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GYNECOLOGIC

EMERGENCIES
FARHAD TAKHTI M.D.
SENIOR CONSULTANT
LANDESKLINIKUM NEUNKIRCHEN
AUSTRIA
CARCINOMA BLEEDING

 VAGINAL BLEEDING:
ADVANCED CERVIX OR ENDOMETRIUM
CARCINOMA.

 INTRAABDOMINAL BLEEDING:
CAPSULE RUPTURE OF AN OVARIAN
CARCINOMA
CLINICAL PICTURE
 VAGINAL BLEEDING
I.SPECULUM EXAMINATION:
THE VAGINA IS FULL WITH CLOTS,
PORTIO EXOPHYTIC OR SHOWS
CARCINOMA CRATER
SURFACE BLEEDING STRONGER AFTER
TOUCHING
II.PALPATION:
OFTEN LARGE TUMOR THAT FILLS THE
SMALL
PELVIS
CLINICAL PICTURE
 INTRAABDOMINAL BLEEDING
I.ABDOMINAL PAIN(localised then
generalised)
ABDOMINAL RIGIDITY
NAUSEA , VOMITING
PALOR , CYANOSIS, WEAK PULSE
II.SONOGRAPHY:
SPACE OCCUPYING LESION
FREE LIQUID IN DOUGLAS SPACE
ACUTE MANAGEMENT
 LOCAL THERAPY:
1. COVER THE CERVIX TUMOR WITH A
HEMOSTYPTICAL PATCH (TACHOCOMB)
2. TAMPONADE THE CERVIX FIRMLY
3. URINARY CATHETER
DO NOT TRY TO ELECTROCOAGULATE
DO NOT TRY TO MAKE SUTURES
ACUTE MANAGEMENT
 GENERAL MEASURES:
AT LEAST 2 IV LINES
TYPE & CROSSMATCH
VOLUME SUBSTITUTION:
PACKED RBC,s-CRYSTALLOIDS
OXYGEN(6 Lit / minute)
SEDATE THE PATIENT ( DIAZEPAM)
DIAGNOSIS
 KNOWN INOPERABLE TUMOR IN
MOST CASES
 BIOPSY & HISTOLOGY
 RECTOSCOPY
 CYSTOSCOPY
 COMPUTER TOMOGRAPHY
 MAGNET RESONANCE IMAGING
 LAPARATOMY
THERAPY
 INOPERABLE TUMOR OF UTERUS:
RADIATION

 LAPARATOMY

 LIGATION OF Art.iliaca interna

 EMBOLISATION OF Art.iliaca interna


EVERY PELVIC SURGEON
SHOULD BE ABLE TO
LIGATE THE INTERNAL ILIAC
ARTERY
UTERUS PERFORATION

 Simple perforation:
Perforation with small Hegar or
uterine sound
without heavy Bleeding.
 Complex perforation:
Perforation of uterus with a large
defect by an
Abortion forceps.
UTERINE PERFORATION
 Etiology:
hysteroscopy, curettage, IUD
insertion.
 Manifestaions:
A. feel no resistance against the
instruments.
B. if a large perforation you see the
intestine
or appendices epiploicae
C.with heavy bleeding the clinical
MANAGEMENT
 STOP THE OPERATIVE PROCEDURE
 IF NO ACTIVE OR REMARKABLE BLEEDING
DO HYSTEROSCOPY;IF NO BLEEDING
SOURCE THEN :OBSERVE THE PATIENT
FOR 24 HOURS
 IF REMARKABLE BLEEDING :GIVE
UTEROTONICS(METHERGIN-SULPROSTON)
AND DO LAPARASCOPY
 IN HEAVY BLEEDING-HYDATIFORM MOLE
AND ENDOMETRIUM CA :HYSTRECTOMY
GENITAL TRAUMA
 DEFINITION:
CONTUSION,SCRATCH,LABIAL TEAR,
PENETRATING INJURY THROUGH
PERINEUM OR ABDOMINAL WALL
 ETIOLOGY:
FALL ON THE FENCE OR BYCYCLE
FRAME,PENETRATING TRAUMA,CAR
ACCIDENTS
SIGNS & SYMPTOMS
 EXCORIATION, CONTUSION AND
HEMATOMA OF THE VULVA AND
MONS PUBIS
 PAIN
 HEMATURIA
 FECAL MATERIAL THROUGH
PENETRATION CANAL
 BLEEDING(EXTERNAL-INTERNAL)
DIAGNOSTIC
 EXACT EXAMINATION OF GENITALIA
 SONOGRAPHY
 COMPUTER TOMOGRAPHY
 MAGNETIC RESONANCE IMAGING
 CYSTOSCOPY
 COLOSCOPY
 INTERDISCIPLINARY COOPERATION
BETWEEN GYNECOLOGIST, SURGEON
UROLOGIST, RADIOLOGIST
COHABITATION INJURY
 DEFLORATION

