EMERGENCY MEDICINE
OB-GYNE
Vaginal bleeding on non-pregnancy
Menstruation
Days Menstruation Ovaries uterus
0 menstruation Follicular proliferative
phase
1-4 Ovulation ovarian uterine
4-8 Luteal phase Secretory
 Follicular – cell; on-going maturation of follicle.
 Estrogen – surrounding the area
 Luteal phase – corpus luteum
 Progesterone – 2nd phase will increase
 Fertilization – embryo -> implant - >
produce hormone- BetaHCG -> alarm
copus luteum continue producing estro
and proges to make the environment
uterus viable to the baby/implanted egg
 If not (no fertilization)- proges and estro
will sudden withdrawal hormone cause
vasoconstriction of the spiral arteries in
the uterus -> will loss of blood supply
ISCHEMIA/ slough off blood ->
MENSTRUATION
 Normal Menstruation flow
 Mens: 28 days (+/- 7 days)
 Duration: 4 days
 Amount: 25-60 ml of blood loss/day
 Pads: 30 ml – full soaked? Moderate soaked?
Or feel niya lang magpalit.
 Menorrhagia – menses more than 7 days
 Metrorrhagia – irregular vaginal bleeding
 Menometrorrhagia – irregular & excessive
 Polymenorrhagia – frequent but light
 Post-coital bleeding – bleeding after
intercourse
 Post-menopausal – bleeding after 6 month
after sensation of menses.
 Average age for menopause –
51 years old
Physical Exam
 Need?
 Consent - to examination; and
explain the procedure
 Companion – know by doctor
 Vulva & urethral opening
 Vagina: laceration, fissures,
lesion, infection & foreign body
 Cervix: polyps, inflammation,
infection, ulcers, discharges
 Position : Lithotomy / sim’s position (elderly
patient)
COMPONENT OF HISTORY
*COMPLETE HISTORY and ADDITIONAL
INFORMATION*
 LMP (LAST MENSTRUAL PERIOD/CYCLE) –
unang araw ng huling regla (NORMAL)
 PMP – Previous menstrual period
 MIDAS – Menarche, Interval (Regualr or
irreg), Duration, Amount (pads?), Symptoms
(dysmenorrhea, headache..etc.)
 OB-SCORING (GPTPAL)
G- Gravida – ilan beses nagbuntis
P – Para (Parity) – umabot sa complete
pregnancy umabot ng 37 weeks.
T- Term – 37 month above
P – Pre- term – below 36 months to
above 20 months
A – Abortion – below 20 months
L- Living – number of children living
*twins – counted as each.
 What to ask? Current sexual activity; barrier
protection; other disease (hive/hepatitis);
previous history of surgery; family history of
coagulopathy (bleeding disorder)
 If everything is clear but still continue the
bleeding suspect for HORMONAL:
 DUB - (dysfunctional uterine
bleeding) inside of uterus
 AUB – (Abnormal uterine Bleeding)
outside of uterus.
 Ovulatory phase. – (+ )signs for any
symptoms: bleeding low estrogen;
breast tenderness; bloated;
dysmenorrhea
 Anovoluntary - immature
 MC bleeding: cancer post menopausal
 Laboratory findings:
 Pregnancy test – routing
examination in all OB Cases female
on reproductive phase.
 If refusing sign a waiver that they
are refusing PT.
 UTZ – usual doing for OB cases
 TRANSVAGINAL - Non
virginal
 PELVIC – virgin
 Look for abscess, masses in
the line of the uterus
 CT-Scan – acute pelvic
abdominal pain bec.
Entertaining other cause. If
repro UTZ
 MRI – staging cancer
 Endometrial biopsy –
sample in the ling of uterus
ptx. AUB younger ptx risk
for CA.
 Short term MNGT:
 Unstable – hemodynamically
unstable, low BP
-> General
Resuscitation ABC (Airway,
Breathing, Circulation)
-> D&C (Dilatation &
Curettage / RASPA)
-> Continues Bleeding:
SGX MNGT – Removal of uterus
 Stable – Oral meds: estrogen or
progesterone – supplement
only
 OCP, Antifibrinolytic
Tranexamic acid basic drug
giving any bleeding ptx.
 Long term MNGT: NSAIDS :
Mefenamic acid, ibuprofen.
