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EMERGENCIES IN GYNECOLOGY

EMERGENCIES IN GYNECOLOGY. Abnormal bleeding. Abnormal Bleeding. Prepubertal Age Group Adolescence Reproductive Age Group Postmenopausal Women. Prepubertal Age Group.

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EMERGENCIES IN GYNECOLOGY

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  1. EMERGENCIES IN GYNECOLOGY

  2. Abnormal bleeding

  3. Abnormal Bleeding • Prepubertal Age Group • Adolescence • Reproductive Age Group • Postmenopausal Women

  4. Prepubertal Age Group • Slight vaginal bleeding can occur within the first few days of life because of withdrawal from the high level of maternal estrogens. • inform new mothers of female infants of this possibility

  5. Vaginal bleeding in the absence of secondary sexual characteristics should be evaluated very carefully.

  6. Prepubertal Age Group • The causes of bleeding range from the medically mundane to malignancies that may be life-threatening. • The source - sometimes difficult to identify, and parents who observe blood in a child's diapers or panties may be unsure of the source. • Pediatricians - look for urinary causes, and gastrointestinal factors.

  7. Causes of Vaginal Bleeding in Prepubertal Girls • Vulvar Lesions • Vulvar irritation • maceration of the vulvar skin, • or fissures can bleed.

  8. Foreign Body • A foreign body in the vagina is a common cause of vaginal discharge, which may appear purulent or bloody. Young children explore all orifices and may place all varieties of small objects inside their vaginas Foreign body (plastic toy) in the vagina of an 8-year-old girl

  9. Precocious Puberty • Precocious puberty occasionally is marked by vaginal bleeding in the absence of other secondary sexual characteristics, • it is more common for the onset of breast budding or pubic hair growth to occur before vaginal bleeding.

  10. Trauma • A careful history should be obtained from • one or both parents or • caretakers • and the child herself, • because trauma caused by sexual abuse is often not recognized. • There is a mandatory legal obligation to report suspected child physical abuse

  11. Other Causes • Other serious but rare causes of true vaginal bleeding include vaginal tumors. • rhabdomyosarcoma (sarcoma botryoides) is associated with bleeding. • Other forms of vaginal tumor are also rare but should be ruled out if no other obvious source of bleeding is found externally

  12. Adolescence • To assess vaginal bleeding during adolescence, it is necessary to have an understanding of the range of normal menstrual cycles. • During the first 2 years after menarche, most cycles are anovulatory. Despite this, they are somewhat regular, within a range of approximately 21 to 40 days.

  13. Normal Menses • The mean duration of menses is 4.7 days; 89% of cycles last <7 days. The average blood loss per cycle is 35 ml, and the major component of menstrual discharge is endometrial tissue. • Recurrent bleeding in excess of 80 ml/cycle results in anemia.

  14. Abormal bleeding • Cycles > 42 days, • < 21 days, • Bleeding > 7 days • during adolescence greater irregularity is acceptable if significant anemia or hemorrhage is not present. • consideration should be given to girls whose cycles are consistently outside normal ranges or whose cycles were previously regular and become irregular

  15. Hormonally active ovarian tumors • lead to endometrial proliferation and bleeding. • Exogenously administered estrogens can result in bleeding.

  16. Anovulatory bleeding • The physiology - failure of the feedback mechanism • In anovulatory cycles, estrogen secretion continues, resulting in endometrial proliferation with subsequent unstable growth and incomplete shedding. • The clinical result is: irregular, prolonged, and heavy bleeding.

  17. Exogenous Hormones • Oral contraceptive use is associated with breakthrough bleeding, which occurs in as many as 30% to 40% of individuals during the first cycle of combination pill use. • In addition, irregular bleeding can result from missed pills

  18. Hematologic Abnormalities • Idiopathic Thrombocytopenic Purpura (ITP), • von Willebrand's disease. • leukemia • Thrombocytopenia, etc. • Adolescents who have severe menorrhagia, especially at menarche, should be screened for coagulation abnormalities, including von Willebrand's disease.

  19. Infections • Irregular or postcoital bleeding can be associated with chlamydial cervicitis. • and screening for chlamydia should be performed routinely among sexually active teens

  20. STD / STI • Menorrhagia can be the initial sign for patients infected with sexually transmissible organisms. • Adolescents have the highest rates of pelvic inflammatory disease (PID) of any age group when only sexually experienced individuals are considered.

  21. Endometritis • PID (endometritis, salpingitis, oophoritis). Occasionally, chronic endometritis will be diagnosed when an endometrial biopsy is obtained for evaluation of abnormal bleeding in a patient without specific risk factors for PID.

  22. Endocrine or Systemic Problems • Thyroid dysfunction. • hypothyroidism • and hyperthyroidism • Hepatic dysfunction (abnormalities in clotting factor production).

  23. Reproductive Age Group • Beyond the first 1 to 2 years after menarche, menstrual cycles generally conform to a cycle length of 21 to 35 days, with a duration of less than 7 days of menstrual flow. • As a woman approaches menopause, cycle length becomes more irregular as more cycles become anovulatory.

  24. Reproductive Age Group • Although the most frequent cause of irregular bleeding is hormonal disorder • Pregnancy-related bleeding (spontaneous abortion, ectopic pregnancy) should always be considered. • pregnancy test !!!!