 INJURY DUE TO ANATOMIC ANOMALY

 INJURY DUE TO GENITAL ATROPHY

 ABNORMAL SEXUAL PRACTIC


RAPE DEFINITION
 THE USE OF PHYSICAL FORCE ,
DECEPTION, INTIMIDATION, OR THE
THREAT OF BODILY HARM
 LACK OF CONSENT OR INABILITY TO GIVE
CONSENT BECAUSE THE SURVIVOR IS
VERY YOUNG OR VERY OLD,IMPAIRED BY
ALCOHOL OR DRUGS, UNCONSCIOUSNESS,
OR MENTALLY OR PHYSICALLY IMPAIRED
 ORAL, VAGINAL,OR RECTAL PENETRATION
WITH A PENIS, FINGER, OR OBJECT
DO NOT FORGET

RAPE OR SEXUAL INTIMIDATION


MEANS A MASSIVE ASSAULT ON THE
PERSONALITY OF THE VICTIM.
THE PSYCHIC HARMS ARE MORE
SERIOUS THAN THE PHYSICAL
INJURIES.
MANAGEMENT
 CAUTIOUS EXPLORATION
 EXPLAIN THE EXAMINATION STEPS
FOR THE VICTIM
 NO DOUBT ON THE CREDIBILITY OF
THE VICTIM
 NO INDIVIDUAL GUILT ALLOCATION
 ADVISE THE VICTIM TO BRING A
CRIMINAL CHARGE AGAINST THE
COMMITTER
EXACT DOCUMENTATION

 DATE AND TIME OF EXAMINATION


 DATE, TIME, AND SCENE OF THE ASSAULT
 THE COURSE OF THE ASSAULT
 WHAT KIND OF ASSAULT: ANAL VAGINAL,
ORAL?
 DID THE ASSAILANT USE CONDOM?
 DID THE VICTIM WASH HERSELF AFTER
THE ASSAULT?
 RELEASING FROM PROFESSIONAL MEDICAL
SECRECY (POLICE, ATTORNEY, HUSBAND)
DIAGNOSTIC STEPS
 HISTORY:
LMP; THE LAST SEXUAL INTERCOURSE
BEFORE THE ASSAULT; CONTRACEPTION;
ALCOHOL AND OTHER DRUGS; THE
VICTIMS STATEMENT OF PAIN OR INJURIES.
 GENERAL CONDITION OF THE VICTIM:
ALCOHOL? DRUGS? PSYCHOLOGICAL
CONDITION OF THE VICTIM; ARE HER
CLOTHES TEARED? DIRTY? BLOODY?
SPOTTED?
DIAGNOSTIC STEPS
 TOTAL BODY EXAMINATION:
SEE FOR ANY INJURIES ESPECIALLY NECK
UPPERARM; WRIST; BREASTS; LOWER
ABDOMEN; THIGHS.
HEMATOMAS BY HOLDING THE VICTIM
FAST ON THE NECK, THE INNER SIDE OF
THE UPPERARMS AND THIGHS.
NOTE: THE HEMATOMAS ARE AT THE
BEGINNING PURPLE OR RED BLUE;AFTER 4
DAYS YELLOW; AND AFTER 7 DAYS GREEN
BROWN.
THE EXTRA GENITAL
INJURIES ARE MUCH MORE
COMMON THAN THE
GENITAL INJURIES.
THEREFORE LOOK FOR :
SKIN BRUISES
BITE MARKS
CONTUSIONS
CHOKING SIGNS
FORENSIC MEDICAL
EXAMINATION
 DO IT AFTER INFORMED CONSENT.
 SHOULD BE NON-JUDGMENTAL AND
OBJECTIVE.
 INCLUDES EXACT DOCUMENTATION
OF VICTIM‘S STATEMENTS AND
PHOTODOCUMENTATION OF
INJURIES.
 SHOULD NEVER TAKE PRIORITY OVER
INJURIES REQUIRING IMMEDIATE
MEDICAL CARE.
PROPHYLACTIC
MEDICATIONS FOLLOWING
RAPE
 LEVONORGESTREL 150 mcg OR A COPPER
IUCD
 CEFTRIAXON 125 mg IM OR
CIPROFLOXACIN 500 mg ORALLY
 AZITHROMYCIN 1 G ORALLY
 TETANUS VACCINATION IF INDICATED
 HIV PROPHYLAXIS: ZIDOVUDINE 300 mg
AND LAMIVUDINE 150 mg bid FOR 28
DAYS
 HEP.B VACCINATION IF THE VICTIM IS NOT
PREVIOUSLY VACCINATED
ECTOPIC PREGNANCY
 ONE OF THE MAJOR CAUSES OF
MATERNAL DEATH
 INCIDENCE : 2% OF PREGNANCIES
 MATERNAL DEATH RATE 0.4/1000
EP,s
 RISK FACTORS: HISTORY OF
PREVIOUS ECTOPIC PREGNANCY,
TUBAL SURGERY HISTORY OF PID
ESPECIALLY BY CHLAMYDIA
TRACHOMATIS
ECTOPIC PREGNANCY
 CONSIDER IT IN ALL WOMEN OF THE
REPRODUCTIVE AGE WITH ABDOMINAL
PAIN+VAGINAL BLEEDING AND IN
PARTICULAR IF THE PATIENT HAS
COLLAPS.

