10 Management of Gynaecologic and Obstetrical Emergencies
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Transcript of 10 Management of Gynaecologic and Obstetrical Emergencies
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MANAGEMENT OF GYNAECOLOGICAND OBSTETRICAL EMERGENCIESIN A RURAL AND URBAN SETTING
IMS Murah-Manoe
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Definition of terms
Epidemiology: - Gynaecologic Emergency
- Obstetric Emergency Etiology of Gynaecologic Emergency
Etiology of Obstetric Emergency
Objective of Management Gynaecologic
Emergency Objective of Management Obstetric Emergency
General Measures Common to both Emergencies
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Definitions
Gynaecology comprises health related issuesaffecting oman from the pubertal period to her last
days! that has to do ith the genital system" It alsoincludes complications pregnancy occurring beforethe ## completed ee$s of gestation
Obstetrics on the other hand is the period ofgestation that e%tends from ## ee$s to & ee$s
post-partum" It includes direct causes! related to thepregnancy and indirect causes! medical affectionsthat may complicate pregnancy in the ante! intra!
post-partum periods
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Gynaecoloic Emerencies
E%cessive sympathetic symptoms of
pregnancy +hyperemesis gravidarum maypresent in an acute state
Medical conditions! diabetes! high blood
pressure! endocrine disorders
+hyperthyroidism! pheochromocytoma etc"may present as emergencies in early
pregnancy
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Gynaecoloic Emerencies
S/I in its acute form .I0 is a gynaecologic emergency
(leeding from the genital tract ithout pregnancy+1eoplasms C* cervi%! endocervical,endometrial polyps!
sub-mucous,intramural myomas! endometrial
hyperplasias, carcinomas! dysfunctional uterine bleeding
.sychosomatic disorders e"g" hysteria! pseudocyesis
Ovarian pathologies: /orsion! rapidly increasing mass etc"
may present as an acute gynaecologic emergency
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!ital Statistics
#5-852 of omen beteen 75-85 years carry
uterine myomas! submucous! intra-mural types may
be very haemorrhagic
85-45 years pea$ age for cervical cancer and
perimenopausal disorders! may present ith life
threatening haemorrhage
09( pathology resulting from immaturity of the
hypothalamo-pituitary a%is! seen around puberty and
perimenopausal periods can be very haemorrhage
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!ital Statistics
ebrile conditions! malaria! meningitis!
encephalopathies+viral! to%oplasmosis etc"occurring in early pregnancy
Convulsions! coma occurring in early
pregnancy
*bdominal pain in early pregnancy
0ifficulty in breathing in early pregnancy
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O"#ecti$es of Manaement
0etermine the degree of illness
.revent maternal morbidity and mortality
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General Meas%res
Ra&i' Initial Assessment
Assess Daner sins Consi'er
-*iray,(reathing Cyanosis! respiratory Severe anaemia! heartdistress! s$in pallor! failure! asthma
lung fields !
-Circulation+signs S$in cool ; clamy! Shoc$
of shoc$ pulse! (.
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General Meas%res
Ra&i' Initial Assessment
Assess Daner sins Consi'er
-'igh fever =ea$!lethalgic!fre>uent Malaria! pyelonephritis!
painful micturition! .I0! pelvicabscess
unconscious! nec$ stiffness! postabortalperitonitis
lungs! abdominal tenderness! pneumonia
vaginal discharge"
-*bdominal Gestational age! (.! .ulse Ovariancyst!
.ain temperature! si?e of uterus!*ge appendicitis ; pregnancy .allor! pulse! (.! speculum ectopic pregnancy
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Im&lementin Ra&i' Initial Assessment
Sc(eme
@apid initiation of treatment! immediate recognition specificproblem! >uic$ action:
/rain all staff Conduct clinical or emergency drills Ensure easy assess to all the services! e>uipment functional" Establish norms and protocols! display this for easy assess
hen needed
Auic$ly revie all aiting patients .rovide emergency drugs! services pending payment @espect the omanBs dignity! right to privacy and donBt be
judgemental" .rovide corrective counselling at the end
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Im&lementin Ra&i' Initial Assessment
Sc(eme
Socio-demographic characteristics may influence
management:
Marital status! relationship ith her partner
Social status of the oman,couple! their cultural
and religious practices! beliefs and e%pectations
.ersonality of persons involved! >uality and natureof social! practical and emotional support
1ature! gravity and prognosis of the problem! the
availability and >uality of the health services
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Im&lementin Ra&i' Initial Assessment
Sc(eme
Communicate ith patient and family!
