Emergency Obstertrics & Gynecology

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Emergency Obstertrics & Gynecology

  1. 1. Obstetrics and Gynecology Emergency
  2. 2. Gynecologic Emergency <ul><li>Women Acute Problems </li></ul><ul><ul><li>Abnormal vagina bleeding </li></ul></ul><ul><ul><li>Acute Abdominal pain </li></ul></ul>
  3. 3. Women Acute Problems <ul><li>Approach to the problem </li></ul><ul><li>History taking </li></ul><ul><li>Physical Examination </li></ul><ul><ul><li>General Physical Examination </li></ul></ul><ul><ul><li>Pelvic Examination </li></ul></ul><ul><li>Laboratory test </li></ul>
  4. 4. Women Acute Problems <ul><li>History takin g </li></ul><ul><li>Chief complain </li></ul><ul><li>Present illness </li></ul><ul><li>Past history </li></ul><ul><ul><li>PMP (past normal menstruation period) </li></ul></ul><ul><ul><li>LMP (last normal menstruation perio d ) </li></ul></ul><ul><ul><li>Gravida & parity </li></ul></ul><ul><ul><li>Abortion </li></ul></ul><ul><ul><li>Sexual intercourse </li></ul></ul><ul><ul><li>Contraception </li></ul></ul><ul><ul><li>Pregnancy & Delivery </li></ul></ul>
  5. 5. The Physician Role <ul><li>The physician is </li></ul><ul><ul><li>A good listener </li></ul></ul><ul><ul><li>Empathic </li></ul></ul><ul><ul><li>Honest </li></ul></ul><ul><ul><li>Genuine </li></ul></ul>
  6. 6. The Physician Role <ul><li>The physician use </li></ul><ul><ul><li>Understandable language </li></ul></ul><ul><ul><li>Appropriate body language </li></ul></ul><ul><ul><li>A collaborative approach </li></ul></ul><ul><ul><li>Open dialogue </li></ul></ul><ul><ul><li>Appropriate emotional content </li></ul></ul><ul><ul><li>Humor and warmth </li></ul></ul>
  7. 7. The Physician Role <ul><li>The physician is not </li></ul><ul><ul><li>Confrontation </li></ul></ul><ul><ul><li>Combative </li></ul></ul><ul><ul><li>Condescending </li></ul></ul><ul><ul><li>Overbearing </li></ul></ul><ul><ul><li>Judgmental </li></ul></ul>
  8. 8. Normal menstruation <ul><li>Beyond the first 1 to 2 years after menarche menstrual cycle conform to a cycle length of 21 to 35 days with a duration of less than 7 days </li></ul><ul><li>Recurrent amount more than 80 cc/cycle cause anemia </li></ul>
  9. 9. Women Acute Problems <ul><li>Physical examination </li></ul><ul><li>General physical examination </li></ul><ul><li>Abdominal examination </li></ul><ul><ul><li>Bowel sound </li></ul></ul><ul><ul><li>Mass </li></ul></ul><ul><li>Point of tenderness or Ascites </li></ul><ul><li>Guarding & Rebound tenderness </li></ul>
  10. 10. Women Acute Problems <ul><li>Pelvic examination </li></ul><ul><li>M/N IUB: Discharge, appearance </li></ul><ul><li>Vagina: Mucosa & Discharge </li></ul><ul><li>Cervix: Discharge, Erosion, Os status, Excitation pain </li></ul><ul><li>Uterus: Size, Shape, Position </li></ul><ul><li>Adnexae: Mass, Tenderness </li></ul><ul><li>Caldesac: Bulging, Mass, Tenderness </li></ul>
  11. 11. Women Acute Problems <ul><li>OPD laboratory </li></ul><ul><li>Wet smear </li></ul><ul><ul><li>NSS </li></ul></ul><ul><ul><li>KOH </li></ul></ul><ul><li>Gram stain </li></ul><ul><li>Complete blood count </li></ul><ul><li>Urine examination </li></ul><ul><li>Urine pregnancy test </li></ul><ul><li>Option: Culture & sensitivity </li></ul><ul><ul><li> Endometrial aspiration </li></ul></ul><ul><ul><li> Tissue Biopsy, PAP </li></ul></ul>
  12. 12. Urine pregnancy test <ul><li>Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of whether she states that she has had intercourse. </li></ul>
