Principles of organization

of emergency care
for gynecological patients at the
stage of female clinics
 Order No. 417

Of MES of Ukraine
“On the organization of
outpatient obstetric and
gynecological care in
Ukraine”
of 15.07.2011
 Groups of causes of “acute abdomen”

I group II group III group

intra-abdominal bleedings,
due to an impairment of an
ectopic pregnancy, ovarian
apoplexy or traumatic damage
to the uterus of iatrogenic or
criminal origin
conditions associated with acute purulent
malnutrition of tumors of inflammatory
the internal genital organs - diseases of the internal
torsion of the legs of the genital organs
ovarian tumor and necrosis
of the uterine fibromatous
node
 Symptoms of “acute
abdomen”

 sudden pain in full health, often begins in

the lower abdomen, gradually intensifying
and spreading throughout the abdomen;
can be so strong that results in fainting
 nausea, vomiting
 violation of intestinal motility and the
passage of intestinal gases and feces
 symptoms of peritoneal irritation
Gynecological diseases requiring emergency care

 Ectopic pregnancy (graviditas

exstrauterina s. ectopica)

 Ovarian apoplexy (apoplexia ovarii)

 Ovarian cyst rupture

Description One.


93%
Twisting the legs of an ovarian cystoma
or uterine myoma Description Two.
69%
 External genital injuries
All diseases with
presentation of “acute
abdomen” require
immediate hospitalization
of patients, correct and
timely diagnosis and
emergency care
 Ectopic pregnancy
occurs due to implantation of the ovum outside the uterus

It poses a serious danger to the health

and life of women, since in the absence of
conditions for development in most cases
 terminates in the early stages,
Description One.
 is accompanied by abdominal 93%
bleeding
Description Two.
 becomes the cause of “acute 69%
abdomen”
Symptoms of rupture of the fallopian tube

sudden pain in the lower abdomen, in the inguinal

01 region, sometimes with radiation to the shoulder
blade, shoulder (phrenicus symptom)

02 short-term loss of consciousness

signs of intra-abdominal bleeding (drop in blood

03 pressure, weak and accelerated pulse, pallor of the
skin)

04 posthemorrhagic collapse

05 vaginal discharge is bloody or absent

Symptoms of a tubal miscarriage

cramping pains in the bloody discharge from the genital tract is often of
lower abdomen coffee grounds type, due to rejection of the decidual
modified uterine mucosa due to termination of
pregnancy

dizziness formation of uterine

hematoma
 Blood test
 hemoglobin reduction
 picture of hypochromic
Speculum examination shows anemia
cyanosis of vaginal mucosa,
discharge of  leukocyte shift to the left
dark color often of
 ESR increase
coffee grounds type

Vaginal examination
the posterior vaginal fornix is flattened,
the uterus is mobile, “floats”, sharp pain
when trying to move the cervix forward
and sharp pain when palpating the
posterior fornix, “Douglas cry”
Management

Every woman with a suspected

ectopic pregnancy should be
hospitalized and stay in hospital
until a clinical diagnosis is
established - confirmation or
refutation of suspected ectopic
localization of the fetal egg
Algorithm of action at the stage of
female clinic in suspected ectopic
pregnancy

 monitoring of pulse, blood pressure, hemoglobin

level in the follow-up for timely detection of the
onset of internal bleeding

 upon the appearance of its signs (pallor of the

skin, dizziness, fainting, decreased blood
pressure, frequent and weak pulse), immediate
hospitalization to the nearest hospital
 Emergency care for suspected
ectopic pregnancy

 Call an ambulance immediately. Hospitalization to the gynecological department

 Have the patient lie down - prevention of collapse
 Reassure the patient - relieve the fear of death and prepare for hospitalization
 Put ice on the lower abdomen - reduce intra-abdominal bleeding
 Measure blood pressure and heart rate – monitoring of the state
 Prepare syringes, IV systems, tourniquets, cotton balls, alcohol
 Ovarian apoplexy
apoplexia ovarii

 defined as a sudden hemorrhage in the

ovary due to a rupture of the vessels of the
follicle, ovarian stroma, follicular cyst or
corpus luteum cyst, accompanied by a
violation of the integrity of its tissue and
bleeding into the abdominal cavity

 observed at any age (up to 45-50 years)

