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URGENTEGINECOLOGICE
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URGENTE GINECOLOGICE
Prezentari obisnuite:
Durere abdominala (abdomino-pelvina)
Infectii Sangerare vaginala
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DUREREA ABDOMINALA ACUTA
Necesita luarea in considerare a
cauzelormedicale/chirurgicale/ginecologice
Atentie la varsta pacientei
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DUREREA ABDOMINALA ACUTA
Considerare
Cauze non-ginecologice
Cauze ginecologice
Este o urgenta?
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DUREREA ABDOMINALA ACUTA
Daca e necesar resuscitare ABC,identificare necesitate chirurgie de
urgenta
Linie i.v.
Analgezie!
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DUREREA ABDOMINALA
ACUTA Se poate pune un dg? Anamneza:
Caracteristicile durerii, prezentadispareuniei, fenomene asociate
(sangerare, scurgeri) Alte semne asociate urinare,
gastro, febra
Istoric ob-gin: UM (normal cadata, durata si cantitate?), SEU
in anteced?, BTS?,contraceptie?
APP
durerea din SEU deobicei unilaterala,
BIP bilateral
- durerea iradiata inumar + discomfortrectal sugestiv pt.SEU
- mittelschmerz =durerea la ovulatie lajumatatea ciclului
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DUREREA ABDOMINALA
ACUTA Examen clinic general
Semne vitale (atentie lasoc compensat),temperatura, aspect general
al pacientei Examen abdomen
Inspectie, palpare,percutie
Se cauta cicatrici, distensieabd., semne de iritatieperitoneala, mase tumorale,hernii etc.
Examinare seriata
Examen cu valve si TV
Golire vezica!
Leziuni
perineale/vaginale,secretie
Palpare col durere
Uter marime,consistenta
Anexe dimensiuni,durere
Recoltare secretie
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DUREREA ABDOMINALA ACUTA
Paraclinic Examene uzuale:
HLG, SU Test sarcina! Uree, ionograma, amilaza
Secretie vaginala Imagistica:
Ecografie abdominala/transvaginala RX abd.,laparoscopia(BIP)
Alte teste: Grup sg. VSH, CRP, Teste hepatice Markeri tumorali
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DUREREA ABDOMINALA ACUTA
Cauze frecvente SEU
Avort
Chist ovarian torsionat, rupt
BIP
Cauze mai rare Fibrom (torsionat)
Cauze rare Hematocolpos
Torsiuni ale altor structuri (chist fimbrial,hidrosalpinx)
Sd. de hiperstimulare ovariana
Haematometra, pyometra
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DUREREA ABDOMINALA ACUTA
Atitudine
ABC
Analgezie (opiod),AINS Protectie sarcina
Tratament conservator cand este posibil(evitare chirurgie)
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DUREREA ABDOMINALA ACUTA
De retinut
Nu orice pacienta prezentata ca urgenta
ginecologica va avea o cauza ginecologica a durerii!
Toate femeile de varsta fertila cu durere abdominala
acuta ar trebui sa beneficieze de:
Test de sarcina
HLG (L sugereaza procese inflamatorii ca boala
inflamatorie pelvina - BIP, apendicita)
SU Investigatiile ulterioare depind in general de
rezultatul celor de mai sus
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INFECTII
BIPUrgenta ginecologica
Forme clinice variate de la infectie
endocervicala asimptomatica pana laendometrita, endosalpingita, pelviperitonita siabces tubo-ovarian
Complicatii
Pe termen scurt: abces tuboovarian, perihepatita
Pe termen lung cicatrici trompe, aderente siconsecintele: infertilitate, SEU, dispareunie etc.
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INFECTII
BIPEtiologie:
Neisseria gonorrhoeae
Chlamydia trachomatis
Infectii polimicrobiene
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BIPFACTORI DE RISC
Parteneri sexuali multiplii
Abuz sexual
Dusuri vaginale frecventeDispozitive intrauterine,PCO
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INFECTII
BIPEvaluare Anamneza: activitate sexuala, ultima menstruatie,
sangerari anormale, contraceptie, dispareunie/durerirectale la defecatie, proceduri recente (gineco/chir.)
