Emergency Obstertrics & Gynecology

Obstetrics and GynecologyEmergency

Gynecologic Emergency

Women Acute Problems Abnormal vagina bleeding Acute Abdominal pain

Women Acute Problems

Approach to the problem History taking Physical Examination

General Physical Examination Pelvic Examination

Laboratory test

Women Acute Problems History taking Chief complain Present illness Past history

PMP (past normal menstruation period) LMP (last normal menstruation period) Gravida & parity Abortion Sexual intercourse Contraception Pregnancy & Delivery

The Physician Role

The physician is A good listener Empathic Honest Genuine

The Physician Role

The physician use Understandable language Appropriate body language A collaborative approach Open dialogue Appropriate emotional content Humor and warmth

The Physician Role

The physician is not Confrontation Combative Condescending Overbearing Judgmental

Normal menstruation

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

Recurrent amount more than 80 cc/cycle cause anemia

Women Acute Problems

Physical examination General physical examination Abdominal examination

Bowel sound Mass

Point of tenderness or Ascites Guarding & Rebound tenderness

Women Acute Problems Pelvic examination M/N IUB: Discharge, appearance Vagina: Mucosa & Discharge Cervix: Discharge, Erosion, Os

status, Excitation pain Uterus: Size, Shape, Position Adnexae: Mass, Tenderness Caldesac: Bulging, Mass,

Tenderness

Women Acute Problems OPD laboratory Wet smear

NSS KOH

Gram stain Complete blood count Urine examination Urine pregnancy test Option: Culture & sensitivity

Endometrial aspiration Tissue Biopsy, PAP

Urine pregnancy test

Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of whether she states that she has had intercourse.

Abnormal (vaginal) bleeding

Introituses Vagina Cervix Uterus

Introituses

Infection Trauma Sexual Abuse

Vagina

Congenital Trauma (sexual abuse) Infection Tumor

Cervix

Congenital Trauma (sexual abuse) Tumor Infection

Abnormal Uterine Bleeding

Metrorhagia Menorrhea Hyper menorrhea (Hypo menorrhea)

Abnormal uterine Bleeding

Extreme age Prepubertal Adolescent Perimenopause Postmenopause

Reproductive

Abnormal Uterine Bleeding

Reproductive age

Pregnancy complication Not pregnancy condition

Abnormal Uterine Bleeding

Reproductive age Pregnancy complication

Abortion: Threaten, inevitable, complete, incomplete

Molar pregnancy Ectopic pregnancy

Abnormal Uterine Bleeding

Reproductive age Not pregnancy condition

Congenital Anomaly Trauma Tumor: Benign or Malignant Infection Other medical disease Exogenous hormonal or drug used

Abnormal Uterine Bleeding

Extreme age

Children and Early adolescent Menopause

Abnormal Uterine Bleeding

Extreme age: Children and Early adolescent

Organic disease Congenital anomaly Trauma: foreign body, sexual abuse Tumor: benign or malignant Infection: sexual abuse

Functional condition: Anovulation

Abnormal Uterine Bleeding

Extreme age: Menopause

Peri-menopausal bleeding Post-menopause bleeding

Organic disease Functional condition

Abnormal Uterine Bleeding

Peri-menopause: Organic disease

Myoma uteri Cervical or endometrial polyp Endometrial hyperplasia Endometrial carcinoma

Abnormal Uterine Bleeding

Peri-menopause: Function condition (dysfunctional

uterine bleeding, DUB) Anovulatory bleeding Hormonal effect: HRT, Other

hormone

Abnormal Uterine Bleeding

Post-menopausal bleeding Causes are the same as peri-

menopause bleeding but malignant tumor is more

likely

Abnormal Uterine Bleeding

In peri and post menopausal women, malignant tumor must be rule out before dysfunctional uterine bleeding (DUB) is diagnosed and treatment.

Acute pelvic pain

Gynecologic disease or dysfunction

Recurrent pelvic pain. Gastrointestinal Genitourinary Musculoskeletal Others

Acute Pelvic Pain

Gynecologic disease or dysfunction

Complication of pregnancy Acute infection. Adnexal disorder.

