Gynecology

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Gynecology

• Department of EMS Professions
• Temple College

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External Genitalia
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External Genitalia (Vulva)

• Mons Pubis
• Labia
• majora
• minora
• Perineum
• Prepuce
• Clitoris
• Uretheral opening (meatus)
• Vestibule
• Skenes glands
• Bartholins glands
• Vaginal entrance (Introitus)
• Anus

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Female Reproductive System
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Internal Reproductive Organs

• Vagina
• Cervix
• Uterus
• Corpus
• Fundus
• Fallopian Tubes
• Ovary

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Female Reproductive System
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Female Reproductive Organs

• Endometrium
• Mucosal
• Myometrium
• Circulation
• Smooth Muscles
• Perimetrium
• Serous
• Fundus 1/2 Corpus

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Menstrual Cycle

• Menarche
• usually between 9 and 13
• initially irregular
• Normal
• usually 28 day
• Hormones
• FSH
• LH
• Estrogen
• Progesterone
• Menopause
• 45 - 55 years old

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Menstrual Cycle

• Pituitary produces follicle stimulation hormone
  (FSH)
• FSH stimulates ovarian follicle maturation
• Follicles mature, release estrogen
• Estrogen stimulates thickening of endometrium
• Estrogen acts on pituitary to decrease FSH
  release
• FSH levels begin to fall, LH levels rise

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Menstrual Cycle

• After ovulation, luteinizing hormone (LH) acts on
  remains of follicle
• Promotes corpus luteum formation
• Corpus luteum produces progesterone
• Progesterone stabilizes, maintains uterine lining

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Menstrual Cycle

• If ovum is not fertilized
• Corpus luteum dies
• Progesterone levels drop
• Endometrium deteriorates, sloughs
• Menstrual period occurs

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Menstrual Cycle

• If ovum is fertilized
• Zygote implants in endometrium
• Human chorionic gonadotropin (HCG) released
• HCG sustains corpus luteum
• Corpus luteum produces progesterone
• Endometrium remains stable
• Pregnancy continues

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Menstrual Cycle
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Pelvic Inflammatory Disease

• Pathophysiology
• Acute or chronic infection involving female
  reproductive tract, associated structures
• Cervix (cervicitis)
• Uterus (endometritis)
• Fallopian tubes (salpingitis)
• Ovaries (oophoritis)
• Pelvic peritoneum

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PID

• Pathophysiology
• Causative organisms include
• Gonorrhea
• Chlamydia
• E. coli, other gram negative bacilli
• Gram positive cocci
• Mycoplasma
• Viruses

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PID

• Most cases sexually transmitted
• Risk factors include
• Previous infection
• Multiple partners
• Adolescence
• Presence of IUD

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PID

• History
• Moderate to severe diffuse lower abdominal pain
• May localize to one quadrant or radiate to
  shoulders
• Gradual onset over 2-3 days beginning 1 -2 weeks
  after last period

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PID

• History
• Pain worsened by intercourse (Dyspareunia)
• Associated symptoms
• Fever
• Chills
• Nausea, vomiting
• Vaginal discharge
• Erratic periods

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PID

• Physical Exam
• Patient appears ill
• Fever usually present
• Tender abdomen
• Rebound tenderness
• Walks bent forward holding abdomen

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PID

• Management
• Position of comfort
• General supportive care (oxygen, IV)
• Transport
• May be at risk for rupture of pyosalpinx or
  tubo-ovarian abscess

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Dysfunctional Uterine Bleeding

• Pathophysiology
• Usually younger women
• Ovum not released from ovary regularly
• Without ovum release/corpus luteum formation,
  menstrual cycle is not completed

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Dysfunctional Uterine Bleeding

• Pathophysiology
• Endometrium continues to thicken
• Outgrows blood supply, breaks down
• Massive vaginal bleeding results

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Dysfunctional Uterine Bleeding

• History
• History of missed, irregular periods
• Continuous, profuse vaginal bleeding possibly
  persisting 8 days

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Dysfunctional Uterine Bleeding

• Physical Exam
• Signs/symptoms of hypovolemic shock
• Positive tilt test
• Passage of tissue with vaginal bleeding

