Gynaecological emergencies

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  • Note patient’s gravida and parity
    Chaperone can guard the door to prevent sudden inadvertent interruption.
    Use a chaperone even when the patient is being examined by female members of staff.
    Document the name of the chaperone in the medical record.
    Perform urinary or serum beta-HCG pregnancy test
  • Consider first: could any associated vaginal bleeding be from ectopic pregnancy or threatened abortion?
    Physiological dysmenorrhoea – Pain regularly preceding menstruation and peaking on the first day of a period may be physiological. Suggest NSAID and refer to GP.
    Endometriosis – Growth of functional endometrial tissue in the pelvis outside the uterus may produce cysts and adhesions. Patients often present age approx. 30 years with dysmenorrhoea and menstrual problems, infertility and dyspareunia. Symptoms are usually chronic and recurrent in a cyclical fashion and are appropriately followed up by the GP. Occasionally, an endometrial cyst may rupture and bleed severely into the pelvis, presenting in similar fashion to ruptured ectopic pregnancy. Resuscitate for hypovolaemia and refer urgently.
    Rupture of corpus luteum cyst – Occurs pre-menstrually but may also cause significant haemorrhage, requiring resuscitation.
    Mittelschmerz – (German for “middle pain”) Mid-cycle extrusion of an ovum from a follicular cyst can cause abdominal pain, which seldom requires admission or investigation. Usually subsides within hours but can last 2-3 days. Mittelschmerz is believed to have a variety of causes: 1) Follicular swelling 2) Ovarian wall rupture
    3) Fallopian tube contraction 4) Smooth muscle cell contraction (At ovulation, this pain may be related to smooth muscle cell contraction in the ovary as well as in its ligaments. These contractions occur in response to an increased level of prostaglandin F2-alpha, itself mediated by the surge of luetinizing hormone (LH) 5) Irritation
    Uterine
    Perforation is seen esp. in presence of IUCD
    Leiomyomas (‘fibroids’) may undergo torsion (sudden severe colicky pain with tender uterus), or may infarct (‘red degeneration’) particularly during pregnancy. Refer such suspected problems for specialist investigations.
    Ovarian
    Torsion causes sudden onset sharp unilateral pain and usually involves an already enlarged ovary (cyst, neoplasm). Abdominal and PV tenderness may be present. Clinical diagnosis is difficult: if suspected, refer for USS and/or laparoscopy
    Bleeding into an ovarian cyst may present similarly and require investigation
  • Laparoscopic view of endometriosis. The bottom of the patient's uterus is at the top of this photo. The uterosacral ligaments are the thick bands of tissue at the left and right extreme of the photo. There are multiple, dark red endometriosis implants on the shiny peritoneal tissue. If one were to poke a needle through this tissue (i.e. directly into the middle of the photo) it would come out of the vagina. This is called the cul-de-sac, and is a common location of endometriosis. All of this tissue was removed with laparoscopic scissors.
  • This is a photo taken during laparoscopy of a corpus luteum cyst.This is a normal, physiologic cyst found each month in women in their"reproductive years" (the time between puberty and menopause). Thesecysts develop when an egg is released (you can see the actual area the egg came from in this photo- it's the "bump"pointing at you). After the egg is released, a corpus luteum cyst forms, and begins making progesterone. If the egg is fertilized, the cyst makes enough progesterone to help the egg and sperm "hold on" when implanted into the uterine wall. If the egg is not fertilized, the cyst slowly shrinks, and the whole cycle begins again next month. These cysts are generally about 2-5 cm in size.
  • This is a photo taken during laparoscopy of an ovarian torsion. Torsionoccurs when an ovarian cyst causes the ovary to twist on it's blood supply.This usually causes tremendous pain that brings patients to the emergency room. If the ovary is not untwisted soon, it can "die off" which is called necrosis in medical terminology. Treatment is usually detorsion by laparoscopy. In this photo, we see an ovary that is literally black and blue from oedema and blood. The black colour suggests that necrosis has set in, and that the ovary cannot be saved. You can see the ovary at the top of the photo, and a large cyst just below it. Notice the healthy, pink colour ofthe surrounding tissue. This ovary had to be removed, which is seen in the bottom photo. The bottom photo shows the ovary, which has been cut away, being put in a sterile bag. The bag is then pulled through a small opening, the cyst is drained, and it is removed from the body. This patient went home the same day as her laparoscopic surgery.
  • Very good at recognizing the unstable patient with an acute process occurring in the abdomen - whether it be from gut or gynaecological pathology. These patients need to be stabilized- and brought to the OR. These patients are not the ones we have the diagnostic difficulty with…
  • History can give you a lot of clues to cause of pain:
    Age - younger age groups more suspicious of infection. Older women consider carcinoma as potential cause.
    Of course, need to characterize pain- onset/duration, alleviating/aggravating, association with intercourse, menses, any associated symptoms- bleeding, discharge, dysuria, N/V, fever.
    Sudden onset of severe colicky pain follows ovarian torsion and acute vascular events; more insidious onset and continuous pain occur in infection and inflammation.Radiation of pain into back or legs suggests gynaecological origin.
    Menstrual history is important - especially last period- she could be pregnant. Also whether she has regular periods.
    Other important points are related to her previous obstetrical and gynaecological history - assessing risk for infection, ectopic pregnancy, or STD diagnoses.
  • Chandelier sign
    Term referring to severe pain elicited during pelvic examination of patients with pelvic inflammatory disease in which the patient responds by reaching upwards towards the ceiling for relief.
    The shamefulness associated with the examination of female genitalia has long inhibited the science of gynaecology. This 1822 drawing by Jacques-Pierre Maygnier shows a "compromise" procedure, in which the physician is kneeling before the woman but cannot see her genitalia. Modern gynaecology has shed these inhibitions.
    Bimaual pelvic examination
     
