Gynecology and Obstetrics

Introduction
Gynecology
– Branch of medicine that deals with the health
maintenance and the diseases of women.
Mainly reproductive organs
Most patients that you will encounter will be
experiencing either abdominal pain or vaginal
bleeding.
 Review of Female
Reproductive Anatomy
 Anatomy and Physiology of the
Female Reproductive Organs
External Genitalia
– Accessory functions
Protect body openings
Important role in sexual functioning
Internal Genitalia
– Most important organs of reproduction
– The ovaries, fallopian tubes, uterus, and vagina
 External Genitalia
Perineum
– Muscular tissue that
separates the vagina
and the anus
Mons Pubis
– Fatty layer of tissue
over the pubic
symphysis
Labia
– Structures that protect
the vagina and the
urethra
 Internal Genitalia
Vagina
– Female organ of
copulation
– Birth canal
– Outlet for
menstruation
Uterus
– Site of fetal
development
 Internal Genitalia
Fallopian Tubes
– Transports the egg
from the ovary to the
uterus
– Fertilization usually
occurs here
Ovaries
– Primary female
gonads
Female Anatomy
 The Uterus
Provides a site for
fetal development
Two major parts:
– Body (or corpus)
– Cervix (or neck)
Tissue layers
– Endometrium
– Myometrium
– Perimetrium
Reproductive Anatomy
 Uterine Anatomy

Endometrium- inner lining of uterine wall

Myometrium – thick middle layer of the
uterine wall (smooth muscle)
Perimetrium – Outermost layer of the
uterine wall
Ovary: Details of Histology &
Physiology

Figure 26-12d: ANATOMY SUMMARY: Female Reproduction

 Menses
Onset between ages 10 and 14
Menarche – the onset of menses
“Periods”
– Every 28 days
– 1st day of menstrual cycle is the beginning of menstrual
bleeding
– Average amount of bleeding 30-50cc
– Prepares the uterus to receive fertilized egg
– Regardless of the length of menstrual cycle the time from
ovulation to menstruation is always 14 days
– Cycle is controlled by the female hormones estrogen and
progesterone
 The Phases of the Menstrual
Cycle
The menstrual cycle has 4 phases:
The Follicular or Proliferative Phase
The Luteal or Secretory Phase
The Ischemic Phase
The Menstrual Phase
 Proliferation Phase
First two weeks of the menstrual cycle
– Dominated by estrogen
– Uterine lining will gradually thicken and become engorged with
blood
High levels of Follicle Stimulating Hormone (FSH) secreted by the
pituitary gland
– Function is to stimulate follicles in the ovaries
Endometrium proliferates
– One follicle begins to ripen and brings an egg to maturity
– Follicle secretes Estrogen
 Proliferation Phase Cont’d

Day 14
– Surge in leutenizing hormone (LH)
– Ovulation occurs
– Follicle develops the corpus luteum
If fertilization occurs, egg implants in uterus
– If not, the endometrium sheds in normal menses
Ovulation
 Length and Timing of the Cycle
Mittelschmerz - middle pain; cramping in lower
Abdomen that occurs during ovulation
 Secretory Phase
Stage immediately surrounding ovulation
– If the egg is not fertilized, the woman’s estrogen level
drops sharply
– Progesterone dominant hormone during this phase
Ovulation - follicle ruptures open and releases the mature
egg into the abdominal cavity and begins to develop the
corpus luteum under the influence of Leutenizing Hormone
 Hormones and Menstruation
Phase 3 - Luteal Phase or Secretory Phase
– After releasing the egg, the follicle turns into the corpus
luteum (a small yellowish body of cells responsible for
hormone production)
The corpus luteum manufactures progesterone
Without implantation of the fertilized egg, the
corpus luteum will atrophy 3 days prior to onset of
menstruation
If fertilization occurs the corpus luteum will
continue to produce progesterone until the
placenta takes over production
 Corpus Luteum
The corpus luteum develops from an ovarian follicle during the luteal phase of
the menstrual cycle or estrous cycle, following the release of a secondary
oocyte from the follicle during ovulation. The follicle first forms a corpus
hemorrhagicum before it becomes a corpus luteum, but the term simply refers
to the visible collection of blood left after rupture of the follicle and has no
functional significance. While the oocyte (later the zygote) traverses the
Fallopian tube into the uterus, the corpus luteum remains in the ovary.
The corpus luteum is typically very large relative to the size of the ovary; in
humans, the size of the structure ranges from under 2 cm to 5 cm in diameter.
[1][2]

