Endometriosis

Definition : painful condition caused by growth of

endometrial tissue outside the uterus.

Organs of the Pelvic Cavity are the most common

locations for the ectopic growths.

Complication : one of the leading causes of Infertility in

women.

Clinical presentation

Pain

Pelvic

Low back pain

painful sexual intercourse

Dysuria and painful defecation

Painful menstrual cramps

bleeding

Heavy menstruation

Intermenstural spotting

Gastrointestinal bleeding

Fatigue Mistaken for

chronic fatigue

syndrome

Management

Prehospital care is based on the patient's complaint :

1. If the patient reports severe Pain → provide pain relief

with analgesics if allowed in your protocol.

2. Use dressing or towels as needed to absorb any significant

Bleeding.

3. Let the patient position herself so she is comfortable.

4. Transport to hospital.

Pelvic inflammatory disease (PID)

Definition : PID is an infection of the female Upper

Genital organs i.e. uterus , ovaries and fallopian tubes.

It affects mainly Young Menstruating Sexually Active

females younger than 25 years old

Risk factors include:

A. The use of an IUD as a contraceptive device.

B. Frequent sexual activity with multiple partners.

C. History of previous PID.

Pathogenesis of PID

1. Organism enter the vagina with seminal fluid .

2. It travels up and infects the uterine cavity .

3. Then it affects both the fallopian tube and ovary .

4. The infection can spread to abdominal cavity

causing peritonitis and pelvic abcess.

Pathogenesis of PID

Clinical presentation

Pain 1 -achy2 -Starts with or after

normal menstruation3 -Diffuse and spread to both abdominal quadrants

4 -Pain increase with walking and sexual intercourse

Additional symptoms 1 -Fever and chills

2 -Vaginal discharge

3 -Burning micturition

Special notes

Symptoms may mimic that of Acute Abdomen .

Complication : septicemia , peritonitis and infertility.

Management :

1. Address ABCs .

2. Transport in comfortable position .

3. No treatment in field for PID , definitive treatment is

by antibiotics for 10 – 14 days .

Vaginitis

Vaginitis: infection of vagina which is very

common.

Vulvovaginitis : inflammation of both vagina and

vulva.

Fungal or yeast vaginitis is one of the most common

types .

Yeast vaginal infection is caused by candida

albicans fungus .

Pathophysiology of candida vaginitis

Candida albicans is normal bacterial flora .

It inhabits the vagina in small number .

Overgrowth of candida is prevented by normal

acidic ph. of the vagina.

Factors that alter vaginal acidity ( decrease )

causes over growth of candida .

Pathophysiology of candida vaginitis

1. Use of oral contraceptives,

2. Menstruation,

3. Pregnancy.

4. Some antibiotics.

5. Moisture and irritation.

6. Stress from lack of sleep, illness, or poor diet.

7. Immune suppressive diseases such as HIV infection or

diabetes.

Risk factors

Common symptoms of vaginitis

Vaginitis what ever the causative agent present with

common symptoms :

1. Itching and Irritation ( burning ).

2. Discharge.

3. Odor.

4. Painful intercourse.

5. Lower abdominal pain.

Symptoms of vaginal yeast infections

1. Itching and Burning.

2. Burning on urination.

3. itchy feeling in the vagina and around the opening.

4. Thick, white vaginal discharge

5. Pain during sexual intercourse.

6.Lower abdominal pain

Symptoms of vulvovaginitis

1. Pain and burning sensation

2. Itching ( intense itching ) which increase before

and the time of menstruation.

3. Redness and Swelling of the vulva skin.

Complication and management

Complication of vaginitis :

1. Infertility.

2. Preterm birth.

3. Endometritis and PID.

4. Increased risk for STDs.

Management

1. Prehospital treatment is supportive.

2. Definitive treatment of vaginitis is that of the

causative organism antibiotics or antifungal .

3. Vulvovaginitis topical creams(antifungal and

steroids cream combination) are added.

Bartholin abcess

Definition : Inflammation of Bartholin gland .

Pathophysiology :

1. Bartholin glands opens by two small ducts in

lower part of the vagina , it secretes mucous that

acts as lubricants during sexual intercourse.

2. These ducts could become obstructed leading to

mucous accumulation and cyst formation .

Pathogenesis

Cyst is painless swelling .

With time, the fluid within the cyst may become

infected, resulting in pus accumulation and

abscess formation.

Bartholin gland

Anatomy of Bartholin gland Bartholin cyst

BARTHOLIN ABCESS

Assessment

Clinical presentation :

1. The Bartholin abscess is usually unilateral.

2. Patient may report the following:

painful mass.

Swelling and redness of the vulva.

Painful intercourse.

Management :

Drainage ( Marsupialization ) and antibiotics.

Ovarian cyst

Ovarian cyst : is a fluid-filled sac that forms on or within

an ovary.

Types :

1. Functional cyst .

2. Follicular cyst.

3. Corpus luteum cyst.

4. Polycystic ovarian disease.

Complicated ovarian cyst is

a true gynecological

emergency

A. Functional cyst :

1. The most common type of cyst.

2. During the menstrual cycle, the ovaries form tiny sacs

(cysts) to hold the oocytes.