    Introduce yourself
    History
     
    - Explain reason for exam – when first start use contraception; irregular or heavy periods; painful periods; lower abdominal pain; attend for cervical (Pap) smear.
     
    - Patient void bladder prior to exam; Wash hands; Put gloves on
     
    Position – Patient at very edge of exam table with feet in padded stirrups, knees flexed and relaxed outwards. Use bright light.
     
    Inspection –
    1) Pubic hair – Lice? Nits?
    2) Perineum and anus
    3) Vulva – Labia – warts? (use magnification); separate labia – look for surface lesions, swellings, redness; Gently retract clitoral hood and expose clitoris – any peri-clitoral lesions?
    4) Hymen (or remnants) – redness just exterior to hymen remnants eg. vulvar vestibulitis
    5) Peri-urethral glands (Skene’s glands) – tiny ducts open to surface next to urethra. Discharge from urethra? (e.g. Gonorrhoea? Chlamydia?)
     
    Palpate –
    1) Upper labia majora – masses? (e.g. hernias extending through Canal of Nuck)
    2) Middle and Lower labia majora – masses? (e.g. Bartholin Duct Cyst)
     
    WARM VAGINAL SPECULM WITH WARM WATER!!!!!!
    Insert speculum – separate labia with one hand and insert speculum with other hand. Insert rotated 45 degrees (i.e. blades are not horizontal but oblique). Once past introitus, rotate speculum back to normal position. Labia minora sensitive to stretching/pinching – try not to catch it when inserting speculum!!
     
    OBTAIN SPECIMENS FOR PAP SMEAR AND CULTURES AS NEEDED
     
    BIMANUAL EXAM – 1 (more comfortable for patient) or 2 fingers (index and middle fingers allows for deeper penetration and more control of pelvic structures). Individualize for specific patient.
     
    1) Put lubricant on index and middle fingered gloves
    2) Explain what you are about to do to patient (“We will continue the exam now. You will feel me insert 2 fingers into the vagina”)
    3) Exert pressure posteriorly; palpate vaginal wall posteriorly, laterally and anteriorly Vagina – irregularities or tenderness of walls? Include urethra and bladder next.
    4) Turn palm upwards + compress urethra against underside of pubic bone. Normally not hurt; if discomfort – some degree of urethritis?
    5) Insert deeper, keep palm up, curl vagina finger up and compress bladder against pubic bone – should create sensation of want to urinate but not hurt; if hurt – cystitis; endometriosis
    6) Cervix – shape, size, consistency, regularity, mobility, tenderness. Should be non-tender and mobile. Feel fornices around cervix.
    7) Place other hand flat on abdomen – gently push down whilst pushing cervix up - feel size, shape, consistency, mobility, masses or tenderness of uterus.
    Non-pregnant woman – may feel ante-verted uterus above symphysis – firm and mobile
     
    Ask throughout any pain or discomfort?
    9) Abdominal hand RIF and press down and medial and vaginal hand to lateral fornix - feel size, shape, consistency, mobility, masses, tenderness of ovaries and adnexa. And LIF etc. Ask throughout any pain or discomfort?
     
    Difficult exam in obese or non-relaxed women
     
    Combined rectovaginal exam – index finger in vagina, middle finger in rectum - helpful in feeling utero-sacral ligament (common site of endometriosis)
     
    If exam is too painful – STOP
    1) Rectal exam with finger
    2) EUA
    3) U/S – abdominal and trans-perineal
     
    External genitalia – normal appearance. No enlargement of Skene or Bartholin glands.
    Urethra and bladder – non-tender
    Vagina – clean and without lesions
    Cervix – Smooth and without lesions. Motion of cervix causes no pain.
    Uterus – Normal size, shape, contour
    Adnexa (tubes and ovaries) – Not tender or enlarged
     