  13. 13. Abnormal (vaginal) bleeding <ul><li>Introituses </li></ul><ul><li>Vagina </li></ul><ul><li>Cervix </li></ul><ul><li>Uterus </li></ul>
  14. 14. Introituses <ul><li>Infection </li></ul><ul><li>Trauma </li></ul><ul><li>Sexual Abuse </li></ul>
  15. 15. Vagina <ul><li>Congenital </li></ul><ul><li>Trauma (sexual abuse) </li></ul><ul><li>Infection </li></ul><ul><li>Tumor </li></ul>
  16. 16. Cervix <ul><li>Congenital </li></ul><ul><li>Trauma (sexual abuse) </li></ul><ul><li>Tumor </li></ul><ul><li>Infection </li></ul>
  17. 17. Abnormal Uterine Bleeding <ul><li>Metrorhagia </li></ul><ul><li>Menorrhea </li></ul><ul><li>Hyper menorrhea </li></ul><ul><li>(Hypo menorrhea) </li></ul>
  18. 18. Abnormal uterine Bleeding <ul><li>Extreme age </li></ul><ul><ul><li>Prepubertal </li></ul></ul><ul><ul><li>Adolescent </li></ul></ul><ul><ul><li>Perimenopause </li></ul></ul><ul><ul><li>Postmenopause </li></ul></ul><ul><li>Reproductive </li></ul>
  19. 19. Abnormal Uterine Bleeding <ul><li>Reproductive age </li></ul><ul><ul><li>Pregnancy complication </li></ul></ul><ul><ul><li>Not pregnancy condition </li></ul></ul>
  20. 20. Abnormal Uterine Bleeding <ul><li>Reproductive age </li></ul><ul><li>Pregnancy complication </li></ul><ul><ul><li>Abortion: Threaten, inevitable, complete, incomplete </li></ul></ul><ul><ul><li>Molar pregnancy </li></ul></ul><ul><ul><li>Ectopic pregnancy </li></ul></ul>
  21. 21. Abnormal Uterine Bleeding <ul><li>Reproductive age </li></ul><ul><li>Not pregnancy condition </li></ul><ul><ul><li>Congenital Anomaly </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Tumor: Benign or Malignant </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Other medical disease </li></ul></ul><ul><ul><li>Exogenous hormonal or drug used </li></ul></ul>
  22. 22. Abnormal Uterine Bleeding <ul><li>Extreme age </li></ul><ul><ul><li>Children and Early adolescent </li></ul></ul><ul><ul><li>Menopause </li></ul></ul>
  23. 23. Abnormal Uterine Bleeding <ul><li>Extreme age: Children and Early adolescent </li></ul><ul><li>Organic disease </li></ul><ul><ul><li>Congenital anomaly </li></ul></ul><ul><ul><li>Trauma: foreign body, sexual abuse </li></ul></ul><ul><ul><li>Tumor: benign or malignant </li></ul></ul><ul><ul><li>Infection: sexual abuse </li></ul></ul><ul><li>Functional condition: Anovulation </li></ul>
  24. 24. Abnormal Uterine Bleeding <ul><li>Extreme age: Menopause </li></ul><ul><ul><li>Peri-menopausal bleeding </li></ul></ul><ul><ul><li>Post-menopause bleeding </li></ul></ul><ul><ul><ul><li>Organic disease </li></ul></ul></ul><ul><ul><ul><li>Functional condition </li></ul></ul></ul>
  25. 25. Abnormal Uterine Bleeding <ul><li>Peri-menopause: </li></ul><ul><li>Organic disease </li></ul><ul><ul><ul><li>Myoma uteri </li></ul></ul></ul><ul><ul><ul><li>Cervical or endometrial polyp </li></ul></ul></ul><ul><ul><ul><li>Endometrial hyperplasia </li></ul></ul></ul><ul><ul><ul><li>Endometrial carcinoma </li></ul></ul></ul>
  26. 26. Abnormal Uterine Bleeding <ul><li>Peri-menopause: </li></ul><ul><li>Function condition (dysfunctional uterine bleeding, DUB) </li></ul><ul><li>Anovulatory bleeding </li></ul><ul><li>Hormonal effect: HRT, Other hormone </li></ul>
  27. 27. Abnormal Uterine Bleeding <ul><li>Post-menopausal bleeding </li></ul><ul><li>Causes are the same as peri-menopause bleeding </li></ul><ul><li>but malignant tumor is more likely </li></ul>