 On vaginal
examination

 uterus of normal size

A painful form of ovarian apoplexy is
observed in hemorrhage into follicle or  ovary is slightly enlarged
corpus luteum tissue and painful
 vaginal arches are deep,
 an attack of pain in the lower abdomen without radiation,
loose
sometimes with nausea and vomiting  there is no accumulation
 no signs of abdominal bleeding of fluid in the cul de sac
 skin and mucous membranes of normal color
 hemoglobin reduction
 heart rate and blood pressure are normal
 tongue is clean, wet
 the stomach is soft
 pain in the iliac region, often on the right
 no peritoneal symptoms
 Hemorrhagic (anemic) form
of ovarian apoplexy

 The main symptoms are related to intra-abdominal bleeding.

 The disease begins acutely, often due to external causes (sexual

intercourse, physical stress, trauma, etc.)

 Pain in the lower abdomen often radiates to the anus, leg, sacrum,
external genitalia, accompanied by weakness, dizziness, nausea,
vomiting, fainting
 Apoplexy
On palpation
 sharp pain is observed
in one of the iliac sections
Most often occurs two weeks after menstruation or throughout
On examination hypogastrium, peritoneal
symptoms are most
 skin and visible mucous membranes are pale pronounced in the lower
 cold sticky sweat on the skin sections

 blood pressure is educed, tachycardia  percussion can determine

the free fluid in the
 dry tongue sloping places of the
 tense abdomen, slight bloating possible abdomen (right, left side
channels)
 Apoplexy

 Vaginal arches overhang

Bimanual
 Uterus of normal sizes, painful
examination
 On the side of apoplexy, a painful, slightly
may be difficult due to
enlarged ovary is palpated
severe soreness of the
 Vaginal arches overhang anterior abdominal wall
 Traction for the cervix is sharply painful
 Hemoglobin reduction
 A slight increase in white blood cells without
shifting the formula to the left
Emergency care for ovarian
apoplexy
 Horizontal position with raised upper trunk
 Control lining
 Cold to the lower abdomen
 Blood pressure monitoring, respiratory rate,
PS, temperature and volume of blood loss
 Catheterization of 2-3 main veins: 0.9%
sodium chloride 4.0 or a solution of 5%
glucose 400.0
 Urgent hospitalization to the gynecological
department
 Ovarian cyst rupture

A cyst is a benign mass filled with fluid

Cysts occur on the ovaries at any age, but more often
in young women and adolescent girls.

 Rupture of an ovarian cyst is a severe complication, accompanied by

severe pain, often loss of consciousness and fever
 Requires emergency medical care in a hospital
 Without surgery, it can lead to the development of peritonitis. The sooner
assistance is provided, the greater the likelihood of avoiding undesirable
health effects and maintaining fertility.
Main presentation

sudden severe pain in the lower abdomen; pain is

01 localized from the side of the ovary on which the cyst
is located

02 short-term loss of consciousness

intestinal motility disorders, mainly constipation,

03 possible diarrhea, difficulty urinating

bloody discharge from the vagina (scanty or

04 moderate)

05 severe weakness, dizziness

Ovarian cyst rupture

On examination:
 pallor of the skin and visible mucous membranes
 cold sweat
 slight increase in body temperature
 Increased heartbeat
 reduced blood pressure
 Urgent care

 Call an ambulance

 Cold on stomach

 Reassure the
patient
 Torsion of the legs of the ovarian bone

Clinical signs  tachycardia

 sharp pain in the lower abdomen  abdomen is distended, painful at
on the affected side the site of tumor projection
 nausea, vomiting  dry tongue, coated with plaque
 delays in feces and gases  the muscles of the anterior
(intestinal paresis) abdominal wall are tense
 the skin becomes pale  positive Shchetkin-Blumberg
sign
 cold sweat
 blood leukocytosis
 body temperature rises (usually up
to 38° C)  ESR increased
Torsion of the legs of the ovarian leg