Clinic: semne generale de infectie,durerea la ex.abd.: semneperitoneale,singerare,secretii,dispareunie,disurie
Ex. cu valve & TV: evidentiere secretie vaginala(culoare, cantitate, textura), durere, col, anexe,Douglas
Laborator: HLG, SU+urocult., HCG, culturi secretie,frotiu
Ecografie,biopsie endometru,laparoscopia
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INFECTII
BIPDiagnosticDurere abdominala
joasa
+durere/sensibilitatela mobilizareacolului uterin
+durere/sensibilitateanexiala
+ unul din urmatoarele:
L > 10500
tC > 38C Culdocenteza aspirat
purulent
L >5 in frotiu secretie
endocervicala Diplococi G- in frotiu secretie
endocervicala
Anticorpi anti C. trachomatis
in secretia endocervicala Masa/colectie palpata la ex.
bimanual sau vizualizataecografic
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INFECTII
BIPTRATAMENT-eradicare infectiei si minimizarea sechele Sepsis ABC
Antibiotice mai multe regimuri de administrare, i.v.
sau p.o., include metronidazol + cefalosporina + doxi/ probenecid / fluorchinolone
Laparoscopie daca nu se rezolva in 24-48h cu AB
Abces tuboovarian tt. chirurgical
Endometrita si hemoragii secundare postpartumAB +/- chirurgie
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INFECTII
BARTOLINITA
Dg. : tumef. dureroasa labia majora
colectie la niv. gl. BartholinNu se indica antibioterapie fara drenare
chirurgicala abces
ABCESUL VULVAR/LABIAL
Dg. localizare mai anterioara decatbartholinita
Tratament +/-AB + drenaj chirurgical
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INFECTII
VAGINITE
Bacteriene
Candida Trichomonas
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INFECTIISINDROMUL SOCULUI TOXIC
Cauzat de exotoxina Staphylococcus aureus,asociere cu menstruatia si fol. tampoanelorintravaginale
Clinic: febra brusc, mialgii, rash
Mortalitate mare
Atitudine:
ABC
tratat ca soc septic! Indepartare tampon
Antibiotic rezistent la betalactamaze: Fluoxacilina,cefuroxima
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SANGERARI VAGINALE
Pot aparea la orice varsta
De exclus complicatii ale sarcinii
Poate sa reprezinte debut de malignitate
!orice femeie de varsta fertila care se
prezinta cu sangerare vaginala trebuieconsiderata insarcinata pana la probacontrarie
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SANGERARI VAGINALE
anormaleIn afara sarcinii
Singerari anormale ovulatorii si anovulatorii
Menoragie sangerare menstruala mai abundenta,se datoreaza de obicei anomaliilor anatomiceuterine, tulburarilor hormonale
Metroragie sangerare intre menstre, in tulburarianatomice / sistemice
Meno-metroragiesingerare vaginala f.neregulatasi abundentea anovulatorie, orice etiologie
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SANGERARI VAGINALE
Informatii importante
Simptome de sarcina timpurie sau test
de sarcina recent + ?gesta, ?para, UM, ?activitate sexuala,
contraceptie
Episodul actual cand?, cat?, ciclic/non-ciclic?, aspect, cantitate
Insotite de durere?
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SANGERARI VAGINALE
Informatii importante
Boala sistemica cunoscuta? Ex.:DZ, tulb.
endocrine, discrazii sgv.Medicatie (inclusiv AINS)
Alergii
Obiceiuri droguri, fumat, alcool Istoric de BIP,BTS,SE,I.chir.
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SANGERARI VAGINALE
Ex. clinic:General:
Semne de hipovolemie?
Tulburari de coagulare leziuni cutanate
Semne vitale
Abdomen
N, exceptand sangerare intraperitoneala sau
intrauterina mare (ex.: SEU, ruptura uterina,abruptio placentae)
Durere / aparare musculara
Estimare varsta sarcina
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SANGERARI VAGINALE
Ex. cu valve si ex.vagino abdominal sirectovaginal
Examinare atenta pentru stabilirea sursei desangerare (orificiul cervical, structurile din jur)
Aspect organe genitale externe plagi,inflamatii, hemoragii
Col uterin culoare, consistenta, orificiu, durerela mobilizare
Uter , ssb., consistenta, neregularitati
Anexe ssb., mase T
Funduri de sac vaginale pline=lichid (sange,puroi)
Eval. rect, uretra ca surse de san erare
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SANGERARI VAGINALE
Paraclinic
Laborator:
test sarcina (urina)
si/sau HCG in sange(dozari cantitative)
HLG, grup, Rh
Teste coagulare si pt.
