


    Hormonal management (OC)

    • Low-dose oral contraceptives may be used:

      • during the perimenopausalyears

      • in healthy nonsmoking women

      • who have no major cardiovascular risk factors.

    • The benefits of menstrual regulation in such women often override the potential risks.


    • For patients in whom estrogen use is contraindicated, progestins, both oral and parenteral, can be used to control excessive bleeding.

    • Cyclic oral medroxyprogesterone acetate, administered from days 5 to 26 of the cycle, results in a reduction of menstrual flow


    Postmenopausal Women

    • A significant change in withdrawal bleeding (e.g., absence of withdrawal bleeding for several months followed by resumption of bleeding or a marked increase in the amount of bleeding) should prompt endometrial sampling.


    !

    Neoplasia !!!!!

    • Endometrial, cervical, and ovarian malignancies must be ruled out in cases of postmenopausal bleeding.

    • The Pap test results are negative in some cases of invasive cervical carcinoma because of tumor necrosis => biopsy, or conisation !!!.


    Wide range of surgical options

    • from hysteroscopy with resection of submucous leiomyomas to

    • laparoscopic techniques of myomectomy to

    • uterine artery embolization to

    • endometrial ablation to

    • hysterectomy (TAH+BSO).

    • The choice of procedure depends on the cause of the bleeding.

    • The assessment of the relative advances, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research.


    PELVIC PAIN


    Pelvic pain

    • is the most challenging symptom confronting the practitioner.

    • The problems of acute, cyclic, and chronic pelvic pain encompass a large proportion of gynaecologic complaints.

    • The etiology is diverse.

    • Dysmenorrhea is one of the most common medical issues in gynaecology.


    • Acute pain is intense and characterized by sudden onset, sharp rise, and short course.

    • Cyclic pain refers to pain that occurs with a definite association to the menstrual cycle.

    • Chronic pelvic pain has been defined as pain of greater than 6 months' duration


    • Dysmenorrhea, or painful menstruation, is the most common cyclic pain phenomenon and is classified as primary or secondary on the basis of associated anatomic pathology


    • ACUTE pelvic pain often is associated with signs of inflammation or infection:

      • fever and leukocytosis,

        which are absent in chronic pain states.


    • Rapid onset of pain is most consistent with perforation of a hollow viscus or ischemia.

    • Colic or severe cramping pain is commonly associated with muscular contraction or obstruction of a hollow viscus, such as intestine or uterus,

    • pain perceived over the entire abdomen suggests a generalized reaction to an irritating fluid within the peritoneal cavity.


    Acute pelvic pain !!!

    Ectopic pregnancyPelvic inflammatory disease (PID) - Salpingitis- oophoritis - Tuboovarian abscess (TOA) Hemorrhagic ovarian cystOvarian torsionBartholin gland abscess


    Ectopic pregnancy


    - ectropic pregnancy = outside the uterus- heterotropic pragnancy = both intrauterine pregnacy (IUP) + ectopic pregnancy, 1 : 30000 pregnancies


    sites of ectopic implantation:

    - 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


    2.Differential diagnosisb. nonreproductive tract- appendicitis- pyelonephritis- pancreatitis


    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.


    5. Treatment

    a. Conservative treatment

    -iv hydration.

    - 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

    - laparotomy


    Methotrexate: Applications

    • Molar Pregnancy / GTN

    • Ectopic Pregnancy

    • Cancer Chemotherapy

    • Rheumatoid Arthritis

    • Psoriasis

    • First Trimester Abortion


    MTX / Misoprostol Abortion:

    • Most Effective in Early Pregnancy

      (≤ 56 days LMP)

    • 90-97% Effective

    • Requires Compliant Patient, Several Visits

    • Not Yet Covered By Most Insurers


    MTX

    Stomatitis

    Gastritis

    Alopecia

    Elevated LFT’s

    Misoprostol

    Diarrhea

    Nausea

    MTX / Misoprostol Side Effects:


    MTX / Misoprostol vs Misoprostol

    (Crenin and Vittinghoff JAMA 272:1190-1195, 1994)

    Percent Complete Abortion


    • 6. Disposition

    • A patient with a raptured ectopic pregnancy needs immediate surgery.

    • Patient with non- ruptured ectopic pregnancy are admitted to the ob..gyn service. Definitive treatment may be done operatively or with methotrexate.

    • Stable patients with low suspicion and inconclusive testing may be discharged home with follow-up in 48 hours to check a B- hCG level.


    Pevic inflamatory disease

    (PID)


    Pevic inflamatory disease

    Pelvic inflammatory disease (PID) is an inflammatory disorder of the:- uterus,- fallopian tubes,- and adjacent pelvic structures.


    PID

    = 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


    Risk factors for PID

    • include young age at first intercourse,

    • multiple sexual partners,

    • intrauterine device (IUD) insertion,

    • and tobacco smoking.

      A delay in diagnosis or treatment can result in long-term sequelae such as tubal infertility.


    Clinical features

    1. Symptoms may include:

    - Acute onset of bilateral lower abdominal or pelvic pain

    - Fever

    - 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


    • Chlamydia trachomatis: C trachomatis, an intracellular bacterial pathogen, is the predominant STD organism causing PID. Clinically, infection with this obligate intracellular parasite may manifest as mucopurulent cervicitis.

    • Cytomegalovirus (CMV):

    • Endogenous microflora: In iatrogenically induced infections, the endogenous microflora of the vagina predominate.

    • Gardnerella vaginalis

    • Haemophilus influenzae

    • Enteric gram-negative organisms (Escherichia coli)

    • Peptococcus species

    • Streptococcus agalactiae

    • Bacteroides fragilis: This can cause tubal and epithelial destruction.

    • Neisseria gonorrhea: the role of N gonorrhea as the primary cause of PID has decreased.


    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


    Pelvic adhesions:

    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.


    Tuboovarian abscess (TOA)


    - 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


    2. Diagnostic testsa. B-hCG to look for pregnancyb. Preoperative laboratory studies: CBC, chemistry panel, PT, APTT, and type and screen.


    3.Treatmenta. IV hydrationb. IV antibiotics ( cefoxitin + doxycycline or gentamycin + clindamycin)c. Emergency laparotomy if TOA has ruptured


    4. Disposition

    - 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


    3. Treatmenta. IV hydrationb. Blood transfusion if massive hemorrhage occurs (operative intervention may be needed for massive bleeding).


    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.


    Bartholin gland abscessBlockage of the duct leads to the formation of a cyst, and sometimes an abscess.


    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.


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