  28. 28. Abnormal Uterine Bleeding <ul><li>In peri and post menopausal women, malignant tumor must be rule out before dysfunctional uterine bleeding (DUB) is diagnosed and treatment. </li></ul>
  29. 29. Acute pelvic pain <ul><li>Gynecologic disease or dysfunction </li></ul><ul><li>Recurrent pelvic pain . </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Genitourinary </li></ul><ul><li>Musculoskeletal </li></ul><ul><li>Others </li></ul>
  30. 30. Acute Pelvic Pain <ul><li>Gynecologic disease or dysfunction </li></ul><ul><ul><li>Complication of pregnancy </li></ul></ul><ul><ul><li>Acute infection . </li></ul></ul><ul><ul><li>Adnexal disorder . </li></ul></ul>
  31. 31. Acute Pelvic Pain <ul><li>Complication of pregnancy </li></ul><ul><ul><li>Ruptured ectopic pregnancy </li></ul></ul><ul><ul><li>Abortion: threaten or incomplete </li></ul></ul><ul><ul><li>Degeneration of liomyoma </li></ul></ul>
  32. 32. Ectopic pregnancy Triad <ul><li>Missed period </li></ul><ul><li>Abdominal or pelvic pain </li></ul><ul><li>Adnexal mass . </li></ul>
  33. 33. Acute Pelvic Pain <ul><li>Acute infection </li></ul><ul><ul><li>Endometritis </li></ul></ul><ul><ul><li>Pelvic inflammatory disease </li></ul></ul><ul><ul><li>Tubo-ovarian abscess </li></ul></ul>
  34. 34. PID <ul><li>Minimum criteria </li></ul><ul><ul><li>1 . Lower abdominal tenderness, </li></ul></ul><ul><ul><li>2. Adnexa tenderness </li></ul></ul><ul><ul><li>3. Cervical motion tenderness </li></ul></ul>
  35. 35. PID <ul><li>Additional Criteria </li></ul><ul><ul><li>1. Oral temperature > 101 F (>38.3 C) </li></ul></ul><ul><ul><li>2. Abnormal cervical or vaginal discharge </li></ul></ul><ul><ul><li>3. Elevated erythrocyte sedimentation rate </li></ul></ul><ul><ul><li>4. Elevated C-reactive protein </li></ul></ul><ul><ul><li>5. Laboratory documentation of cervical infection with N. gonorrhea or C. trachomatis </li></ul></ul>
  36. 36. PID: Admitted criteria <ul><li>1. Surgical emergencies such as appendicitis cannot be excluded. </li></ul><ul><li>2. The patient is pregnant. </li></ul><ul><li>3. The patient does not respond clinically to oral antimicrobial therapy. </li></ul><ul><li>4. The patient is unable to follow or tolerate an outpatient oral regimen </li></ul>
  37. 37. PID: Admitted criteria <ul><li>5.The patient has severe illness, nausea and vomiting, or high fever. </li></ul><ul><li>6.The patient has a tubo-ovarian abscess. </li></ul><ul><li>7.The patient is immunodeficiency (i.e., has HIV infection with low CD4 counts, is taking immunosuppressive therapy, or has another disease). </li></ul><ul><li>8. The patient is adolescent . </li></ul>
  38. 38. Acute Pelvic Pain <ul><li>Adnexal disorders </li></ul><ul><ul><li>Hemorrhagic function ovarian cyst </li></ul></ul><ul><ul><li>Torsion of adnexa </li></ul></ul><ul><ul><li>Twisted par ovarian cyst </li></ul></ul><ul><ul><li>Ruptured of functional or neoplastic ovarian cyst . </li></ul></ul>
  39. 39. Recurrent pelvic pain <ul><li>Mittelschmerz (midcycle pain) </li></ul><ul><li>Primary dysmenorrhea </li></ul><ul><li>Secondary dysmenorhea </li></ul>
  40. 40. Recurrent pelvic pain <ul><li>Gastrointestinal </li></ul><ul><ul><li>Appendicitis </li></ul></ul><ul><ul><li>Bowel obstruction </li></ul></ul><ul><ul><li>Diverticulitis </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Irritable bowel syndrome </li></ul></ul>
  41. 41. Recurrent pelvic pain <ul><li>Genitourinary </li></ul><ul><ul><li>Cystitis </li></ul></ul><ul><ul><li>Pyelonephritis </li></ul></ul><ul><ul><li>Ureteral lithiasis </li></ul></ul>