CID
SU excluderehematurie
Ecografie transabdominalasi transvaginala
Culdocenteza (punctionarea
fundului de sac vaginal post.) orienteaza dg. in functie delichidul aspirat:
Sange non-coagulabil
sugereaza SEU Purulent sugereaza
infectie (pelviperitonita)
Lichid serosangvinolent
sugereaza chist ovarianru t
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SANGERARI VAGINALE
In afara sarcinii
Etiologie diferita:
Sangerare uterina disfunctionala(menoragie)
Polipi cervicali / fibroame Hemoragie secundara dupa chirurgie
ginecologica majora
Trauma tract genital, inclusiv viol
Sangerare post conizatie Malignitate
Sangerare post-menopauza
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SANGERARI VAGINALEIn afara sarcinii
Atitudine
Stabilizare ABC
Considerare variante de tratament
pentru oprirea sangerarii Mesaj vaginal (poate sa fie necesar sa fie
efectuat in sala de operatie)
Sutura punctelor de sangerare
Chiuretaj de urgenta
Tratamentul ulterior depinde desuspiciunea dg.-estrogeni inafara
sarcinei si cancer
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SANGERARI VAGINALE
Sangerarea uterina disfunctionala
Sangerare anovulatorie
Menoragie
Tratament
ABC (resuscitare, transfuzii daca enecesar)
Medical: estrogeni,PCO,progesteron p.o. i Chirurgical: daca e necesar: histeroscopie
si chiuretaj, tamponament cu balon
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SINGERARI VAGINALE
IN SARCINA - TRIM I
Orice femeie aflata la virsta fertila carese prezinta in urgenta cu singerarevaginala si /sau durere abdominalatrebuie testata pentru sarcina!
Orice femeie aflata la virsta fertila care
se prezinta cu sincopa,hipotensiune saumodificarea status mental trebuie testatapentru sarcina si SE trebuie luata incalcul.
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SANGERARI VAGINALE
IN SARCINA TRIM I
Poate fi benigna datorita modificarilorcervixului (epiteliu friabil, sangereaza usor
Atentie! Abuz?
Avort spontan
SEU
B. trofoblastica gestationala
Corp galben hemoragic
Uter incarcerat
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SANGERARI VAGINALE
Avortul spontan = expulzia prematura a unui produs de conceptie
neviabil (
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SINGERARI VAGINALE
Cauze de avort spontan:
- anomalii cromozomiale (50-60%)
-virsta inaintata -afectiuni medicale
-avort anterior
-infectii(sifilis,HIV) -anomalii anatomice genitale
-fumat,metale grele,ag.anestezici
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SANGERARI VAGINALE
Boala trofoblastica gestationala
Anomalii de proliferare a trofoblastului
Sangerari sange inchis la culoare + expulzie devezicule molare, fenomene de disgravidie, dureri
abdominale, HCG, ecografie aspectcaracteristic
Forme:
Mola hidatiforma (benigna)
Mola invaziva (local) Coriocarcinom (malign)-metastaze
Terapie _ chiuretaj prin aspiratie,complicatii-hemoragie,embolie trofoblastica,betaHCG
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SANGERARI VAGINALE
Corpul galben hemoragic
Persista pana in S8
Ruptura - sangerare - dgSEU
Uter incarcerat
Cauza rara de sangerare in trim. I
Uter retrovers si retroflex a carui anteversie nu
are loc in timpul expansiunii in sarcina poateramane prins in bazinul osos
Netratat retentie de urina, avort spontan
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SARCINA ECTOPICA
= nidare + dezvoltare ou in afara cavitatiiuterine / in afara endometrului
Varietati anatomice: tubara, uterina (corn,diverticul, intramurala), cervicala,intraligamentara, ovariana, abdominala,concomitent intra-si extrauterina
! Dg. de sarcina ectopica de luat in considerare laorice femeie de varsta fertila cu durere
abdominala, sangerare vaginala sau soc!
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SARCINA ECTOPICA-cauze
BIP
Istoric de operatii pe trompe
Dispozitive intrauterine SE anterioara
Tehnici de fertilizare
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SARCINA ECTOPICA
Clinic-variabilitate simptomatica
Triada durere abdominala + sangerare vaginala+ tulburari menstruatie = sarcina ectopica pana
la infirmare dg.