    Discuss procedure and findings with the patient!!!!
    Thank patient!!!!
  • Triple swab – Swab 1) High Vaginal Swab (posterior fornix) for C+S in Stuarts medium Swab 2) Endo-cervical swab for C+S in Stuarts medium Swab 3) Endo-cervical swab for Chlamydia in Chlamydia swab.
    Stuarts medium is basically agar and charcoal and is a standard transport medium for most microbiological specimens.
    The difference between a KUB and an abdominal plain film is the position of the film over the abdomen. The KUB, as its name implies, is a radiograph that includes the kidneys, ureters, and bladder. The abdominal plain film visualises the top of the diaphragm and does not include as much of the lower abdomen as the KUB, usually only to the level of the iliac crests.
  • Answer what is the most serious diagnosis
    Important points- need to rule out ovarian torsion - is an unexpected event that can happen at any age. Is more common with enlarged ovaries - cysts between 10-12 centimetres. Tend to be benign cysts- rare in malignancy because of adherence. Can twist and cut off blood supply- sometimes can detort by self. To save ovary- just like testicular torsion need to make diagnosis as soon as possible. Surgical management if suspect ovarian torsion
  • Many different types of ovarian cysts- can divide into the functional cysts that occur in the normal menstrual cycle; and both benign and malignant neoplasms, such as the dermoid cyst.
  • In general, vaginal infections (BV, TV, Candida) cause a lot of discharge compared with cervical infections (GC, Chlam)
    Herpes Simplex Virus – sexually transmitted. Usually due to type II but is increasingly due to type I (responsible for cold sores). Primary infection is extremely painful lasting up to 3 weeks and sometimes causes urinary retention. Look for shallow yellow vulvovaginal or perineal ulcers with red edges. Cervical ulcers may also be present, although pain may prevent speculum examination. Refer primary infections immediately for aciclovir. Recurrent infections are less severe, but may last up to 1 week. Treat with topical and oral aciclovir (200mg 5 tiems a day for a week) and arrange GU follow up with advice to avoid sexual contact in meantime. Do not prescribe aciclovir in pregnancy, but arrange for an obstetric opinion.
    Other STDs – refer to GU clinic and advise to abstain from sexual contact until treated.
    Squamous Cell Carcinoma – Causes indurated ulcers with everted edges esp. in elderly. Refer.
    Behcets syndrome – arthritis, iritis, genital ulcers, aphthous ulcers. Cause unknown – possible autoimmune affecting small blood vessels. More frequent and severe in those from Eastern Mediterranean and Asia. Genetic and environmental factors (eg. microbes) implicated. Not contagious.
    Bartholin’s abscess – infection of vestibular (Bartholin’s) cysts/gland at the posterior part of the labium majus. Usually due to Staph, Strep., or E. coli. But may be due to N. gonorrhoea. Refer for incision and drainage under GA and a full GU screen.
    Infected sebaceous cyst may also require I+D under GA
    Urethral carbuncle – small, red, painful swelling at the external urethral meatus is due to urethral mucosal prolapse. It may cause dysuria. Refer to an appropriate clinic to consider excision or diathermy.
  • Vulvar lesions of herpes virus infection are clinically obvious in this patient, but up to 70% of herpes simplex virus type II infections are totally asymptomatic, with no history of overt clinical disease.
  • This is a common condition which is difficult to diagnose and it is based on a combination of signs and symptoms ie. lower abdominal pain with pelvic tenderness and cervical excitation.
    Severity can range from no symptoms to chronic low grade infection (with relatively mild symptoms) to acute infection (with severe symptoms) which may result in abscess formation.
    Fitz-Hugh-Curtis syndrome is a rare complication of PID named after the two physicians, Fitz-Hugh and Curtis who first reported this condition in 1934 and 1930 respectively. Usually caused by N. gonorrhoea or chlamydia trachomatis. Consist of RUQ pain resulting from ascending pelvic infection and inflammation of the liver capsule or diaphragm. FHC occurs in 15-30% of women with PID. Overwhelmingly female, a few cases reported in males.
  • 90% are sexually transmitted: sexually active women aged 15-20 yrs are at particular risk.
  • Antibiotics
    Mild/moderate disease:
    1st line – Doxycycline 100mg bd PO 4 days + Metronidazole 400mg bd PO 5 days + Ceftriaxone 250mg IM stat (Ceftriaxone 1gm IV or Cefixime 400mg PO stat, if IM route contraindicated)
    Alternative – if vomiting and initially unable to take oral medication – Ceftriaxone 250mg IM stat+ Metronidazole 500mgs tds IV + Clarithromycin 500mg bd IV (change to Doxycycline + Metronidazole as above when oral route available)
    Severe disease:
    1st line – Ceftriaxone 1gm od IV + Metronidazole 500mg tds IV + Doxycycline 100mg bd PO or Clarithromycin 500mg bd IV if unable to take oral medication (change to oral Doxycycline + Metronidazole to complete 14 days treatment when clinically improved for 24hrs, doses as above)
    Alternative – if contraindication eg. pregnancy
    Ceftriaxone 250mg IM stat + Metronidazole 400mg bd PO for 5 days + Erythromycin 500mg qds PO for 14 days
    If allergy to penicillin or cephalosporins – Ofloxacin 400mg bd PO for 14 days + Metronidazole 400mg bd for 5 days. If also NBM, discuss with microbiologist. NB. Due to rising quinolone resistance in gonococci, patients treated with this regimen should be monitored closely and any cultures reviewed for sensitivity.
  • Have to decide whether to treat patient in hospital or not. First two are obvious - if suspect other surgical causes, need observation- likely laparoscopy. In HIV patient, can be fulminant disease- need IV treatment. Adolescent- issues of compliance and also long term risks of scarring of tubes- and ectopics. If patient throwing up, and unable to keep PO intake down- need to treat initially with IV antibiotics
    Finally, two major considerations- if did not respond to initial outpatient treatment after reassessment in 48-72 hours, and if cannot rely on patient to be followed-up in 48 hours
  • Physiological – a creamy white discharge is normal. Variation in its consistency and amount occurs with puberty, pregnancy, OCP use, ovulation and immediately prior to menstruation.
    Atrophic vaginitis – A profuse, sometimes bloody, yellow discharge may result from vaginal epithelial thinning due to decreased oestrogen levels associated with menopause. This responds well to local topical or oral oestrogens from GP.
    Thrush – Candida albicans is commonest vaginal infection. A white discharge accompanies a red painful vulvovaginitis. Occurs in pregnancy, after oral antibiotics and with HIV and diabetes. Check for glycosuria. Treatment options include clotrimazole pessaries, oral fluconazole and topical application of live yoghurt. GP follow up.