Acute Pelvic Pain

Complication of pregnancy Ruptured ectopic pregnancy Abortion: threaten or incomplete Degeneration of liomyoma

Ectopic pregnancy Triad

Missed period Abdominal or pelvic pain Adnexal mass.

Acute Pelvic Pain

Acute infection Endometritis Pelvic inflammatory disease Tubo-ovarian abscess

PID

Minimum criteria 1. Lower abdominal tenderness, 2. Adnexa tenderness 3. Cervical motion tenderness

PID Additional Criteria

1. Oral temperature > 101 F (>38.3 C) 2. Abnormal cervical or vaginal discharge 3. Elevated erythrocyte sedimentation rate 4. Elevated C-reactive protein 5. Laboratory documentation of cervical

infection with N. gonorrhea or C. trachomatis

PID: Admitted criteria 1. Surgical emergencies such as

appendicitis cannot be excluded. 2. The patient is pregnant. 3. The patient does not respond

clinically to oral antimicrobial therapy.

4. The patient is unable to follow or tolerate an outpatient oral regimen

PID: Admitted criteria 5.The patient has severe illness,

nausea and vomiting, or high fever. 6.The patient has a tubo-ovarian

abscess. 7.The patient is immunodeficiency

(i.e., has HIV infection with low CD4 counts, is taking immunosuppressive therapy, or has another disease).

8. The patient is adolescent.

Acute Pelvic Pain

Adnexal disorders Hemorrhagic function ovarian cyst Torsion of adnexa Twisted par ovarian cyst Ruptured of functional or neoplastic

ovarian cyst.

Recurrent pelvic pain

Mittelschmerz (midcycle pain) Primary dysmenorrhea Secondary dysmenorhea

Recurrent pelvic pain

Gastrointestinal Appendicitis Bowel obstruction Diverticulitis Inflammatory bowel disease Irritable bowel syndrome

Recurrent pelvic pain

Genitourinary Cystitis Pyelonephritis Ureteral lithiasis

Recurrent pelvic pain

Musculoskelital Others

Acute Porphyria Pelvic thrombophebitis Aneurysm Abdominal angina

Recurrent pelvic pain Primary dysmenorrhea Secondary dysmenorrhea

Imperforated hymen Transverse vaginal septum Cervical stenosis Uterine anomaly Intrauterine synergia Endometrial polyps Uterine liomyoma Adenomyosis Pelvic congestion syndrome Endometriosis

Obstetrics Emergency

Antepartum hemorrhage Acute complication of

preeclamsia Postpartum hemorrhage Acute abdomen during pregnancy Abdominal trauma during

pregnancy Cardiac arrest during pregnancy

Antepartum Hemorrhage

Abortion Abnormal Placentation

Placenta previa Placenta abruption

Antepartum Hemorrhage

Placenta previa Painless bleeding Ultra sonography Maternal bleeding may be severe Termination of pregnancy

Antepartum Hemorrhage

Placenta abruption Painful vagina bleeding Fetus in jeopardy

Acute complication of preeclampsia

Seizer MgSo4 is appropriate than diazepam or

phenetoin Hypertension

More than 160/110 mmHg Hydralazine Nifedipine Sodium nitroprusside

Postpartum Hemorrhage

Immediate PPH Delayed PPH

Infection Retain piece of conceptive product Uterine atony

Acute Abdomen during Pregnancy

Acute appendicitis Renal stone Acute cholecystitis

Abdominal Trauma during Pregnancy

Blunt or sharp Fetal viability Maternal condition Fetal well being

Abdominal Trauma during Pregnancy

Physical abuse Sexaul Assault Automobile accidents Fetal injury and death Placenta abruption Uterine rupture

Abdominal Trauma during Pregnancy

As in none pregnant women Evaluate and stabilization maternal

injuries Fetal assessment may divert from life

threatening maternal injuries Repositioning the large uterus away

from the great vessel

Cardiac Arrest during Pregnancy

Basic life support (BLS) Advance cardiac life support

(ACLS) Pregnancy physiologic change Post mortem cesarean section