OB-GYN EMERGENCIES

1. OB-GYN EMERGENCIES Peggy Andrews EMT-Paramedic Chemeketa Community College

2. Abuse in pregnancy Breech presentation Cystitis Delivery Diabetes in pregnancy Early antepartum hemorrhage Eclampsia Ectopic pregnancy Endometritis Endometriosis Fertilization Gestational changes Late antepartum hemorrhage OBJECTIVES

3. Ovulation PID PIH Postpartum Hemorrhage Pre-eclampsia Prolapsed cord Ruptured ovarian cyst Sexual Assault Trauma in pregnancy Mittelschmertz Threatened abortion Vaginal hemorrhage Objectives, cont.

4. Amenorrhea Antepartum Birth canal Bloody show Cervix Crowning EDC Endometrium Effacement Gravida Menarche Menstruation Menopause Menses Terminology

5. Multigravida Multipara Neonate Ovulation Parity Placenta Polyhydramnios Postpartum Prenatal period Preterm labor Primipara Prenatal Primagravida Sexual assault

6. Basic Anatomy - External • Protect body openings • Vulva • Perineum • Mons Pubis • Labia • Vestibule • Clitoris • Urethra

7. Gynacoid pelvis 11 cm anterior-posterior 12.75 cm oblique 13.5 cm transverse Female pelvis

8. occiputoanterior position vs face-to-pubis (sunny-side up)

9. Basic Anatomy - Internal • Vagina • Elastic, 9-10 cm • Connects external genitalia to uterus • Vaginal artery

10. Internal anatomy, cont. • Uterus; hollow, muscular organ • Flexed forward between bladder and rectum • ~7.5 cm long, 5 cm wide • Provides site for fetal development • At term, measures ~ 40 cm in length

11. Uterine arteries; branches of internal iliac artery • Enervated by autonomic nervous system • Two major parts • Body (corpus) • Cervix

12. Internal anatomy, cont. • Fundus • Above point where fallopian tubes attach • Measurement of fundal height most accurate from 22-34 weeks

13. Uterine body • Endometrium • Innermost layer • menses • Myometrium • 3 distinct layers of smooth muscle • Middle layer made up of figure-8 patterns of muscle fibers • Surround large blood vessels • Perimetrium • Serous membrane – layer of viseral peritoneum

14. Internal anatomy, cont. • Cervix • Connects uterus with vagina • ~ 2.5 cm long • Dilates to 10 cm diam. during labor

15. Internal Anatomy, cont. • Fallopian tubes; 10 cm long • Fertilization usually occurs in distal third

16. Ovaries • connected to uterus by ovarian ligament • produce estrogen & progesterone • Development and release of ovum

17. The menstrual cycle • Menarche • 10 – 14 y/o • Menstrual cycle • 21 – 32 day cycle • Ovulation – menstruation always 14 days

18. The proliferative phase • At birth, ovaries contain ~ 2,000,000 ova • 400 eventually released • The first two weeks • Dominated by estrogen • LH (luteinizing Hormone)surge at day 14 • Ovulation

19. FSH (Follicle Stimulating Hormone), estrogen levels increase • Ovum discharges into abdominal cavity • Cilia on fimbriated ends of fallopian tubes draw egg into tube

20. The secretory phase • Stage of menstrual cycle immediately surrounding ovulation • If egg not fertilized, estrogen level drops, progesterone level dominates • Uterine vascularity increases

21. The ischemic phase • Fertilization doesn’t occur; estrogen, progesterone levels fall • Vascular changes cause endometrium to become pale, small blood vessels rupture

22. The menstrual phase • Ischemic endometrium is shed • Normal flow lasts 3 – 5 days • Average blood loss 50 cc • PMS • Menopause • 45 – 55 y/o • Estrogen levels decrease • Hot flashes, mood swings, night sweats

23. Contraceptives • Rhythm method • Coitus interruptus • Diaphragm • Cervical Cap • Condoms • Spermicide

24. Contraceptives • Intrauterine device • Oral contraceptives • Norplant • NuvaRing • Tubal ligation • Vasectomy • Abstinence