 CONSIDER IT STRONGLY IF THE PREG TEST


IS POSITIVE AND THERE IS NO UTERINE
GESTATIONAL SAC BUT FREE FLUID IN
DOUGLAS SPACE IN VAGINAL
SONOGRAPHY.
LABORATORY DIAGNOSIS
 IN A VIABLE INTRAUTERINE PREGNANCY
THE ß-hCG DOUBLES EVERY 2 DAYS.
 IF SERIAL ß- hCG SHOWS AN INCREASE OF
LESS THAN 66% IN 2 DAYS IT IS AN
NONVIABLE PREGNANCY (ECTOPIC OR
INTRAUTERINE).
 IF PROGESTERONE LEVEL IS 25 ng/ml OR
GREATER, AN ECTOPIC PREGNANCY
COULD BE EXCLUDED WITH A 98%
CERTAINTY.
 IF PROGESTERONE LEVEL IS LESS THAN 5
ng/ml , IT IS A NONVIABLE PREGNANCY
EITHER INTRAUTERINE OR EXTRAUTERINE.
HCG and SONOGRAPHY
DO NOT FORGET
 IF THE ß-hCG LEVEL IS GREATER THAN 1500 mIU/ml AND ON
VAGINAL US A PREGNANCY (GESTATIONAL SAC) IS NOT SEEN
IT IS EITHER AN ECTOPIC OR FAILED INTRAUTERINE
PREGNANCY.

 IN A VIABLE INTRAUTERINE PREGNANCY : YOU SEE AT


ß-hCG 1500 mIU /ml :GESTATIONAL SAC
ß-hCG 5000 mIU/ml :FETAL POLE
ß-hCG 17000 mIU/ml: FETAL CARDIAC ACTIVITY
OCCAM,S RAZOR

 ENTIA NON SUNT MULTIPLICANDA


PRAETER NECESSITATEM.
 ENTITIES MUST NOT BE MULTIPLIED
BEYOND NECESSITY.
 LAW OF PARSIMONY IS ALSO VALID FOR
DOCTORS:
 THE SIMPLEST THEORY IS ALWAYS THE
MOST PLAUSIBLE ONE ,AND NEW
THEORIES SHOULD BE ASSUMED ONLY, IF
THEY ARE ABSOLUTELY NECESSARY.
DIFFERENTIAL
DIAGNOSIS
 ACUTE APPENDICITIS
 ADNEXAL TORSION
 ABORTION
 CORP.LUTEUM OR FOLL.CYST RUPTURE
 PID
 DEGENERATING FIBROIDS
 ENDOMETRIOSIS
 URINARY TRACT INFECTION
 KIDNEY STONES
 DIVERTICULOSIS
TREATMENT OPTIONS
 MEDICATIONAL :METHOTREXATE

