10 Management of Gynaecologic and Obstetrical Emergencies

8/19/2019 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



-'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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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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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



- *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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I1/@*.*@/9M:


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.ostpartum


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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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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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10 Management of Gynaecologic and Obstetrical Emergencies

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