Inhibit prostaglandins dev’t
vasoconstriction. Control
bleeding
Clinical Condition
Genital trauma:
 Von Willebrand Disease (VWD) –
deficiency factor 8
- Replacement of factor 8
 Polycystic Ovarian Syndrome (PCOS)
 TRIAD: obesity,
hirsutism,
oligomennorrhea
 Not in all triad cases
symptoms should not
be present but in most
cases you can diagnose
with that.
 Variation in the menstrual cycle can
also be affected by:
 Stress
PART II
Abdominal Pain non pregnant
 History and PE
 Usual chief complaint
 Very tricky to diagnose lots of causes, or
radiating in other organs.
P- Provoking/palliative/predisposing
Q- Quality
R- Radiation/region
S- Severity (pain scale 1-10)
T- Time
 Past medical history
 Physical Examination:
 Internal Exam
 Digital Rectal Exam
 Fecalysis – get a sample
 Manual extraction
  Abdominal quadrant
Areas of abdomen – can cause
abdominal pain – sometimes other
organs radiates to other
 Lab exam:
 PT (pregnancy test) exam
 CBC (complete blood count)
 Urinalysis
 Pelvic utz
 Narcotic Drug : not given should be
observed
 NSAIDS : remove but sometimes it will
rapture the organ
 Analgesic : can give reduce anxiety and
reverse the symptoms
 Anti-emetics : anti vomiting –
metoclopramide
 antibiotics
 Migration epi gastric- hypo – right lower
 Out Patient without analgesics : minsan
pwde pag hindi pa ganun kasevere pero
observe and kailangan bumalik within
12 - 24 hours with serial examination
Cause abdominal pain
 Adnexal torsion – EMERGENCY
Torsion- twist ang fallopian
tube sa uterus
 MC: cyst
 s/s: sudden unilateral
pain
 DX: UTZ with Doppler
(see blood supply)
 Ovarian Cyst – no pain usually but with
pain; raptured, torsion, enlarge, naiipit
ibang organ
 DX: UTZ
 Types of ovarian cyst
 Functional Ovarian Cyst-
Functional cell during menstrual
cycle can able to enlarge and
cause pain (rapture, hemorrhage)
 Misle murch? - Brief pain on the
structure; dysmenorrhea (can
occur before or after)
 Monster cyst – dermoid cyst –
comprise epithelial lining with
hair, tooth, nails,
 Endometriosis – outside uterus
 Endometrioma - Condition kalat
lalat ang stroma (chocolate
cyst) – blood color chocolate
 Adenometriosis – wala sa uterus
nagkakaroon ng menstruation sa
labas (fallopian, anywhere.);
cyclic bleeding
 Adenomyosis - endometrium
(menstrual cycle) invade
myometrium
 Futz- hugh - curtis syndrome
- Secondary to PID (cured or
not) ; inflammation expanded to
Glisson’s capsule ; adhesion ; look like
hepatitis (pain; RUQ ; (-) in liver fxn
test) : history: have previous symptoms
PID
- TX: SAME WITH PID
(doxycycline; metroxycline
- DX: CT SCAN
 Leiomyomas – MC: pelvic mass (benign)
can cause problem when enlarge;
bleeding; pain;
 LOC: outside, sa gilid.