Its cells develop from the follicular cells surrounding the ovarian follicle.[3]
 The Ischemic Phase
Estrogen and progesterone levels fall without
fertilization
The endometrium breaks down
– Vascular changes cause the endometrium to become
pale and small blood vessels to rupture
 Length and Timing of the Cycle
Normal menstrual cycle = 20 to 36 to 40 days;
– Average is about 28 days
Menstruation begins on day 1 and continues
until about day 4 or 5
Follicular phase extends from about day 5 to
about day 13
Ovulation occurs on day 14
Luteal phase extends from day 15 to the end of
the cycle, day 28
 The Menstrual Phase
Menstruation
– Ischemic endometrium is shed, along with a discharge
of blood, mucus, and cellular debris
– A “normal” menstrual cycle depends on the regular
pattern
Premenstrual syndrome (PMS)
– Symptoms include:
Breast tenderness or engorgement, transient weight gain or
bloating, excessive fatigue, and/or cravings for specific foods,
migraine headaches
 The Menstrual Phase
Menopause
– Menstruation occurs until a woman is 45 to 55
– Menopause signals the cessation of ovarian function
and the cessation of estrogen secretion
Periods decline in frequency and length until they ultimately
stop
Surgical menopause
– Hormone replacement therapy
 Assessment of the
Gynecological Patient
The most common emergency complaints of
women in the childbearing years are abdominal
pain and vaginal bleeding.
– Often due to problems of the reproductive organs.
Conduct an initial assessment, focused history,
and physical exam as normal.
Conduct yourself professionally.
If patient is reluctant to discuss, transport while
treating any life-threats.
 Assessment of GYN Complaints
History is of primary concern over physical exam
in most circumstances
Never perform internal vaginal exam
– Obtain specific information
LNMP (date)
Last sexual intercourse/sexually active
Fever, chills
Vaginal discharge/bleeding
Abdominal pain
Urinary problems
GI problems
Obstetric history (Gravida, Para/Parity, Abortion)
 History
Initial Assessment—SAMPLE
Does the patient complain of pain?
Use OPQRST
– Dysmenorrhea/dyspareunia
Associated signs or symptoms
Has she ever been pregnant?
– Gravida/parity/abortion
Document last menstrual cycle
Medications—Contraceptives
Contraceptive Methods
 Physical Exam
Respect patient’s privacy
Be professional and explain all procedures
Observe patient
Check vital signs
Assess bleeding or discharge:
– Do not perform an internal vaginal exam in the field
Abdominal examination
GYN Emergencies

•8-80 pregnant until proven otherwise

•Cancer
•Dysfunctional uterine bleeding
•STDs
•Prolapsed uterus
•Abnormal mensus
 Menstrual Problems

Dysmenorrhea - painful menstruation

Amenorrhea - absence of menstruation
– Primary amenorrhea - when girl has not
menstruated by about age 18
– Secondary amenorrhea - absence of
menstruation if she has had at least one period
 Rule out Malignancy

Cervical cancer (Pap)

Vaginal cancer (Exam)
Ovarian cancer (Exam)
Uterine cancer
(Endometrial biopsy, but
under age 40, cancer
very rare)
Invasive Cancer of the Cervix
Mechanical Problems

Polyps

Fibroids
 Pelvic Inflammatory Disease
Predisposing factors
– Multiple sexual partners, prior history of PID, recent
gynecological procedure, or an IUD
– Infertility results from scarring of the fallopian tubes
Signs and symptoms
– Abdominal pain (may intensify either before or after
the menstrual period)
Worsens during intercourse
– Patients may walk with a shuffling gait
– A yellow, foul-smelling vaginal discharge
– Midcycle bleeding
 Pelvic Inflammatory Disease

General
One million cases treated annually
2.5 million physician visits annually
Total costs annually exceed $4 billion
Reportable as of 3-1-89
 Pelvic Inflammatory Disease

Polymicrobial infection
- spectrum changing
Gonorrhea – 20-40%
Chlamydia – 60-70%
One in four women will suffer long term sequelae
 Pelvic Inflammatory Disease
Physical Exam
– Appearance reveals ill or toxic patient
– Moderate to severe abdominal pain
Worse with palpation
Rebound tenderness may be present
– Fever may or may not be present
Treatment
– Definitive treatment is IV antibiotics
– Prehospital treatment is supportive
 Pelvic Inflammatory Disease

Complications
Chronic pelvic pain
Infertility
Ectopic pregnancy
Tubo-ovarian abscess
 Pelvic Inflammatory Disease