    Other infections – Refer to GUM clinic and advise abstinence in sexual contact in meantime
    Neoplasm – classically presenting with bleeding between periods; may cause discharge. Refer to gynaecologist.
    Fistulae – Colovaginal fistulae may follow diverticulitis or locally invasive colorectal carcinoma. Other fistulae (eg. vesicovaginal and ureterovaginal) may occur after pelvic surgery. Refer for admission and Ix.
    Foreign Bodies – Tampons, condoms, and various other items may be ‘lost’ or forgotten about in the vagina. Removal with forceps under direct vision should cure the offensive vaginal discharge. If a condom has been removed, ascertain whether post-coital contraception is required. Consider Hep B/HIV prophylaxis and GU referral for STD screen. Vaginal tampons (esp. highly-absorbent ones which have been left in situ for many hrs) are associated with ‘toxic shock syndrome’
    Toxic Shock Syndrome – Tampons used during menstruation have been implicated in many cases of the ‘toxic shock syndrome’. First described in 1978, it is caused by exotoxin produced by Staph. Aureus (usually TSS toxin 1) or occasionally, Strep.. Multi-organ failure may follow.
    Features – High fever, headache, vomiting, diarrhoea, myalgia, altered conscious level, hypotension and a widespread erythematous macular rash (with subsequent desquamation 1 week later, esp. of palms and soles).
    Diagnosis – Based upon clinical findings. Recent menstruation and the above features should prompt suspicion.
    Ix – Vaginal examination, U+E, LFT, clotting screen, FBC, ABG, blood and vaginal cultures, ECG, CXR
    Treatment – If due to a tampon – remove it! IVA and give crystalloid for hypotension. If refractory, consider measuring CVP, starting inotropic support and refer to ICU. Give an anti-staphylococcal antibiotic to prevent recurrence. The use of antitoxin antibodies remains uncertain. 5-10% mortality.
  • Facial erythroderma secondary to Staphylococcus aureus toxic shock syndrome in a woman who was obtunded and hypotensive on admission.
    Erythroderma that blanches on pressure in a patient with toxic shock syndrome. The mortality rate for staphylococcal toxic shock syndrome is lower than that of streptococcal toxic shock syndrome.
  • Menstrual cycle- normal is between 21-35 days. Flow 3-7 days.
    Need precise sequence of events during menstrual cycle with appropriate amounts of progesterone and estrogen. If the ovary is not primed properly- endometrium shed irregularly.
    Divided into two phases- follicular or proliferative phase; and luteal or secretory phase
    Follicular phase- prepares ovary for ovulation. Oestrogen stimulation of endometrial growth
    At ovulatiion (day 14) surge of LH and FSH causes release of oocyte.
    During luteal phase- corpus luteum produces progesterone which matures endometrium and prepares for implantation.
    Without HCG from fertilized embryo- corpus luteum regresses; drop in progesterone and oestrogen levels.
    Spiral arteries supplying endometrium become restricted- ischemia and sloughing of lining.
    Release vasoactive substances, like prostaglandins, nitric oxide, EDRF, heparin which results in orderly flow. Influenced by oestrogen.
    Then cycle starts all over again.
  • Attempt to assess the amount of bleeding. Interpretation of a patient’s description is notoriously difficult but useful pointers are the presence of clots and the rate of tampon use.
    Always consider the possibility of pregnancy: ruptured ectopic pregnancy can present before a period is missed.
  • Depending upon the circumstances, speculum and bimanual vaginal examinations may be required: local policy will determine who should perform this.
  • Commonest at menarche
  • Oestrogen most useful treatment in ER situation. It works by stimulation the proliferation of denuded and necrotic endometrium, therefore stabilizing and stopping bleeding.
    No benefit of PO versus IV. Both types have same side effects of nausea/vomiting. Both usually work within 2-3 doses
    Progesterone - especially useful for the adolescent who has immature hypothalamic pituitary access. Giving the progesterone will cause orderly withdrawal bleeds. Forewarn patient first bleed may be heavy, but should stop in usual amount of time. Can continue with this treatment q monthly until axis matures, or use BCPs
    Literature cites many different ways to use birth control pills. Most do advocate the use of a contraceptive pill that contains at least 50 mcg estradiol. The one most of us are familiar with is Ovral. There has been studies shown that you can use any other monophasic birth control pills and they do work- but may take longer to stop bleeding. Most people advocate continuing on BCP for minimum of three months to regulate periods before discontinuing. Most important is follow up with the family doctor or gynecologist.
    NSAIDs - NSAIDS are particularly helpful for women with ovulatory bleeding. They can dramatically decrease the menstrual flow for women with ovulatory DUB. The mechanism of action is blocking prostraglandin release. There is also an analgesic effect. Advise to use in first 3 days of flow, regardless of anovulatory vs. ovulatory bleed. Contraindicated of course for patients with history of GI problems (prev. ulcer)
    Anti-fibrinolytics - Have been noted to be helpful in studies-target the increased fibrinolytic activity in menstrual blood of patients with DUB. Tranexamic acid prevents activation of plasminogen and has been shown to decrease menstrual blood loss by as much as 84%. However, reports of intracranial thrombosis has limited use. Also side effects of nausea, diarrhoea, dizziness, headache, abdominal pain.
    Danazol decreases flow from 200 cc to 25 cc/ cycle!!
    Seen it used by women as last ditch effort before resorting to surgical options.
    Not something to be started in the Emergency department, but nice to know. Side effects related to the androgenic effects- weight gain, acne, abnormal lipid profile
    GNRH are another last ditch attempt. Causes medical menopause by depleting the pituitary of bioactive gonadotropins and desensitizing the pituitary to further GNRH stimulation. End result inhibition of further gonadotropin release, suppression of ovarian activity and hypogonadotrophic hypogonadism. Very expensive, and the concerns related to early menopausal state makes it not an ideal tx.
  • Stops pregnancy. Needs to be taken within 72hrs (3 days) of unprotected sex. Earlier take it, better.
    UK – 1) Levonelle one step (OTC) 2) Levonelle 1500 (prescription)
    Contains levonorgestrel (synthetic derivative of the naturally occurring female sex hormone, progesterone)
    (NB. BAC – Only national voluntary sector provider of free and confidential sexual health advice and services specifically for young people <25years; Founded in 1964 by Helen Brook; Registered charity; 17 centres running sessions in over 40 locations; 40yrs experience of providing professional advice through specially trained doctors, nurses, counsellors and outreach and information workers)
    Alternative
     
