urgente ginecologice

8/3/2019 URGENTE GINECOLOGICE

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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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Considerare

Cauze non-ginecologice

Cauze ginecologice

Este o urgenta?


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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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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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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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Atitudine

ABC

Analgezie (opiod),AINS Protectie sarcina

Tratament conservator cand este posibil(evitare chirurgie)


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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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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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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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Intrerupere schimburi materno-fetale

Suferinta fetala moarte

Hipovolemie, socCoagulopatie de consum

Transfuzie feto-materna

Embolie cu lichid amniotic


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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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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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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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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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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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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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RUPTURA UTERINA

Tratament

Resuscitare Interventie chirurgicala de urgenta

Mortalitate materna si fetala mare
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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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TRAVALIU PREMATUR-CAUZE

RPM

Abruptio placentae

Sarcini multipleConsum de droguri

Polihidramnios

Incompetenta cervicala Infectie
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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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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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URGENTE POSTPARTUM

Endometrita postpartum

Embolia cu lichid amniotic

Cardiomiopatia peripartum
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urgente ginecologice

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