Amenoree, durere spontan si la palpareabdomen in fosele iliace, TV: modificari uter
durata amenoreei, laterouterin impastaredureroasa sau masa tumorala
Sarcina ectopica rupta hemoperitoneu, soc
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SARCINA ECTOPICA
Clinic
Hematocelul = forma cea mai frecventa
se formeaza ca urmare a uneisangerari (unica/repetata), sangele seacumuleaza in Douglas, se poateobiectiva ca masa pseudotumorala
Orice disconfort,durere la o femeie devirsta fertila SE ?
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SARCINA ECTOPICA
Sarcina ectopica rupta
Tipic durere lancinanta in una dinfosele iliace urmata de lipotimie,semne de soc hemoragic; TVDouglas sensibil
Atipic - durere, forme pseudoapendiculara, pseudoocluziva,pseudohemolitica, asociere CID
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SARCINA ECTOPICA
Dg. test sarcina din urina si ser, ecografie
Dg.
In evolutie chist de ovar,BIP,apendicita,colicarenala ,b.intestinala
Avort,cervicita,carcinom cervical,sarcina molara
Hematocel T pelvina, pelviperitonita
Rupta cauze soc hemoragic
Un test de sarcina corect efectuat, pozitiv vaconfirma dg de sarcina ectopica in contextul clinic
si paraclinic
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SARCINA ECTOPICA
Tratament
Rupta interventie chirurgicala de
urgenta-laparotomie si salpingotomie Tratamentul socului hemoragic
Sarcina nerupta tratamentchirurgical(salpingostomielaparoscopica) / metotrexat
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SANGERAREAUTERINA IN ULTIMUL
TRIMESTRU DESARCINA
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PLACENTA PRAEVIA
DECOLAREA DE PLACENTA
RUPTURA UTERINA TRAVALIU (PREMATUR / LA TERMEN)
INCOMPETENTA CERVICO-ISTMICA
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PLACENTA PRAEVIA
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PLACENTA PRAEVIA
Implantarea totala / partiala a placentei pesegmentul inferior uterin care poate obstruaorificiul intern al canalului cervical
Varietati Centrala Partial centrala Marginala Laterala Anatomica
Patogenie implantare primitiva/secundara aoului in regiunea istmica
Etiologiemultipare,uter cicatricial
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PLACENTA PRAEVIA
Clinic Sangerare fara dureri in trimestrul al
III-lea = placenta praevia pana laproba contrarie !!
Sangerare brusca, indolora, farasimptome premonitorii,fara durere
Sange rosu
Se repeta
Survine de obicei noaptea
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PLACENTA PRAEVIA
Ex. cu valve: exteriorizare sange din cervix Ecografie :dg.sigur in 93-98%din cazuri
De preferat
Dg. precoce, necesita reconfirmare TV e periculos singerare catastrofala
Rar!!!! (unul singur), bland, nu exploraredigitala intracervicala
Colul este tras spre partea pe care se inseraplacenta
Semnul saltelei
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PLACENTA PRAEVIA
Tratament
Tratamentul socului hemoragic daca e
cazul + cezariana de urgentaHemoragii mici si repetate repaus,
tocolitice etc.
Consult obstetrical
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DECOLAREA DE PLACENTA
Abruptio placentae
Sindrom determinat dedecolarea accidentalapartiala / totala a placenteidin sediul sau normal deinsertie, oricand inainte denastere
Apare in 1% din nasteri
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DECOLAREA DE PLACENTA
Etiologie
Factori favorizanti:
varsta >35 ani
carente vitaminice / proteice Fumat,droguri
preeclampsie
tulburari endocrine etc.
multiparitate
Factor determinant: leziuni vasculare: spasm arterial, ischemie
detasare insertie placenta hematom retroplacentar
Factori declansatori:
Puseu acut de TA
Descarcare masiva desubstante ssblz.
