Stroke

2. INTRODUCTION
Spectrum of gynaecological diseases that
causes acute symptoms, necessitating
urgent and prompt management.
Presentation of gynaecologic emergencies
 Acute pelvic pain
 Abnormal vaginal bleeding
 Abnormal vaginal discharge
 Acute pelvic swelling

3. CAUSES OF GYNECOLOGICAL EMERGENCY
a) Pelvic inflammatory disease
b) Ruptured ovarian cyst
c) Cystitis
d) Mittelschmertz
e) Endometriosis
f) Ectopic pregnancy
g) Vaginal hemorrhage
h) Degenerating uterine fibroid or torsion of
pedunculated fibroid.
DDx: Appendicitis

4. PELVIC PAIN - GYNAECOLOGIC
Pregnancy
 Ectopic, uterine, miscarriage
Pain related to menstrual cycle
 Physiological dysmenorrhoea
 Endometriosis
 Rupture of corpus luteum cyst
 Mittelschmerz
Pain not related to menstrual cycle
 Uterine: fibroids, polyps, rupture
 Ovarian: torsion, bleeding
 Infection: PID, STD

5. PELVIC PAIN – NON GYNAECOLOGIC
GIT:
 Appendicitis, diverticulitis, gastroenteritis, obstruction, hernia
Urinary:
 Pyelonephritis, cystitis, renal stones
Abdominal wall pain

6. GYNAECOLOGICAL PROBLEMS – GENERAL
APPROACH
Hx and Ex require attention to privacy and
confidentiality
Obtain full menstrual, contraceptive and
sexual hx
Digital and speculum vaginal examination
except certain circumstances (eg.
children, painful vulval ulcers)
Consider pregnancy

7. Most common cause of
nontraumatic abdominal
pain.
Infection of the female
reproductive tract.
Usually involves the
uterus, fallopian tubes,
and ovaries.
Common causes:
gonorrhea and
chlamydial infections.
Staph or strep can also be
causative agents.
May be either acute or
chronic.
May develop into sepsis if
left untreated.
Adhesions can occur,
causing organs to stick
together.
Adhesions is a common
cause of chronic pelvic
pain and also increase
the frequency of ectopic
pregnancies.
PELVIC INFLAMMATORY DISEASE

8. Most common complaint is
abdominal pain.
It is a diffuse pain and
located at the along the
lower abdomen.
Moderate to severe.
Hard to distinguish from
appendicitis.
Pain may intensify during
menstrual period
Pain may also intensify
during sexual
intercourse.
Walk in a shuffling gait,
which decreases the
pain.
May be accompanied by
fever, chills, nausea,
and vomiting.
Vaginal discharge: yellow
ASSESSMENT OF PID

9. MANAGEMENT OF PID
Primary treatment is antibiotics, IV infusion.
Make the patient comfortable.

10. ECTOPIC PREGNANCY
Implantation of a pregnancy in outside the
endometrial cavity.
Most common site is within the fallopian tubes.
This is a surgical emergency
Rupture can occur with resultant hemorrhage.
Patients present with one-sided abdominal pain,
late or missed period, occasionally with
vaginal bleeding.

11. OVARIAN CYSTS
Cysts are fluid-filled pockets. When in the
ovary they can rupture and be a source of
abdominal pain. May undergo torsion.
When ruptured, a small amount of blood is
spilled into the abdomen causing irritation to
the peritoneum and the cause of abdominal
pain and rebound tenderness.

12. APPENDICITIS
Difficult to distinguish from PID or ectopic
pregnancy.
Abdominal pain that develops around the
navel and moves to the RLQ.
Pain may be associated with anorexia, fever,
nausea, vomiting, or shock.

13. CYSTITIS
Bladder infection.
Because the bladder lies anterior to the
reproductive organs, it causes pain above
the symphysis pubis once inflamed.

14. MITTLESCHMERTZ
Abdominal pain in mid of menstrual cycle.
Ovulation pain.
This pain is referred to as mittleschmertz, and
is associated with the release of an egg
from the ovary.

15. Vaginal hemorrhage due to abortion may be
associated with acute severe abdominal
pain.
Degenerating uterine fibroid or torsion of
pedunculated subserosal uterine fibroid may
present with acute severe abdominal pain.

16. EVALUATION

17. HISTORY
Characteristics of pain
 Dyspareunia
Pelvic fullness, PV bleeding, discharge
Associated symptoms
 Urinary, GIT, pyrexia
Obstetrical and Gynaecological History
 LMP, previous ectopics, TA, previous PID, STDs, hx of ovarian
cysts, partners
Contraception
 IUCD, OCP, Barrier
Surgical History

18. PHYSICAL EXAM
General
 Looks unwell, dehydrated, colour
CVS
Chest
Abdominal
 Distension, bowel sounds, hernia, tenderness, mass
Back

19. PELVIC EXAMINATION
Speculum & digital Exam
Vaginal
 Lesions, discharge
Cervix
 Chandelier sign, os open/closed
Uterus
 Size, shape, regularity, tenderness, position, mobility
Adnexa
 Masses, tenderness, ovaries
Rectal
 Mass, tenderness, blood

20. INVESTIGATIONS
Blood
 FBC, beta-HCG, CRP, ESR
Microbiology
 Blood cultures, Endocervical swab, urine C+S
Urine
 Urinalysis, beta HCG
Radiology
 KUB, abdominal
USS
 Abdominal, pelvic

21. MANAGEMENT
Depends on cause
Ovarian cysts
Very common cause of adnexal enlargement with
pelvic pain
Important points:
 Ovarian torsion
 Ovarian neoplasm - older women

22. MANAGEMENT
A patient with acute severe abdominal
pain should be treated urgently.
May need oxygen
IV Fluids may be needed: crystalloid of
choice.
Put in position of comfort.

24. CAUSES OF GYNECOLOGICAL TRAUMA
Straddle Injury (bicycle)
Blows to the perineal area
Foreign body insertion into the vagina
Attempts at abortion
Lacerations following childbirth
Sexual assault

25. GYNECOLOGICAL TRAUMA
Injuries to the external genitalia should
be managed by simple pressure over
the laceration.
IV crystalloid if bleeding is severe.
Monitor hemodynamic state
Repair any tears

26. SEXUAL ASSAULT
60% are not even reported. And sexual abuse
of children is reported even less.
There is no “typical victim”
Defined: sexual contact without the consent of
the person assaulted.
Rape: Vaginal or rectal penetration without
consent.

27. SEXUAL ASSAULT
In most states penetration must occur for an act
to be classified as rape.
Sexual assault is a crime of violence with
serious physical and psychological
implications.
Most victims know the assailant. Motivation is
unclear, control of the victim, desire to inflict
pain, aggression have been implicated.

28. MANAGEMENT OF THE ASSAULT VICTIM
Counselling: Psychological and emotional
support is the most important help you can
offer. Maintain a nonjudgmental attitude.
Assure confidentiality. Provide safe
environment (well lit area).
P.E.P
Emergency Contraception
STIs Prevention
Repair of physical injuries

29. THAT HORMONE THING AKA MENSTRUAL
CYCLE
Normal 21-35 days. Flow 3-7
days
Precise sequence of events with
appropriate amounts of
progesterone and oestrogen
2 phases – Follicular and Luteal
Follicular – oestrogen stimulates
endometrial growth
Ovulation – surge of LH and FSH
causes release of oocyte
Luteal – CL produces
progesterone which matures
endometrium
Without HCG from embryo, CL
regresses. Drop in Prog &
Oest
Spiral arteries supplying
endometrium restricted and