  25. Anatomic Causes • Anatomic causes of abnormal bleeding in women of reproductive age occur more frequently than in women in other age groups. • Uterine leiomyomas occur in as many as one-half of all women older than 35 years of age and are the most common tumors of the genital tract

  26. Neoplasia • Abnormal bleeding is the most frequent symptom of women with invasive cervical cancer. • Any obvious cervical lesion should be evaluated by biopsy!!!

  27. TREATMENT

  28. Nonsurgical Management • Most bleeding problems, including anovulatory bleeding can be managed nonsurgically. • Treatment with NSAIDs such as ibuprofen and mefenamic acid has been shown to decrease menstrual flow by 30% to 50% (Novak’s Gynaecology 2002)

  29. Hormonal management • frequently can control excessive or irregular bleeding. • Although there is a paucity of randomized controlled trials demonstrating the effectiveness of oral contraceptives in reducing menstrual flow, oral contraceptives have long been used clinically to decrease menstrual flow

  30. Hormonal management (OC) • Low-dose oral contraceptives may be used: • during the perimenopausalyears • in healthy nonsmoking women • who have no major cardiovascular risk factors. • The benefits of menstrual regulation in such women often override the potential risks.

  31. For patients in whom estrogen use is contraindicated, progestins, both oral and parenteral, can be used to control excessive bleeding. • Cyclic oral medroxyprogesterone acetate, administered from days 5 to 26 of the cycle, results in a reduction of menstrual flow

  32. Postmenopausal Women • A significant change in withdrawal bleeding (e.g., absence of withdrawal bleeding for several months followed by resumption of bleeding or a marked increase in the amount of bleeding) should prompt endometrial sampling.

  33. ! Neoplasia !!!!! • Endometrial, cervical, and ovarian malignancies must be ruled out in cases of postmenopausal bleeding. • The Pap test results are negative in some cases of invasive cervical carcinoma because of tumor necrosis => biopsy, or conisation !!!.

  34. Wide range of surgical options • from hysteroscopy with resection of submucous leiomyomas to • laparoscopic techniques of myomectomy to • uterine artery embolization to • endometrial ablation to • hysterectomy (TAH+BSO). • The choice of procedure depends on the cause of the bleeding. • The assessment of the relative advances, risks, benefits, complications, and indications of these procedures is a subject of ongoing clinical research.

  35. PELVIC PAIN

  36. Pelvic pain • is the most challenging symptom confronting the practitioner. • The problems of acute, cyclic, and chronic pelvic pain encompass a large proportion of gynaecologic complaints. • The etiology is diverse. • Dysmenorrhea is one of the most common medical issues in gynaecology.

  37. Acute pain is intense and characterized by sudden onset, sharp rise, and short course. • Cyclic pain refers to pain that occurs with a definite association to the menstrual cycle. • Chronic pelvic pain has been defined as pain of greater than 6 months' duration

  38. Dysmenorrhea, or painful menstruation, is the most common cyclic pain phenomenon and is classified as primary or secondary on the basis of associated anatomic pathology

  39. ACUTE pelvic pain often is associated with signs of inflammation or infection: • fever and leukocytosis, which are absent in chronic pain states.

  40. Rapid onset of pain is most consistent with perforation of a hollow viscus or ischemia. • Colic or severe cramping pain is commonly associated with muscular contraction or obstruction of a hollow viscus, such as intestine or uterus, • pain perceived over the entire abdomen suggests a generalized reaction to an irritating fluid within the peritoneal cavity.

  41. Acute pelvic pain !!! Ectopic pregnancyPelvic inflammatory disease (PID) - Salpingitis- oophoritis - Tuboovarian abscess (TOA) Hemorrhagic ovarian cystOvarian torsionBartholin gland abscess

  42. Ectopic pregnancy

  43. - ectropic pregnancy = outside the uterus- heterotropic pragnancy = both intrauterine pregnacy (IUP) + ectopic pregnancy, 1 : 30000 pregnancies

  44. sites of ectopic implantation: - 95% develop in oviducts - ampullary 79%,- isthmic, fimbrial also cornual - abdominal - uncommon, - cervical and ovarian are very rare- DGN at 6-8 week

  45. Clinical presentationa. Unruptured ectopic pregnancy- amenorrhea 6-8 weeks- abnormal vaginal bleeding - abdominal pain- adnexal or cervical motion tenderness - adnexal mass - nausea- fatigue- cervix is getting blue

  46. Clinical presentationb. Ruptured ectopic pregnancy- internal bleeding and hypovolemia- tenderness, rebound, or guarding of abdomen- uterine size normal or smaller than expected- echymoses of umbiliculus-Cullen sign- orthostatic blood pressure and pulse changes indicate blood loss

  47. 2.Differential diagnosisa. reproductive tract- spontaneous abortion- molar pregnancy- ruptured corpus luteum- acute PID- adnexal torsion

  48. 2.Differential diagnosisb. nonreproductive tract- appendicitis- pyelonephritis- pancreatitis

  49. 3.Risk factors- Pelvic inflammatory disease (PID)- Previous ectopic pregnancy- Sexually tranmitted diseases (STDs)- Previous surgeries, particulary tubal ligation- Presence of intrauterine device???? (IUD)- User of fertility agents- Cigarettes smoking

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