diagnosis! treatment! prognosis
*rrange for treatment or referral
Schedule a follo-up visit to chec$
progress and discuss available options
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Manaement
Emergencies do occur suddenly or as a complicationof treatment or failure to properly manage or monitor
Some emergencies can be prevented by carefulplanning e"g . and prevention of unantedpregnancies! folloing clinical guidelines e"g" ectopicpregnancy! septic abortions! .I0 etc! closemonitoring e"g" transfusional accidents! ectopicpregnancy
.re-re>uisite to emergency management is thatmembers of the team should $no their roles
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Manaement
/eam members should $no: the clinicalsituations! the diagnosis ; treatment! drugs!their use! administration and side-effects hoto use emergency e>uipments and ho itfunctions
*bility of a facility to deal ith emergenciesshould be assessed and reinforced byfre>uent practice of emergency drills
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Initial Manaement
Stay calm! thin$ logically! focus on the needs of theoman
/eam spirit must be respected! thus call for 'ED. 0istribute roles if an emergency team is non-
e%istantin the facility If patient is 91CO1SCIO9S see table
If shoc$ is suspected! immediately start treatment Intervie patient and relatives for major symptoms!
e%amine and ma$e a presumptive diagnosis
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Initial Manaement
Get an Iuate infra-structure or
incompetence of personnel
@e-evaluate and modify treatment accordingly
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Meas%res S&ecific to Gynaecoloy
Continue treatment folloing diagnosis:
3" Emergency laparotomy for ectopic pregnancy"
Ectopic pregnancy is a gynaecologic emergency!
ith active bleeding!thus surgery is urgent ith or
ithout blood if parameters are stable" Fetamine is
usually the preferred anaethetic drug
#" 'yperemesis gravidarum! admission! isolation!
rehydration! 1il peros! counselling to partner and
family
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Meas%res S&ecific to Gynaecoloy )
3" Molar pregnancy: *spirate after baseline
investigations! histology! follo-up (eta hCGassay! for at least to years! counselling as
concerns ris$ associated
#" Infections are managed accordingly
7" Convulsions managed according todiagnosis" Consult the various specialist as
indicated
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Meas%res S&ecific to Gynaecoloy
8" (leeding not related to pregnancy: Good
history and e%amination! presumptivediagnosis! lab test +hormone profile! (C!
clotting profile! thyroid disorders! .*. smear!
endometrial biopsy etc" and treat
accordingly
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Iss%es S&ecific to R%ral Comm%nities
Dac$ of >ualified staff! infra-structure 0istant beteen the district health facility and
specialised centres here ade>uate treatment ispossible
Do socio-economic status of the patients thusfinancial constraints
Dac$ of specific medications e"g" prostaglandins!
blood and blood products @oads and absence of ambulances in some of our
rural areas Influence of cultural norms! religious beliefs
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O"stetrics* Intro'%ction
Most pregnancies and deliveries usually occur
ithout any complications
/oday the high ris$ approach! abandon because
all pregnancies carry some ris$! be it maternal
morbidity and mortality
*bout 342 of all pregnant omen do develop a
complication that may jeopardi?e her life
/hese complications may necessitate the use of
major obstetrical intervention
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O"#ecti$es of Manaement
Evaluate the degree of illness
.revent maternal morbidity and mortality
.revent foetal morbidity and mortality
Most emergencies can be prevented by
>uic$ assessment
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General Meas%res
Ra&i' Initial Assessment
Assess Daner sins Consi'er
- *iray ; Cyanosis!respiratory distress Severe anaemia!(reathing mucous membranes! lungs heart failure!
pneumonia! asthma
-Circulation +shoc$ (.!pulse
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General Meas%res
Ra&i' Initial Assessment-9nconscious or Gestational age! (. Eclampsia! malaria!
convulsion .ulse! temperature epilepsy!tetanus-'igh temperature =ea$ness! lethargy! 9/I! Malaria!
fre>uent micturition! endometritis!
e%amine-unconscious! mastitis etc
conplete e%amination
-*bdominal pain Gestational age!(. Dabour!.ulse! temperature chorioamnionitis!
abruptio placenta!
uterine rupture
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Meas%res S&ecific to O"stetrics
Continue treatment accordingly: *1/E.*@/9M-bleeding: .lacenta praevia!
determine amount of bleeding! conservative oremergency management
*bruptio placenta: @upture membrane! I< o%cytocin!C,S hen indicated
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Meas%res S&ecific to O"stetrics
I1/@*.*@/9M:
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Meas%res S&ecific to O"stetrics
.ostpartum
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Meas%res S&ecific to O"stetrics
Dacerations to the genital tract! perinealtears!
cervical tears! vaginal tears! episiotomy
0isseminated intravascular coagulation!
I90! chorioamnionitis! abruptio placenta or
retro placental haematoma
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Meas%res S&ecific to O"stetrics
0yspnoea! chest pain! pulmonary embolism
Convulsions! eclampsia! epilepsy!
encephalopathies+viral! bacterial! proto?oal
ever , pain! endometritis! mastitis!
malaria! typhoid fever! post-traumatic
cellulitis! managed accordingly
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