  Risk Factor: low  TX: steroids; anti
Estrogen, age histamine
 Vulvoginitis  Atropic dermatitis – lumiliit; elderly; no
 Factors: infection, allergic estrogen; no nourish the vaginal ; dry;
contact, foreign body, lack of sore; itching; dyphrenia (painful sexual
estrogen during menopausal intercourse); discharge; epithelium
and after appears (think, inflamed, ulcerated);
 MC: Bacterial Vaginosis kulang na sa dilig (estrogen) 
 Bartholene’s glands cyst – labia minora
Bacterial Vulvovaginit Trichomona
-> 4oclock and 8 ocolock; FUNCTION:
Vaginosis is s
add moisture to area; limiliit when you
candidiasis vaginitis
Cause Gardnerella Candida trichomonas got higher age; pwde cyst or abscess
vaginalis albicans (enlarge or pus (nana) )
discharg Thin; Thick; Thin  TX: antibiotic (pain reliever)/
e Asymptomat thrush; watery; Surgery (hiwain for drain and
ic; with odor “cottage adherent; warm compress)
cheese”; gray in  Pinworm – enterobius; notorious sa
itch; pruritus color; itchy; anal pruritus at night; intestine->
discoloratio anus->vagina
n;  DOC: albendazole / pyrantel
“Strawberry  DX: gray ham scotch tape
cervix” method – parang wax
PH: less More than Less than More than
 Vaginal foreign bodies –
than 4.5 4.5 4.5 4.5
 Chronic vaginal discharge –
Whiff + - +
test foul odor; if mababaw
Pap Clue cells Pseudohyph motile irrigation of PLNSS or manual
smear ae (yeast) removal
decriptio  TX: UTZ
n:
Infection
Numerou
s  PID (pelvic inflammatory Disease)
lactobacil  Most common disease in
li gynecology in states any
(normal
infection along the way or
flora)
whole reproductive
DOC metronidazol fluconazole metronidaz
 Oopharitis - Inflammation in
e ole
ovaries
 Contact vulvovaginitis -Like skin disease
 Salphingitis - Fallopian tube
(dermatitis); itchiness; allergic reaction;
 Endometritis, myometritis
local swelling; burning sensation;
 RF: multiple sexual partners;
 RF: napkin, panty liner,
STD; sexual abuse; IUD gushing;
feminine wash,
adolescent younger years
underwear, maduming
 STD bacteria enter vagina
kamay (HAWAK NG
during contact-> seminal fluid->
HAWAK)
 localized to one area ->
peritonitis
 MC: abdominal pain
 LAB TEST: result- INFECTION
(increase WBC, ESR,ESRP..ETC.)
 TX: TRANSV – collection of fluid
in pouches
 CC (chief complaint) Lower
abdominal pain - Ptx pasok sa
RF above; tenderness; cervical
tenderness - > start antibiotic
 DOC: doxycycline,
metronidazole; cephalosporins
 Complication: fitz-hugh-curtis;
tuboovarian abscess (tube
ovaries)
 When to admit? Inability to
exclude surgical emergency
(other cause); high fever; vomit;
TOA
BREAST DISORDERS
 Galactorrhea
 MC: elevated prolactin levels
Inflammatory Breast disease
 Acute Mastitis
 Infection localized area of
erythema; not fluctuant; no
pus;
 MC: staph. Aureus (nose of the
baby while sucking)
 Yes to BF(breastfeeding) – need
to express
 abscess
 (collection of pus in the capsule)
 NO BF
 Mammary Gland estasia
 lumiliit ang duct; no secretion;
inflammation sa gilid.
 Inflammatory breast cancer
 Inflammation and mastacia but
usually treat as mastitis but
this is the CA late to DX look
like infection.
 Nipple inverted
 Color: Orange; dippling
 Non-inflammatory
 MC: pain; nipple discharge
 Worried: serious sanginous - >
signify CA ; Watery; small
percentage
 Mondour disease
 (thrombophlebitis) like various
vein; ung vein pumapalibot sa
breast; Cord like mass on the
breast.
 Red flag: (know if cancer or not)
 Breast mass
with/without
adenophathy
 Ulcerated Mass
(matigas; kabahan ka;
masakit wag kakabahan)
 Epsilateral arm edema –
blockage of lymph drainage
 Breast trauma hematoma
 MC: seat belt; After SGX ;
Benign but observe 1.5 ml
blood clot -> increase/expand -
> drain
 Multiple breast syndrome
 Incontinence
 Involuntary leakage of urine
due to:
 Detrusor muscle over activities
 Stress (sphincter function)
 To little tone
 Urge – contraction
 MIX – urge + to little tone
 Over flow – cannot handle in
the small amount
 Prolapse
o cytocele - Bladder
o uretrocyctocele - Part of
urethra
o rectocele - Anus
 o enterocyctocele – Intestine
 Parity (marami na)
 Vaginal pressure
 Previous Surgery (NSVD)
 TX: SGX
 Most common Cause: Cancer
 Uterine- gyne
 Ovarian – 2nd most deadly
 Cervical – HPB (human
Papiloma virus)
 Vagina – LOC: posterior wall
upper 1/3 related to dES
(diethylstilbestrol)