    Can have coil fitted
    Adv – 1) can put in up to 5 days after sex 2) continues to offer protection against pregnancy
    Disadv – Minority of doctors trained
  • Levonelle one step
    One tablet (one double strength tablet). Take ASAP – ideally within 12hrs not >72hrs of unprotected sex.
    Not sold to girls <16yrs. Therefore see doctor – GP/A+E/FPC
    Ask about last period and when last have sex – i.e. is the MAP suitable? (can work in any part of menstrual cycle except if period is late i.e. pregnant!)
    If vomit <3hrs after taking tablet need to take another one
    Only emergency use – not recommended for repeated use as it can disrupt menstrual cycle
    Does not protect you from STD!
    Caution – Crohn’s disease; rare hereditary problems of galactose intolerance; LAPP lactase deficiency
    Avoid – Pregnancy; Unprotected sex >72hrs; Late menstrual period; Severe decreased liver fxn; known allergy
    NB. Small amounts will pass into breast milk. Not known to be harmful but take tablet immediate after last feed to minimise dose in next feed.
     
    S/E – Little; nausea. 1 in 60 vomit. Vaginal bleed; Abdominal pain; Fatigue; early or delayed start to next period; menstrual spotting or irregular bleeding; headache; diarrhoea; dizziness; breast tenderness
     
    People who should not take it – Severe liver disease; porphyria. (NB. St John’s Wort decreases effectiveness – will therefore need larger dose of MAP)
     
    Drug interactions – MAP less effective if taking antiepileptic medication (Carbamazepine; Phenytoin; Phenobarbital); Barbiturates; Griseofulvin; Nevirapine; Protease inhibitors for HIV; St John’s Wort
    Therefore take another tablet 12hrs later!!!! OR coil fitted
    May decrease level of lamotrigine! May increase level of cyclosporine!
     