  42. 42. Recurrent pelvic pain <ul><li>Musculoskelital </li></ul><ul><li>Others </li></ul><ul><ul><li>Acute Porphyria </li></ul></ul><ul><ul><li>Pelvic thrombophebitis </li></ul></ul><ul><ul><li>Aneurysm </li></ul></ul><ul><ul><li>Abdominal angina </li></ul></ul>
  43. 43. Recurrent pelvic pain <ul><li>Primary dysmenorrhea </li></ul><ul><li>Secondary dysmenorrhea </li></ul><ul><ul><li>Imperforated hymen </li></ul></ul><ul><ul><li>Transverse vaginal septum </li></ul></ul><ul><ul><li>Cervical stenosis </li></ul></ul><ul><ul><li>Uterine anomaly </li></ul></ul><ul><ul><li>Intrauterine synergia </li></ul></ul><ul><ul><li>Endometrial polyps </li></ul></ul><ul><ul><li>Uterine liomyoma </li></ul></ul><ul><ul><li>Adenomyosis </li></ul></ul><ul><ul><li>Pelvic congestion syndrome </li></ul></ul><ul><ul><li>Endometriosis </li></ul></ul>
  44. 44. Obstetrics Emergency <ul><li>Antepartum hemorrhage </li></ul><ul><li>Acute complication of preeclamsia </li></ul><ul><li>Postpartum hemorrhage </li></ul><ul><li>Acute abdomen during pregnancy </li></ul><ul><li>Abdominal trauma during pregnancy </li></ul><ul><li>Cardiac arrest during pregnancy </li></ul>
  45. 45. Antepartum Hemorrhage <ul><li>Abortion </li></ul><ul><li>Abnormal Placentation </li></ul><ul><ul><li>Placenta previa </li></ul></ul><ul><ul><li>Placenta abruption </li></ul></ul>
  46. 46. Antepartum Hemorrhage <ul><li>Placenta previa </li></ul><ul><ul><li>Painless bleeding </li></ul></ul><ul><ul><li>Ultra sonography </li></ul></ul><ul><ul><li>Maternal bleeding may be severe </li></ul></ul><ul><ul><li>Termination of pregnancy </li></ul></ul>
  47. 47. Antepartum Hemorrhage <ul><li>Placenta abruption </li></ul><ul><ul><li>Painful vagina bleeding </li></ul></ul><ul><ul><li>Fetus in jeopardy </li></ul></ul>
  48. 48. Acute complication of preeclampsia <ul><li>Seizer </li></ul><ul><ul><li>MgSo 4 is appropriate than diazepam or phenetoin </li></ul></ul><ul><li>Hypertension </li></ul><ul><ul><li>More than 160/110 mmHg </li></ul></ul><ul><ul><li>Hydralazine </li></ul></ul><ul><ul><li>Nifedipine </li></ul></ul><ul><ul><li>Sodium nitroprusside </li></ul></ul>
  49. 49. Postpartum Hemorrhage <ul><li>Immediate PPH </li></ul><ul><li>Delayed PPH </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Retain piece of conceptive product </li></ul></ul><ul><ul><li>Uterine atony </li></ul></ul>
  50. 50. Acute Abdomen during Pregnancy <ul><li>Acute appendicitis </li></ul><ul><li>Renal stone </li></ul><ul><li>Acute cholecystitis </li></ul>
  51. 51. Abdominal Trauma during Pregnancy <ul><li>Blunt or sharp </li></ul><ul><li>Fetal viability </li></ul><ul><li>Maternal condition </li></ul><ul><li>Fetal well being </li></ul>
  52. 52. Abdominal Trauma during Pregnancy <ul><li>Physical abuse </li></ul><ul><li>Sexaul Assault </li></ul><ul><li>Automobile accidents </li></ul><ul><li>Fetal injury and death </li></ul><ul><li>Placenta abruption </li></ul><ul><li>Uterine rupture </li></ul>
  53. 53. Abdominal Trauma during Pregnancy <ul><li>As in none pregnant women </li></ul><ul><li>Evaluate and stabilization maternal injuries </li></ul><ul><li>Fetal assessment may divert from life threatening maternal injuries </li></ul><ul><li>Repositioning the large uterus away from the great vessel </li></ul>
  54. 54. Cardiac Arrest during Pregnancy <ul><li>Basic life support (BLS) </li></ul><ul><li>Advance cardiac life support (ACLS) </li></ul><ul><li>Pregnancy physiologic change </li></ul><ul><li>Post mortem cesarean section </li></ul>

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