Classic constellation
– Fever
– Leukocytosis
– Peritoneal signs
– Purulent vaginal discharge
– Adnexal, cervical motion and abdominal
tenderness
Present in only 20%
 Pelvic Inflammatory Disease

Current diagnostic criteria somewhat controversial

Minimum diagnostic criteria
– Women at risk for STDs presenting with pelvic or
lower abdominal pain, and cervical motion tenderness
– Uterine tenderness, OR Adnexal tenderness
– Additional criteria only supportive in making the
diagnosis:
– Oral temp > 101
– Cervical or vaginal discharge
 Pelvic Inflammatory Disease

Treatment guidelines
– Better to overtreat than undertreat this disorder
Polymicrobial; mandates broad spectrum coverage
No single drug currently is adequate
Multiple antimicrobial drug regimens required
Adjunctive measures may be needed
Treat sexual partners within last 30 for gonorrhea
and chlamydia
 Ruptured Ovarian Cyst
Cyst is a fluid-filled
pocket
– Usually the result of a
ruptured follicle
Corpus luteum cyst, is
often left in its place
Blood causes irritation
of peritoneum
– Results in pain
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 Ruptured Ovarian Cyst
Physical Exam
– Moderate to severe unilateral abdominal pain
May radiate to back
– Dyspareunia, irregular bleeding, or a delayed menstrual
period
Cyst may rupture during sexual activity or physical activity
– Vaginal bleeding may be present
 Cystitis
Urinary bladder infection
– Usually result of bacteria
May progress to kidneys
Signs and Symptoms
– Abdominal pain
– Urinary frequency, pain or burning with urination
(dysuria)
– Low-grade fever
 Acute Pelvic Pain
Causes
– Ectopic pregnancy
– Ovarian torsion
– Ruptured ovarian cyst
– Mittleschmerz
– Acute appendicitis
– Tubo-ovarian abscess
– Diverticular disease
 Acute Pelvic Pain
Adnexal Torsion
– Usually associated with enlarged ovary
– Simple cyst, dermoid or malignancy
– Up to 20% can occur during pregnancy
– Corpus luteum of pregnancy
– Usually sudden onset of pain, often colicky
– May be episodic; may be resolved at presentation
– 67% have nausea/vomiting
– Tender adnexal mass usually present
 Uterine Prolapse

Occurs In multigravid patients

Usually not life threatening
Minimal to no Uterine bleeding
– Can be serious if it occurs immediately after
birth
Results in massive hemorrhage
 Endometritis

Infection of the uterine lining

– Complication of birth, abortion, gynecological
procedure
– Signs and Symptoms
Abdominal pain
Bloody, foul smelling discharge
Fever
Mimics PID
 Endometriosis
Endometrial tissue is found growing outside the uterus,
most commonly in the abd or pelvis but has been found
throughout the body
– Tissue responds to hormonal changes regardless of location
– Bleeds in a cyclic manner
– Bleeding causes scarring of adjacent tissue and adhesions
Common between ages of 30-40
Signs and Symptoms
– Abnormal uterine bleeding
– Painful bowel movements
– Unusually heavy menstrual bleeding and unusually severe pain
 Ectopic Pregnancy

It is a pregnancy that occurs

outside of the Uterine Cavity.
90% of all ectopic pregnancy occur
in the fallopian tubes (i.e. tubal
pregnancy) but can occur in the
cervix, ovaries or abdominal
cavity.
As the “tubal pregnancy” expands,
it causes the fallopian tube to
rupture and bleeding occurs into
the pelvic cavity.
Symptoms of ectopic usually begin
in the 4 to 6 week of pregnancy
 Ectopic Pregnancy

The scope of the problem

1970 4.5 per 1000 pregnancies
1978 9.4 per 1000 pregnancies
1989 16.8 per 1000 pregnancies
Currently, 1 in 50 pregnancies is an ectopic
pregnancy
 Morbidity and Mortality

Leading cause of maternal death

Most common cause of maternal death in first
trimester
Accounts for 9% of all pregnancy-related deaths
0.3 deaths in 1000 ectopic pregnancies
Fatality rate has dropped by 90%
Current rupture rate only 20%
Hospitalization rates have tripled
 Etiology / Pathophysiology

Delay or prevention of passage 30% have history of PID

of the fertilized egg into the History of endometriosis,
uterine cavity adhesions, failed tubal ligation,
Predisposing factors failed IUD, or prior ectopic
– Previous tubal damage pregnancies.
– Tubal surgery Amenorrhea
– Endometriosis Positive Pregnancy test or
– PID suspected pregnancy
– IVF / previous infertility
– History of > 1 therapeutic
miscarriage
 Presentation – Symptoms
Abdominal pain 80-99% Vaginal bleeding 50-83%
Generalized 44.3% Dizziness/syncope 5-35%
Unilateral 32.7% Pregnancy symptoms 10-
25%
Amenorrhea 63-85%
Shoulder pain 10-22%
Usually 6-7 weeks Passage of “tissue” 5-10%
No missed period 26%
 Presentation – Signs