    NB. Norgeston (progesterone only containing OCP (mini-pill)) and Mirena (contraceptive coil) both contain levonorgestrel.
    Warnings
     
    1) Next period can come early or late. See doctor if not come within days of expected time.
    2) Does not protect from pregnancy for rest of menstrual cycle. Abstain or use barrier method eg. condom
    3) No protection against ectopic pregnancy – if abdominal pain or abnormal PV bleed (shorter or lighter) in coming weeks, see doctor.
     
    Alternative
     
    Can have coil fitted
    Adv – 1) can put in up to 5 days after sex 2) continues to offer protection against pregnancy
    Disadv – Minority of doctors trained
     
    NB ADVISE TO SEE GP or FPC FOR ADVICE REGARDING REGULAR METHOD OF CONTRACEPTION and PREVENTION OF STD!!!!!!!!
  • Ensure privacy by interviewing alone without the partner. Ask gently but directly about the possibility of violence, which may initially be denied.
  • Telephone advice – Women may telephone the ED for advice after being raped. Advise them to inform the police immediately and then attend the police station or the ED. Discourage from washing, changing clothes, using a toilet, or brushing teeth before being examined.
  • Gynaecological emergencies

    1. 1. Gynaecological Emergencies
    2. 2. OUTLINE       INTRODUCTION CAUSES CLINICAL FEATURES INVESTIGATION TREATMENT CONCLUSION
    3. 3. INTRODUCTION       Spectrum of gynaecological diseases that causes an acute symptoms, necessitating urgent and prompt management. Presentation of gynaecologic emergencies Acute pelvic pain Abnormal vaginal bleeding Abnormal vaginal discharge Acute pelvic swelling
    4. 4. Anatomy of uterus
    5. 5. Relationship of ureter to uterus
    6. 6. Common Presentations      Pelvic Pain Infections Vaginal Discharge Vaginal Bleeding Contraceptive Problems
    7. 7. Gynaecological Emergencies  Diagnostic challenges Overlapping and similar symptoms  Must rule out    Pregnancy (esp. ectopic) Non-gynaecological causes
    8. 8. Gynaecological Problems – General Approach       Hx and Ex require attention to privacy and confidentiality Obtain full menstrual, contraceptive and sexual hx Interview without other family members present Wear gloves, examine in unhurried manner and use chaperone Digital and speculum vaginal examination except certain circumstances (eg. children, painful vulval ulcers) Consider pregnancy
    9. 9. Pelvic Pain - Gynaecologic  Pregnancy   Pain related to menstrual cycle      Ectopic, uterine, miscarriage 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
    10. 10. Pelvic Pain – Non gynaecologic  GIT:   Appendicitis, diverticulitis, gastroenteritis, obstruction, hernia Urinary:  Pyelonephritis, cystitis, renal stones  Abdominal wall pain  Thoracic:   Pneumonia, PE Misc:  Porphyria, Sickle Cell, DKA, Uraemia
    11. 11. Approach to Pelvic Pain      Does it need emergent treatment? What is the most serious diagnosis? Can an accurate diagnosis be made? Does the patient need to be admitted? What follow up arrangements need to be made?
    12. 12. Does it need emergent treatment?  Acute abdomen  Stabilise – ABCs Surgical consultation  Theatre 
    13. 13. History  Characteristics of pain    Pelvic fullness, bleed, discharge Associated symptoms   LMP, previous ectopics, TA, previous PID, STDs, hx of ovarian cysts, partners Contraception   Urinary, GIT, pyrexia Obstetrical and Gynaecological History   Dyspareunia IUCD, OCP, Barrier Surgical History
    14. 14. Physical Exam  General     CVS Chest Abdominal   Looks unwell, dehydrated, colour Distension, bowel sounds, hernia, tenderness, mass Back
    15. 15. Pelvic Examination  Empty bladder!   Vaginal   Size, shape, regularity, tenderness, position, mobility Adnexa   Chandelier sign, os open/closed Uterus   Lesions, discharge Cervix   Wash hands, gloves, warm vaginal speculum with warm water, obtain specimens as needed (Pap smear, cultures) Masses, tenderness, ovaries Rectal  Mass, tenderness, blood
    16. 16. Investigations  Blood   Microbiology   Urinalysis, beta HCG Radiology   Blood cultures, Triple swab, urine C+S Urine   FBC, U+E, Creatinine, Glucose, LFT, beta-HCG, CRP KUB, abdominal USS  Abdominal, pelvic
    17. 17. Management   Depends on cause Ovarian cysts   Very common cause of adnexal enlargement with pelvic pain Important points:   Ovarian torsion Ovarian neoplasm - older women