 OPERATIVE THERAPY:
LAPARASCOPY:
A. LINEAR SALPINGOSTOMY
B. SALPINGECTOMY
LAPARATOMY:
A. SEGMENTAL SALPINGECTOMY AND
REANASTOMOSIS
B. SALPINGECTOMY
METHOTREXATE
 DOSIS :50 mg /sq m
 ABSOLUTE CONTRAINDICATIONS:
 ACTIVE HEPATIC OR RENAL DISEASE
 IMMUNDEFICIENCY
 BLOOD DYSCRASIAS
 BREAST FEEDING
 RELATIVE CONTRAINDICATIONS:
 GESTATIONAL SAC >3.5 cm
 ß –hCG >5000 m IU /ml
FETAL CARDIAC ACTIVITY
QUESTIONABLE COMPLIANCE WITH FOLLOW-UP
METHOTREXATE PROTOCOL
 DAY 0 : CBC +BUN +CREATININE
+ LIVER ENZYMES
METHOTREXATE : 50 mg /sq m
 DAY 4 : ß-hCG LEVEL

 DAY 7 : ß-hCG LEVEL : IF >15% DECLINE


OF hCG BETWEEN DAY 4 AND 7 THEN
WEEKLY CONTROL UNTIL hCG REACHES
ZERO.IF <15% DECLINE OF HCG REPEAT
METHOTREXATE OR CONSIDER OPERATIVE
THERAPY.
OHSS
 ONE OF THE MAJOR COMPLICATIONS
OF OVULATION INDUCTION WITH
GONADOTROPINS OR CLOMIPHEN.
 PATIENTS WITH PCO SYNDROME ARE
AT INCREASED RISK OF OHSS IF
THEY ARE GIVEN OVULATION
INDUCTION DRUGS.
 MOST CASES ARE MILD, BUT IT CAN
BE LETHAL IN SEVERE CASES.
OHSS
CLASSIFICATION
 GRADE 1: Abdominal distention+
discomfort
 GRADE 2: Grade 1 symptoms +
nausea vomiting+/-
diarrhoea and enlarged ovaries
 GRADE 3: Above symptoms and
ascites
 GRADE 4: Grade 3 +Hydrothorax
 GRADE 5: Grade 4 +
Haemoconcentration+ Coagulation
OHSS
MANAGEMENT
 CONTROL WEIGHT AND ABDOMINAL
CIRCUMFERENCE AND FLUID
BALANCE DAILY.
 CONTROL THESE PARAMETERS
DAILY: HAEMATOCRIT ,
ELECTROLYTES, E2 CREATININ, BUN .
 IN SEVERE CASES INTENSIVE CARE
UNIT ADMISSION.
OHSS MANAGEMENT
SEVERE CASES
 STRICT FLUID BALANCE
 CENTRAL VENOUS PRESSURE LINE
 CRYSTALOID SOLUTIONS AS NEEDED
 COLLOID SOLUTIONS IF THE HCT >
45% OR IN WORSENING ASCITES OR
IN SEVERE HYPOALBUMINAEMIA
 LOW MOLECULAR HEPARIN TO
PREVENT DEEP VEIN THROMBOSIS
OHSS MANAGEMENT
 DO NOT USE NSAIDs BECAUSE THEY MAY
IMPAIR THE RENAL FUNCTION THAT IS
ALREADY AFFECTED.
 IF ANALGESICS ARE NECESSARY USE
PARACETAMOL OR OPIODS OR OPIATES.
 CONSIDER PARACENTESIS AND
PLEUROCENTESIS IF THE ABDOMEN IS
VERY TENSE OR THE PATIENT HAS
DYSPNEA.
 CONSIDER INTERRUPTING THE
PREGNANCY IF THE SITUATION LIFE
THREATENING.
DO NOT FORGET
 OHSS USUALLY IMPROVES IN THE LUTEAL
PHASE OF THE CYCLE, AND RESOLVES
WITHIN 3 TO 6 WEEKS.
 SEVERE PAIN MAY INDICATE ADNEXAL
TORSION OR ECTOPIC PREGNANCY.
 CONSIDER THE COMPLICATIONS:
 VASCULAR AND CARDIOVASCULAR
 HEPATIC DYSFUNCTION
 RESPIRATORY DISTRESS DUE TO EFFUSION
 RENAL DYSFUNCTION
 ADNEXAL TORSION
TOXIC SHOCK
SYNDROME
 THIS HIGHLY CRITICAL SITUATION
SHOULD BE CONSIDERED IN ANY
YOUNG WOMAN WITH HIGH FEVER ,
A WIDESPREAD RASH THAT LOOKS
LIKE A SUNBURN AND
DESQUAMATES AFTER 7-10 DAYS .
 IT IS CAUSED BY EXOTOXIN OF
S.AUREUS OR ERYTHROGENIC TOXIN
OF GROUP A OR B STREPTOCOCCI
TSS MANAGEMENT
 EXAMINE THE PATIENT CAREFULLY
 SEE FOR ANY FOCUS OF INFECTION
FOR EXAMPLE VAGINAL TAMPONS
AND REMOVE THESE.
 TRANSFER THE PATIENT TO
INTENSIVE CARE UNIT.
 USE PROPER ANTIBIOTICS:
CEFUROXIME OR FLUCLOXACILLIN
PELVIC INFLAMMATORY
DISEASE
 ASCENDING INFECTIONS : COMMON
 VAGINAL INFECTION RESULTS IN ENDOMETRITIS
SALPINGITIS , ADNEXITIS, PELVEOPERITONITIS,
PERITONITIS, SEPTICEMIA, SEPTIC SHOCK.
 ABORTION, DELIVERY, IUD, INTRAUTERINE
OPERATION
 DESCENDING INFECTIONS: SELDOM
 PER CONTINUATION: APPENDICITIS ,
PERITYPHLITIC ABSCESS, SIGMOIDITIS,
PERITONITIS
 HEMATOGENIC SPREAD: TUBERCULOSIS
PELVIC INFLAMMATORY
DISAESE
KEY POINTS
 THE TWO SEXUALLLY TRANSMITTED
BACTERIA RESPONSIBLE FOR MOST OF
CASES ARE C.TRACHOMATIS AND
N. GONORRHOEA
 CHLAMYDIA TRACHOMATIS TENDS TO
CAUSE MINIMAL SYMPTOMS AND CAN GO
UNDETECTED
 GONOCOCCAL OR POLYMICROBIAL PID
CAN CAUSE SIGNIFICANT DESTRUCTION
OF FALLOPIAN TUBES AND
DEVELOPEMENT OF PYOSALPINX OR
TUBOOVARIAN ABSCESS
ADNEXITIS
MANIFESTAIONS
 ACUTE ADNEXITIS:
 SUDDEN ABDOMINOPELVIC PAIN
 FEVER
 MALODOROUS YELOW – GREEN VAGINAL
DISCHARGE
 NAUSEA , VOMOTING, FLATULENCE
 DYSPAREUNIA
 POST MENSTRUAL BLEEDING, SPOTTING
 CERVIX MOTION PAIN
DIFFERENTIAL DIAGNOSIS
ADNEXITIS
 APPENDICITIS