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Dysfunctional Uterine Bleeding

• Management
• Do not pack vagina to stop bleeding
• High concentration oxygen
• IV LR
• MAST if indicated

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Endometriosis

• Presence of normal endometrium at ectopic
  locations
• Signs, symptoms
• Pelvic pain
• Dysmenorrhea
• Pain on intercourse
• Lower abdominal tenderness

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Endometriosis

• History
• Painful intercourse
• Painful menstruation
• Painful bowel movements

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Endometriosis

• Rupture of endometrial masses may cause severe
  pain, internal hemorrhage
• May require surgery
• Long term management is gynecologic issue

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Ruptured Ovarian Cyst

• Ovarian cyst Sac on ovary
• Causes include
• Growth of endometrial tissue in ovary
• Hemorrhaging into mature corpus luteum
• Over-distension of ovarian follicle

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Ruptured Ovarian Cyst

• Cysts rupture into peritoneal cavity
• Peritonitis
• Hemorrhage, shock

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Ruptured Ovarian Cyst

• Signs, symptoms
• History of menstrual irregularities, chronic
  pelvic pain
• Unilateral abdominal pain
• Unilateral tenderness
• Pallor, tachycardia, diaphoresis, hypotension

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Ruptured Ovarian Cyst

• Management
• High concentration oxygen
• IV LR
• MAST if indicated
• Rapid transport

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Cystitis

• Inflammation of the bladder
• Usually bacterial
• Occurs frequently
• May lead to pyelonephritis

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Cystitis

• Assessment
• Suprapubic tenderness
• Frequent urination
• Dysuria
• Blood in urine

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Cystitis

• Management
• Supportive care

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Mittelschmertz

• Pain at menstrual cycle midpoint
• Caused by ovulation
• Occurs on day 14 to 16
• Unilateral, mild to moderate
• Lasts a day or less
• Possible light vaginal spotting

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Mittelschmertz

• Management
• Rule out more serious causes of pain
• Analgesia may be required
• Self-limiting problem
• Can be confirmed by keeping calendar

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Sexual Assault

• Any sexual contact without consent
• Legal rather than medical diagnosis
• Seldom creates medical emergency
• If medical emergency exists, usually is from
  trauma secondary to assault

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Sexual Assault

• History
• Do not question patient regarding details of
  event.
• Do not question patient about sexual history or
  practices
• Avoid taking lengthy histories
• Do not ask questions which may lead to guilt
  feelings
• Anticipate reactions such as anxiety, withdrawal,
  denial, anger, fear

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Sexual Assault

• Physical Exam
• Examine genitalia only if severe injury present
• Avoid touching without permission
• Explain procedures before proceeding
• Maintain the patients modesty

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Sexual Assault

• Management
• Priority to immediate life threats
• Psychological support is important
• Limit intervention to that needed for immediate
  problems
• Protect patients privacy

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Sexual Assault

• Crime Scene
• Handle evidence as little as possible
• Ask patient not to change, bathe, or douche
• Do not allow patient to drink or brush their
  teeth
• Do not clean wounds unless absolutely necessary

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Sexual Assault

• Management
• May be preferable for female paramedic to attend
  patient
• Honor patients wishes
• Do not abandon patient at scene
• Complete trip report carefully

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Gynecological Assessment

• Abdominal Pain
• Bleeding

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Gynecological PA

• Abdominal Pain Female Gender
  
• Gynecologic Problem
  Until Proven Otherwise

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Gynecological PA

• Abdominal pain
• When was last period?
• Was it normal?
• Bleeding between periods?
• Regularity?

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Gynecological PA

• Abdominal pain
• Pregnant?
• Missed period?
• Urinary frequency?
• Breast enlargement or tenderness?
• N/V?
• Contraception? What kind?
• Vaginal discharge?
• Color, amount, odor

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Gynecological PA

• Abdominal Pain
• Aggravation/Alleviation
• OPQRST
• Tenderness/masses at pains location?
• Tilt test

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Gynecological PA

• Vaginal bleeding
• More, less heavy than normal period?
• Possibility of pregnancy?
• Associated pain/tenderness?
• Perform tilt test

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Gynecological PA

• Fever/Chills