    18. 18. Ovarian cysts - Types  Functional     Multiple   PCO Endometriosis   Follicular Corpus luteum Corpus haemorrhagicum Chocolate cysts Neoplasm  Benign – serous/mucinous cystadenomas, dermoid (teratoma)  Malignant
    19. 19. Ovarian cysts - Management  Medical       Expectant management 4-8 weeks Self contained haemorrhagic cysts resorb NSAIDs Follow up with gynaecologist OCP – prevent gonadotrophin ovarian stimulation Surgical      Very large cysts Persistent cysts Haemorrhagic cysts rupture with decreasing Hb Complex adnexal mass Acute abdomen – dermoid cyst; adnexal torsion
    20. 20. Infections   Symptomatic vs. Asymptomatic Lower Genital Infections (STD/Non-STD):     Chlamydia, Gonorrhoea, Herpes, Trichomoniasis, Candidiasis, Bacterial vaginosis, Condyloma Vulval ulcers – consider SCC, Behcets syndrome, TB, Crohn’s Painful lumps – Bartholin’s abscess, infected sebaceous cysts, urethral carbuncle Upper Genital Infections:   Pelvic Inflammatory Disease (PID) Tubo-Ovarian abscess (TOA)
    21. 21. Herpes Simplex Virus Infection
    22. 22. Acute Pelvic Inflammatory Disease   Infection of uterus, Fallopian tubes, adjacent pelvic structures not associated with surgery or pregnancy Symptoms:     Low abdominal pain, pyrexia, N+V Vaginal discharge, intermenstrual bleeding Previous hx of GUM attendance Clinical Features:  Abdominal tenderness, peritonism right sub-costal in Fitz-HughCurtis syndrome, cervical discharge, cervicitis, cervical excitation tenderness, adnexal tenderness
    23. 23. Acute Pelvic Inflammatory Disease  Aetiology     Differential diagnosis   Chlamydia trachomatis, N. Gonococcus, Mycoplasmas, Ureaplasmas, streptococci often mixed with gram-negatives and anaerobes Uncommon : TB PID and actinomycosis Secondary to appendicitis, diverticulitis, pregnancy terminations, D+C, following IUCD insertion Appendicitis, diverticulitis, ovarian cyst accident, ectopic pregnancy, fallopian tube torsion, endometriosis Risks  Septicaemia, abscess, infertility, chronic PID, adhesion formation and recurrent pelvic pain
    24. 24. Acute Pelvic Inflammatory Disease  Investigations:   Triple swabs, FBC, ESR, CRP, Beta HCG, urinalysis, consider general surgical opinion Management:         Refer Resuscitate – ABCs and with IV fluids if shocked Remove IUCD after consultation with seniors and send to microbiology Antibiotics (doxycyline, metronidazole and ceftriaxone or oflaxacin if allergy hx) Analgesia and anti-emetics 4 hourly observations (temp, pulse, RR) Consider laparoscopy if no improvement in pain/pyrexia in 24hrs Follow up in GUM clinic. Treat partner.
    25. 25. Acute Pelvic Inflammatory Disease  Indications for hospitalization          Diagnosis uncertain Possible surgical emergency cannot be excluded Suspect pelvic abscess Pregnant patient HIV +ve Adolescent Unable to follow or tolerate out-patient Rx Did not respond to outpatient Rx Unable to arrange follow up in 48-72 hours
    26. 26. Vaginal discharge         Physiological Atrophic vaginitis Thrush – check for glycosuria Other infections Neoplasm – cervical and endometrial Fistulae Foreign Bodies – tampons, condoms, plus ??? Toxic Shock Syndrome – remove tampon, resuscitate, antibiotics and refer ICU
    27. 27. Toxic Shock Syndrome
    28. 28. Vaginal Bleeding  Pregnancy related:   Non-gynaecological:      Spontaneous abortion, ectopic pregnancy, trophoblastic GI – rectal bleeding Urinary – urethral Systemic disease – hypothyrodism, endocrinopathy, liver disease, renal failure, blood dyscrasias and coagulopathies Iatrogenic – Hormonal (OCP or menopausal), glucocortcoids, anti-coagulants, psychoactive drugs, digitalis Gynaecological
    29. 29. Abnormal vaginal bleeding    Normal blood loss 35cc/cycle >80cc = menorrhagia Primary goals:     Control the bleeding Determine the cause Prevent recurrence Preserve fertility (if desired)
    30. 30. 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 release vasoactive substances
    31. 31. History  How much bleeding?   Obstetrical and gynaecological hx     Miscarriage, endometriosis, STD exposure Medications   Clots, pad count, LMP, symptomatic, duration, menses, regular/irregular Contraception, hormones, anti-coagulants, psychotropics Smoking Stress Other illnesses  Hypothyroidism, liver disease, coagulopathy
    32. 32. Examination      Haemodynamic status – hypovolaemia? Stigmata of liver disease, hypothyroidism, Cushing’s, Polycystic ovaries Abdominal exam –mass, tenderness Pelvic exam – trauma, laceration, infection, polyps, tenderness Cervix – os open/closed, tissue, clots