 EXTRAUTERINE PREGNANCY

 ENDOMETRIOSIS

 COLLITIS ULCEROSA

 DIVERTICULITIS
MANAGEMENTOF PID
ACCORDING TO CDC
OUTPATIENT TREATMENT:
REGIMEN A
CEFOXITIN 2 G IM +DOXYCYCLINE 100 MG
ORALLY TWO TIMES DAILY FOR 14 DAYS +/-
METRONIDAZOL 500 MG TWO TIMES DAILY FOR
14 DAYS
REGIMEN B
OFLOXACIN 400 MG ORALLY TWO TIMES DAILY
FOR 14 DAYS +/-METRONIDAZOL 500 MG ORALLY
TWO TIMES DAILY FOR 14 DAYS
PID MANAGEMANT
INPATIENT TREATMENT
REGIMEN A
CEFOXITIN 2 G EVERY 6 HOURS INTRAVENOUSLY
+/- DOXYCYCLINE 100 MG EVERY 12 HOURS IV
REGIMEN B
CLINDAMYCIN 900 MG INTRAVENOUSLY EVERY 8
HOURS +
GENTAMYCIN LOADING DOSIS OF 2 MG/KG OF
BODY WEIGHT AND THEN 1.5 MG/KG EVERY 8
HOURS
PIONIERS OF
GYNECOLOGY
HERMANN JOHANESS
PFANNENSTIEL
1862-1909
Was born June 28,
1862 in Berlin,
receiving his
medical degree in
1885.
He introduced in
1900 the
transverse
suprapubic incision
of the skin for
PIONIERS OF
GYNECOLOGY
CARL GUSTAV CARUS
1789-1869
Was born January 3,
1789 in Leipzig.
He described the
pelvic inclination
curve.
PIONIERS OF
GYNECOLOGY
HUGH LENOX HODGE
1796 – 1873
Was born, June 27,
1796 in
Philadelphia.
1860 he introduced
the Hodge pessary
for the
management of
uterine prolapse.
THANK YOU
FRIENDS ARE GENERALLY OF
THE SAME SEX, FOR WHEN
MEN AND WOMEN AGREE, IT
IS ONLY IN THE
CONCLUSIONS, THEIR
REASONS ARE ALWAYS
DIFFERENT.
George Santayana