25. Ortho Evra • Paragard • Depo-provera • Lunelle • Protectaid sponge • Essure micro-insert

28. Patient AssessmentSuspect OB emergency in all females!! • Most common complaints; abdominal pain, vaginal bleeding • OPQRST • LMP • Dysmenorrhea • Associated S/S • Fever, chills • N/V/D or constipation • Urinary frequency, pain, cramping • Dyspareunia

29. Patient assessment, cont. • Vaginal discharge, bleeding? • If bleeding, how does amount compare with usual period? • # pads? 30 cc • Syncopal? • Gravida • Para • Ab • Previous ectopic pregnancies, infections, tubal ligation, D&C’s, trauma

30. Patient Assessment • Be professional • Protect modesty • Maintain privacy • Be considerate • Assess skin and mucous membranes • Vital signs • Auscultate, palpate abdomen • Inspect vaginal area prn

31. Case history • You arrive at the home of a 26 year old female who c/o acute abdominal pain. She is pale, diaphoretic, and appears shocky. Her pulse is 130, BP 90/50, RR 28. She is Para 0, Gravida 0, Ab 0. She says she is sexually active, and can’t be pregnant, because she is taking BC Pills. Her LMP was 2 weeks ago. She smokes 1 – 1 ½ packs of cigarettes/day. What is her DDX?

32. Case History, cont • DDX • PE • Sepsic/Toxic shock? • ? • Tx: • ?

33. Management of gynecological emergencies • Primarily supportive • Be alert for s/s of shock • Do not pack dressings in vagina • Consider PASG • Auscultate, palpate abdomen • Oxygen prn • IV’s prn

34. PID • Infection; usually involve uterus, fallopian tubes, ovaries • Sexually active women 15-24 • Most common cause; • Gonorrhea • Chlamydia • Predisposing factors • Multiple sexual partners • PMH

35. PID • May result in sepsis, • Sterility • Adhesions • “PID shuffle” • Fever, chills, N/V, discharge, irregular menses • Tx: antibiotics

36. Case history

37. Case History, cont. • DDX? • Tx:

38. Ruptured Ovarian Cyst • GYN emerg. • Significant internal hemorrhage • A thin walled, fluid-filled sac • Abdominal pain secondary to • Rapid expansion • Torsion • Acute rupture

39. Ruptured Ovarian Cyst • Most common cyst that ruptures – corpus luteum cyst (space left in ovary after ovulation) • Most ruptures occur ~ 1 week before period • S/s • Localized, unilateral lower abdominal pain • Generalized s/s peritonitis • Onset assoc. minimal abdominal trauma, sexual intercourse, exercise

41. Teratoma Cyst

42. Mature cystic teratoma of the ovary prior to exision

44. Cystitis • Inflammation of inner lining of bladder; • Bacterial infection • S/S • Urinary urgency • Dysuria • Low-grad fever • Chills • Pain above symphysis pubis

45. Painful menses H/A Faintness Dizziness Nausea Diarrhea Backache Leg pain Chills Dysmenorrhea – common in women who have not borne children

46. Mittelschmerz • Mid-cycle abdominal pain • Possibly secondary to rupture of graafian follicle, bleeding from ovary • S/S • Unilateral lower quadrant pain, midcycle • Duration about 24-36 hours

47. Endometritis • Inflammation of the uterine lining • Usually secondary to infection • Most common after childbirth or abortion • May affect fallopian tubes and uterus

48. Endometritis • S/S • Onset 48-72 hours after procedure/miscarriage • Fever 101 – 104 deg. F • Purulent vaginal discharge • Lower abdominal pain

49. Endometriosis • Abnormal gynecological condition • Females 30 – 40 y/o • Ectopic growth and functioning of endometrial tissue • Fragments regurgitated backward during menstruation • Average age of women 37 years

50. Endometriosis • S/S • Pain • Painful defecation • Suprapubic soreness • Premenstrual vaginal staining • infertility