Acute conditions in gynecology (ACG)Hanáček Jiří

Katedra gynekologie a porodnictví IPVZ Vedoucí Doc. MUDr J.Feyereisl,CSc.

Ústav pro péči o matku a dítě, PodolíŘeditel Doc. MUDr J.Feyereisl,CSc.

Acute abdominal emergency

• Diseases of the stomach, which is characterized by sudden onset, usually in the middle of full health and rapid progression, requiring surgery

Types of pain – diferential dg

To test the Acute conditions in gynecology

• A detailed history• Assessment of vital signs (pulse, BP, T, breath)• Total approximate physical examination• Detailed evaluation of abdominal findings - look,

listen to percussion, palpation• Examination per vaginae, rectal• Ultrasonic examination of pelvic• Complete laboratory and instrumental

examinations• Documentation, ask consultant

Paraclinic, laboratory tests

• Blood samples - blood count, biochemistry, • hCG, CRP• Ultrasound - vaginal probe• X-native (abdomen)• CT

Ancillary tests - Acute phase proteins

• 3 groups according to speed of onset • first Group - 6 hours after the onset of tissue

damage (maximum 48 hours), C - reactive protein

• second Group - the emergence of 12 to 24 hours after tissue damage (maximum at 72-96 hours), orosomucoid, haptoglobin, antitrypsin

• third Group - the reduction in plasma concentrations of prealbumin, albumin

Human chorionic gonadotropin ( hCG)

• Human chorionic gonadotropin (Aschheim and Zondek - 1928)Glycoprotein m.v. 36,700α - subunit (92 AK) - identical for LH, FSH, TSHβ - subunit (147 AK)

• Synthesis of two subunits – syncytiotrofoblast• In vitro production of detectable 6 days after

fertilization• In vivo levels 9 to 11 day after fertilization• One-time helps determine the diagnosis only in

conjunction with another method ( samples after 2 days, progesteron)

Signes of Acute conditions in gynecology

• Change the overall appearance of the patient• Loss of appetite, nausea, vomiting• Hiccup• Stop of fards and stool• Abdominal pain• Changes in pulse, respiration and blood pressure• Temperature• Vaginal bleeding

Subjective Symptoms of ACG

• PAIN - somatic• somatic - occurs in the peritoneum wall irritation

(stomach contents, urine, blood, pus), breathing, coughing or sneezing worsen the pain, localized in one of 4.kv., spread to the sides, the lateral resolution

• Forces to maintaining constant position , permanent, precise localization, is associated with muscle downloading

• Center: gyrus postcentralis

Subjective Symptoms of ACG

PAIN -visceralvisceral - arise in organs of the abdominal cavity,

the peritoneum is affected by wall colicky pain, with no precise location, location

changes with nausea, no contractions of muscleCenter: regional prefrontalis

Clinical examination - the principles

• "... We start with exam on site which is less unpleasant and less painful..."

Pafko,P.,Moderní gynekologie a porodnictví, 2002

Inflammatory AGC - selected symptoms

• Blumberg - Ščotkinův• Rovsingův • Lennanderův příznak• Pleniésův příznak

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Psoassign

Obturatorsign

Non inflamatory ACG - signes

• Hirschprungs flagWahls flag (Percussion with metal shade in a limited area)Freniks flagCullens flagSolovjevs flag - "krepitující" palpationMeylans, Herzfelds flag - tenesmy, the pressure in the rectum

Clinical examination - local

• Local findings in a small pelvis

• Bimanual examination - per vaginae, rectal

• Range examining finger

• Bowing Douglas space

• Sphincter tone

• Intestinal content - description

Acute conditions in gynecology

bleeding

Acute conditions in gynecologyBleeding Inflamatory Non inflamatory In relation to menstrual cycle

- Ectopic pregnancy- Ruptureof cysts- Bleeding   of genitals- Postoperative   hemorrhage- Violent   hemorrhage

Basic Concepts

• Graviditas ectopica• Ectopic pregnancy• Graviditas extrauterina• Graviditas heterotopica

Ectopic pregnancy

• Implantation of fetal egg outside the uterine cavity

• 95% of ectopic pregnancies in a tube (80% in the ampula)Prevalence of 1:80 to 1:200The mortality rate - 0.1%Etiology - pelvic infections, endometriosis, MCHA, previous GEU, IUD, IVF, sterilization

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Risk factors Estimated risk

High risk

Operace vejcovodů 21,0

Sterilizace 9,3

Předchozí GEU 8,3

IUD 4,2-45

Aplikace DES 5,6

Tubární patologie 3,8-21

Medium risk

Neplodnost 2,5-21

Pánevní zánět 2,5-3,7

Více sex.partnerů 2,1

Low risk

Operace v malé pánvi 0,93-3,8

Kouření cigaret 2,2-2,5

Předčasná koitarché 1,6

Vaginální výplachy 1,1-3,1

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Graviditas ectopica

• Rupture of the tube• Tubal abortion• Necrosis and absorption of GEU• Heterotopic pregnancy

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Ectopic pregnancy- diagnosis

• For women of childbearing age always think of the possibility of pregnancy

• Typical symptoms can be expected in 30 to 70% of women

Ectopic pregnancy- diagnosis

• delayed Menses• Aching and colicky lower abdominal pain in

70-80%• Vaginal bleeding 50-80%• unilateral palpable resistance (graviditas

dolorosa) 50-75%• Haemoperitoneum - peritoneal irritation

(Phrenic symptom)

Laboratory diagnosis

• A normal intrauterine pregnancy doubles the value of hCG from 5 th week of pregnancy every 2 days up to 3.5 days in the 7th week

• Decrease or plateau = ectopic pregnancy, intrauterine pregnancy unprofitable

• hCG 1500 IU / L - the limit for vaginal ultrasound and detection of intrauterine pregnancy (Kadar)

• Progesteron- levels above 25 ml/l – vital pregnancy

Ultrasound diagnostic

• Transvaginal views• Probes 5 - 7.5 MHz• Gestational sac is seen in normal pregnancy

28 days after ovulation• Pseudogestational sac ( bleeding)• Adnexal resistance

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Tzv. Bagel sign

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Cervikální gravidita

Invasive diagnostic test

• Diagnosis and Treatment - Laparoscopy "gold standard" to allow a definitive diagnosis and treatment

Current treatment options

• Surgical treatment

• Medicamental treatment

Medicaments therapy

• Methotrexate• Tanaka (1982) first used in the treatment of GEU• Antimetabolite that inhibits dihydrofolate reductase

thus blocking the synthesis of DNA, RNA and AK and act on rapidly proliferating cells - such as trophoblast

• Systemic and local administration• We use the knowledge of the treatment of gestational

trophoblastic disease• Applications iv, im, after, or local injection into the

tube under the control LSK or ultrasound

Rare types of ectopic implantation

• Interstitial pregnancy• Ovarial pregnancy• Abdominal pregnancy• Cervical pregnancy• Heterotopic pregnancy

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Gynaecological bleeding

• When occurs vaginal bleeding its difficult to determine origin

• Exclusion of pregnancy• Distribution by age - the reproductive age –

postmenopausal• Foreign body

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Gynecological bleeding– ruptur of cystGynecological bleeding– ruptur of cyst

Postoperative early and late bleeding

• Increasing the frequency of a one-day surgery (conization, IVF programs - so-called pick-up)

• Hematoma in the wound, intraabdominal bleeding, haemoperitoneum

• Vaginal bleeding + / -