    33. 33. Investigations  Bloods     Beta HCG, FBC, Clotting screen, TFT, LFT Pap smears and cultures Endometrial biopsy Ultrasound  Polyps, fibroids
    34. 34. Treatment   Depends on cause If shocked, ABC (Oxygen, x-match, Rhesus status, resuscitate IV fluids)
    35. 35. Dysfunctional Uterine Bleeding     Diagnosis of exclusion Abnormal bleeding not caused by recognised anatomical or pathological abnormalities of the uterus Extremes of age Ovulatory vs. Anovulatory DUB:  Ovulatory – abnormal progesterone secretion     A) Regular cyclic bleeding with mid-cycle spotting (decreased oestrogen levels at ovulation) B) Polymenorrhoea – short secretory phase C) Oligomenorrhoea – prolonged secretory phase Anovulatory – absence of progesterone with unopposed oestrogen with irregular cycles
    36. 36. Dysfunctional Uterine Bleeding - Treatment  Medical:       Hormonal treatment – oestrogen, progesterone, combination hormones (OCP. Premarin) NSAIDs – mefenamic acid, ibuprofen, meclofenamate, naproxen Antifibrinolytics – aminocaproic acid, tranexamic acid Danazol GnRH analogs Surgical:     Dilatation and curettage (temporizing) Hysteroscopy Endometrial ablation (85% success rate) Hysterectomy
    37. 37. Contraceptive Problems  Post-coital contraception     MAP stops pregnancy. Needs to be taken <72hrs 1) Levonelle one step (OTC) 2) Levonelle 500 (Prescription) (Alternative – IUCD up to 5 days after sex) Use     Women after unprotected sex Rape Couples who have condom break during sex Women lured into sex after drugs/drinks
    38. 38. Levonelle one step          Take ASAP – ideally <12hrs Ask about LMP If vomit <3hrs after taking tablet, need to take another one Does not protect against STD. Failure rate approx. 1-2% Caution – Crohn’s disease, rare hereditary problems of galactose intolerance, LAPP lactase deficiency Avoid – Pregnancy, Unprotected sex >72hrs, Severe decreased liver fxn, known allergy, porphyria S/E – nausea, vomit (1 in 60), vaginal bleed, abdominal pain, fatigue, early or delayed start to next period, headache, diarrhoea Drug interactions with enzyme inducing drugs Arrange follow up with GP in 3/52. Advise alternative contraception. Warn risk of ectopic pregnancy and return if abdominal pain – document advice.
    39. 39. Genital injury and assault  Hx may be misleading. Have high index of suspicion and full examination to exclude significant injury  Blunt:   Falls astride. Most vulval haematomas settle with rest and ice packs. Very large haematomas may need surgical evacuation Penetrating:  Assault, FB insertion, migration/perforation of IUCD  IVA, G+S, erect CXR, AXR, antibiotics and refer
    40. 40. CAUSES OF ACUTE ABDOMINAL SWELLING     Rupture ectopic GTD/H MOLE Neoplasm Peritonitis-post abortal
    41. 41. Rape and sexual assualt        Vulval penetration by penis without consent Grossly under-reported Privacy essential – should ideally have specialised equipped room Ensure female member of staff present throughout Legible and meticulous documentation Treatment and resuscitation by ED staff; collection of forensic evidence by police surgeon +/- gynaecologist Sometimes women initially decline police involvement: full assessment and documentation may prove useful if there is a change of mind
    42. 42. Rape and sexual assualt      First exclude life-threatening or serious injuries History  Establish type, date, time and place of assault. Obtain contraception and sexual hx. Enquire about LMP/pregnancy Examination  Look for evidence of vaginal, oral or anal injury (+ take swabs). Record any other injuries (photos useful – taken with consent by police) Investigation  Obtain written informed consent. Retain clothing, loose hairs, fingernail clippings, and tampons for evidence. Take appropriate swabs (vaginal, oral, anal). Perform pregnancy test. Take and store blood for future DNA testing. Treatment  Resuscitate as necessary. Consider need for post-coital contraception. Consider prophylaxis against Hep B, HIV and tetanus. Arrange FU to exclude STD. Consider Abx prophylaxis against STD. Provide counselling and ensure safe place to stay (social worker). Arrange future counselling. Inform of independent local advice (eg. Rape Crisis Centre)
    43. 43. Conclusion   Gynaecological emergencies need a good clinical acumen to differentiate the gynecology from non- Gynaecological causes. Moreso, it prompt detection saves lives

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