Bimanual gynecological
examination is often difficult due Emergency care –
to sharp pain and muscle tension urgent hospitalization
in the anterior abdominal wall

Diagnosis is based on
presentation, medical history,
ultrasound
 Uterine myoma
malnutrition

due to a mechanical factor (torsion, bending,

tumor compression)

Clinical signs:
 acute abdominal pain
 tension of the anterior abdominal
wall
 fever and leukocytosis are
possible
 Emergency care
- urgent hospitalization

Bimanual examination
determines the presence in
the uterus of myomatous
nodes, one of which is
sharply painful on palpation

Ultrasound makes it easy to

identify hard-to-reach nodes

You can clarify the

diagnosis using
laparoscopy
Pyosalpinx rupture

Pyosalpinx is accumulation of
pus in the fallopian tube

Clinical signs:
 immediately after a rupture, an acute
cutting pain occurs throughout the
abdomen
 collapse state
 nausea, vomiting
 the abdomen is tense and sharply
painful
 Pyosalpinx rupture

 general condition of the patient rapidly worsens,

facial features sharpen, breathing becomes frequent On bimanual
and shallow examination
 due to intestinal paresis, the abdomen distends,
it is not possible to
peristalsis disappears or is barely audible, delayed
palpate the uterus and
gas discharge
appendages due to
 traction for the cervix is sharply painful sharp pain and tension
of the anterior
 percussion of the abdomen can detect dullness of
abdominal wall and
sound in the lateral regions due to the presence of
vaginal arches
effusion in the abdominal cavity
 pelvic peritonitis often develops
Emergency care

the patient should be put to bed

with a raised head end

drip antibiotics, blood

substitutes, conduct symptomatic
therapy (antipyretic, anti-
inflammatory, analgesics).

transportation of the patient

should be especially careful
 Injuries to the external
genitalia, vagina and uterus

Injuries can occur

 in case of rape
 during childbirth, abortion, sexual
intercourse

Iatrogenic damage is possible as a result of

 radiation therapy for malignant neoplasms,
 careless examination with the help of
speculum of older women with atrophic
changes in the vaginal mucosa,
 abortion perforation
Injuries to the female genital organs can occur in the form of a bruise,
hematoma, subcutaneous hemorrhage, often accompanied by skin
damage. Falls, bumps are a common cause of injuries.

In rural areas, injuries from animal horns are observed. These injuries can
be accompanied by lacerations, which often penetrate deep into the tissue,
sometimes damage the vagina and even the rectum.

In severe injuries, the urethra, bladder, and also the pelvic bones are
simultaneously damaged. In case of damage to the vagina, trauma can
penetrate into the abdominal cavity

Injuries to the external genitalia,
vagina and uterus
Emergent care in falls
 bottle with ice (ordinary bottle with
cold water). Time of exposure to
cold - up to 15 minutes, then a
break of 5 minutes
 Cold helps to constrict blood
vessels the volume of blood loss
will decrease
 immediately hospitalize to
gynecological hospital
Clinical presentation
 pallor of the skin and visible
mucous membranes
 pain, bleeding
 edema, hematomas
 in case of injury to the bladder,
rectum, incontinence of urine,
gas and feces may occur
Diagnosis
 History taking, examination
a  vaginal and rectovaginal
examination
 Treatment at female clinic

topical use of in severe injuries stopping anti-shock broad-spectrum

antiseptic - surgical bleeding and therapy antibiotics
solutions intervention hemodynamic
normalization
Wound treatment

Primary wound treatment - in

clean fresh wounds in the
perineum, apply catgut sutures to
the vaginal mucosa, catgut or silk
sutures to the skin

Description One.
93%
If the wound is contaminated,
anti-tetanus and anti- Description Two.
gangrenous serum are 69%
administered
Wound treatment

In hematomas

if it does not increase: apply a

tight dressing, prescribe
hemostatic agents (tranexamic
acid preparations

if it increases, as well as the

infected hematoma is opened,
the vessels that bleed are tied
up
 Correct and timely
assistance
at the stage of female
clinic contributes to
success in treatment
Thank you for your attention!
Stay safe!