presiunii in spatiul
intervilos
trauma
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DECOLAREA DE PLACENTA
Intrerupere schimburi materno-fetale
Suferinta fetala moarte
Hipovolemie, socCoagulopatie de consum
Transfuzie feto-materna
Embolie cu lichid amniotic
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DECOLAREA DE PLACENTA
Clinic Apoplexia uteroplacentara (rar)
Durere abdominala violenta cu sincopaurmata de soc
Uter marit, boselat, tonus (uter de
lemn)
BCF alterate / absente
Ex. vaginal: sange negricios, col dilatat1-2 cm, cu margini dure si membranein tensiune
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DECOLAREA DE PLACENTA
Clinic-depinde de gradul dezlipirii si alsingerarii
Durere - intensitate variabilaDurere iradiata in spate de luat in
considerare decolarea posterioara
Sangerarea vaginala poate sa nureflecte pierderea de sange reala
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DECOLAREA DE PLACENTA
Ecografia poate rata evidentierea dezlipirii placentei
Monitorizare cardiotocografica pentru cel putin 4 ore
Fara activitate uterina 4 h nu este decolare
>8 contractii/h foarte sugestiv pt. decolare
3-7 contractii/h necesita monitorizare incontinuare
Monitorizare activitate cardiaca fetala evidentieresemne de suferinta fetala (decelerari tardive =semn ca se impune nasterea!)
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DECOLAREA DE PLACENTA-teste de laborator
HLG
Grup sanguin
Teste decoagulare:Tr.,TQ,fibrinogen,PDF
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DECOLAREA DE PLACENTA
Tratament
Stabilizare ABC Semne de suferinta fetala interventie
imediata
Complicatii: CID, sensibilizarea mameiRh neg.
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RUPTURA UTERINA
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RUPTURA UTERINA
Etiologie
Distocii
Manevre obstetricale
intempestive Uter cicatricial
Perfuzii ocitocicenesupravegheate
T uterine
Patogenie
Depasirea procesului dedilatatie
Ruptura prin distensiemaxima prezentatievicioasa (transversa)
Ruptura prin compresieescarificarea unei zone desegment inferior princompresia craniului fetal pebazin
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8/3/2019 URGENTE GINECOLOGICE
63/70
RUPTURA UTERINA
Clinic - in travaliu sd. de preruptura Bandl-FrommelHiperkinezie si hipertonie cu dureri intense
lomboabdominale si suprasimfizare
Uter hiperton, retractat pe fat , cu distensie mare sisubtierea segmentului (palpare foarte dureroasa)
Uter in clepsidra (inel Bandl) cu ligamente rotundepalpate in tensiune
VU tractionata in sus TV: mica sangerare, col dur, edematiat, dilatatie
stationara, craniu fetal cu bosa
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8/3/2019 URGENTE GINECOLOGICE
64/70
RUPTURA UTERINA
Ruptura uterina propriu-zisa
Durere abdominala violenta urmata de
incetarea activitatii uterine Soc hemoragic hemoperitoneu
Palpare abdomen dureroasa, sepalpeaza 2 formatiuni fatul si uterul
Disparitia BCF
Sangerare vaginala sange coagulabil
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8/3/2019 URGENTE GINECOLOGICE
65/70
RUPTURA UTERINA
Tratament
Resuscitare Interventie chirurgicala de urgenta
Mortalitate materna si fetala mare
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8/3/2019 URGENTE GINECOLOGICE
66/70
TRAVALIUL PREMATUR
Travaliu prematur travaliu inainte de 37 S desarcina
Ruptura prematura de membrane ruptura
membrane inainte de debutul travaliului Apare in 10% din nasteri si e principala cauza
de boala si moarte perinatala
Responsabil de 85 % din decese neonatale
nedatorate anomaliilor genetice sau congenitalefetale
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8/3/2019 URGENTE GINECOLOGICE
67/70
TRAVALIU PREMATUR-CAUZE
RPM
Abruptio placentae
Sarcini multipleConsum de droguri
Polihidramnios
Incompetenta cervicala Infectie
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8/3/2019 URGENTE GINECOLOGICE
68/70
TRAVALIU PREMATUR
Viabilitatea fetala sub 24 saptamini eposibila dar scazuta si cu probabilitatemare de handicap
Anamneza privind virstasarcinii,declansare travaliu,a rupturiimembranelor,
Internare de urgenta si terapie tocolitica
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8/3/2019 URGENTE GINECOLOGICE
69/70
URGENTE POSTPARTUM
Boala tromboembolica
Eclampsia
Hemoragia postpartum
-atonia uterina
-ruptura uterina
-laceratii ale tract genital inf.
-tesut placentar retinut-inversiune uterina
-coagulopatie
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8/3/2019 URGENTE GINECOLOGICE
70/70
URGENTE POSTPARTUM
Endometrita postpartum
Embolia cu lichid amniotic
Cardiomiopatia peripartum
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