3. Once the oocyte matures, the sac breaks open and releases

the oocyte before dissolving.

B. follicular cyst :

1. If the sac fails to close after , fluid accumulates inside and

the oocyte may form a follicular sac .

2. Normally disappears within 1 to 3 months.

C. Corpus luteum cyst :

1. Develops if the sac seals itself after release of the oocyte.

2. Fluid accumulates inside the cyst and continues to grow.

3. Fertility drugs can increase the incidence corpus luteum

cysts.

D. Polycystic ovarian disease :

1. Result from repeated and excessive cyst formation with

failure of ova release .

2. Exact etiology is unknown.

Follicular And Corpus Luteum Cyst

3. Pathophysiology and clinical presentation of polycystic

ovarian disease :

Increased androgen and decreased estrogen leading to

menstrual irregularities acne and excessive hair

growth.

Insulin resistance leading to diabetes and obesity.

Increased incidence of hypertension and ischemic

heart disease.

PCOD

Clinical presentation of uncomplicated ovarian cyst

Patient with an ovarian cyst may report the following:

1. Dull, achy pain in the lower back and thighs.

2. Abdominal pain or pressure.

3. Nausea and vomiting.

4. Breast tenderness.

5. Abnormal bleeding and painful menstruation.

6. Painful intercourse.

PCOD

COMPLICATION

1. REPTURE .

2. TORSION.

3. ABCESS FORMATION.

Complication of ovarian cyst

Rupture of ovarian cyst

Leads to Internal Hemorrhage And Acute Abdomen.

Signs and symptoms include:

(a) Lower abdominal pain (usually described as sharp).

(b) Abdominal distention and tenderness.

(c) Dizziness , Weakness and Syncopal episode.

2. Ovarian torsion :

Occurs when the cyst reaches a considerable size causing

the ovary to twist which impair its blood supply .

Clinical picture :

1. Sudden onset of severe unilateral lower abdominal pain

that may radiate to the back or thigh

2. associated with nausea and vomiting.

Requires surgery.

3. Abcess formation

Called Tubo-ovarian abcess .

Patient with A Tubo-ovarian Abscess present with :

1. Severe abdominal pain.

2. Guarding , tenderness and rebound tenderness

3. Abdominal distention

4. Nausea and vomiting

5. Fever , headache , anorexia and malaise .

Any of these conditions, may be complicated with internal

hemorrhage.

Management of complicated ovarian cyst

1. Ensure adequate airway and give high flow oxygen .

2. Check signs of Shock and give an IV fluid via large bore

cannula.

3. Anticipate vomiting

4. Keep the patient in left lateral pain .

5. Give analgesic if allowed

6. Transport rapidly and inform hospital about your

diagnosis and patient condition.

7. Reassess vital signs regularly during transport.

Prolapsed uterus

Definition : drop of the uterus from its normal position into

vagina .

Etiology : occurs due to weakness of muscles and

ligaments holding uterus in its position which may be due to :

1. age .

2. Child birth .

3. Obesity .

4. Low estrogen levels .

There are Four Stages of prolapse :

1. 1st Degree : cervix drops into the vagina.

2. 2nd Degree: cervix sticks out of the opening of the

vagina.

3. 3rd Degree : cervix is outside of the vagina.

4. 4th Degree : the entire uterus is outside the vagina.

STAGES OF UTERINE PROLAPSE

UTERINE PROLAPSE

Clinical presentation

1. Vaginal , pelvic pain and Low back pain,.

2. Dysuria and Incontinence.

3. Infection and bad smelling discharge.

4. Varying degrees of feeling like something is

falling out of or bulging from their vagina.

Management

Prehospital treatment is limited to:

1. Pain management and Treatment for shock if present

2. Do not replace any tissue and Cover with warm,

moist dressings.

3. Do not let the patient walk.

4. Definitive treatment includes devices to hold the

organs in place or surgery.

Toxic shock syndrome

Form of septic shock .

Commonly seen in menstruating female using tampons.

Caused by group A streptococci and staphylococcus aureus .

Clinical presentation :

1. Fever , headache

2. Anorexia , malaise

3. Vomiting and may be syncopal attack.

Management

1. High-flow supplemental oxygen

2. IV therapy

3. Pressors if necessary

4. Cardiac monitoring

5. Rapid transport is indicated.

Sexual assault

Rape is a crime, and police involvement should

be expected.

The rule of the paramedic is to manage the

medical aspects of the case and act as the patient

supporter.

If possible, a female rape victim should be given

the option of being treated by a female paramedic.

Assessment of rape victim

A. Professionalism, kindness, and sensitivity are

important.

B. Do the following:

1. Limit any physical examination to a brief survey for life-

threatening injuries.

2. Examine the vaginal area only if there is evidence of

bleeding.

3. Do everything possible to protect the patient's privacy.

4. Examine the patient with a minimum of people present.

C. Management

1. Do not cut through any clothing or throw away anything

2. Place bloodstained articles in separate paper (not plastic)

bags.

3. Discourage the patient from:

4. Cleaning herself up

5. Using hand sanitizer

6. Changing clothes

7. Moving her bowels

8. Rinsing out her mouth