Abdominal tenderness 55-95%

Adnexal tenderness 64-90%
Adnexal mass 35-66%
Normal sized uterus 70%
Blood in vaginal vault 60%
 Presentation

S+S and Assessment S+S and Assessment

“Classic” triad Sudden Onset
– Amenorrhea Poorly localized lower
– Abdominal pain abdominal pain
– Vaginal bleeding SEVERE SHOULDER PAIN
More commonly seen Vaginal Bleeding. Often
with spontaneous profuse bright red blood.
miscarriage than ectopic Shock
pregnancy A ruptured ovarian cyst (with or
without pregnancy) may have
similar presentation, although
vaginal bleeding may be absent.
 Treatment for Ectopic Pregnancy

Unstable patient ?
Two large bore IVs
Type and cross – at least 6 units
Fluid resuscitation; blood as needed
Emergent gynecologic consultation and surgery
Symptomatic patient ?
Strongly consider gynecologic consultation and
admission
 Treatment for Ectopic Pregnancy

Surgery - The “gold standard”

Usually done via laparoscope
Indications
– Rupture
– Hypotension
– Anemia
– Ectopic sac diameter greater than 4 cm
– Pain greater than 24 hours (??)
 Non-Traumatic
Vaginal Bleeding
Rarely seen in the field unless it is severe
– Obtain history
Menorrhagia
– Excessive menstrual flow
– Be alert for signs of shock
Spontaneous abortion (miscarriage)
– Most common cause of non-traumatic bleeding
– Often associated with cramping abdominal pain and the
passage of clots and tissue
Other causes
– Cancerous lesions, PID, or the onset of labor
 Non-Traumatic
Vaginal Bleeding
Management
– Will depend on the severity of the situation
Initiation of oxygen therapy and intravenous access
– Absorb blood flow
Never pack the vagina
– Transport any blood or tissue to hospital
 Traumatic Gynecological
Emergencies
Causes of Gynecological Trauma
– Blunt Trauma
– Sexual Assault
– Blunt force to Lower Abdomen
– Foreign Bodies Inserted in Vagina
– Abortion Attempts
 Management of
Gynecological Trauma
Apply direct pressure over laceration
– Source of bleeding may not be readily apparent
– Apply cold pack to hematoma
Establish IV if patient is severe or signs of shock
present
Potential organ rupture may lead to peritonitis
Transport
 Sexual Assault
The most rapidly growing violent crime in
America
– 60 percent of all sexual assaults are never reported
– Male victims represent 5 percent of reported sexual
assaults
– No “typical victim” of sexual assault
Most victims know assailants
– Sexual assault is a crime of violence
 Sexual Assault
Assessment
– Patient needs emergency
medical treatment and
psychological support
– Legal concerns
– Victims of sexual abuse
should not be questioned
about the incident in the
field
– Respect the patient’s
modesty
 Management Considerations
Protect the scene
Handle clothing as little as possible
If removing clothing, bag each item separately
Do not cut through any tears or holes in clothing
Place bloody articles in brown paper bags
 Management Considerations
Do not examine the perineal area
Do not allow patient to change clothes, bathe, or
douche
Do not allow patient to comb hair, brush teeth, or
clean fingernails
Do not clean wounds, if possible
 Documentation
State patient remarks accurately
Objectively state your observations of patient’s
physical condition, environment, or torn clothing
Document evidence turned over to hospital staff
Do not include your opinions as to whether rape
occurred
The Prenatal Period
 The Prenatal Period
The prenatal period is the time from conception
until delivery of the fetus.
Significant physiological changes occur in the
mother.
– The result of fetal development
Physiological Changes
of Pregnancy
 Physiologic Changes
of Pregnancy
Reproductive System
– Uterus increases in size
– Vascular system
– Formation of mucous
plug in cervix
– Estrogen causes
vaginal mucosa to
thicken
– Breast enlargement
 Physiologic Changes
of Pregnancy
Cardiovascular
System
– Cardiac output
increases
– Blood volume
increases
– Supine hypotension

Click here to view the cardiovascular

changes of pregnancy.
 Cardiovascular

Heart increased 10 - 15%

Stroke volume increased 10%
CO = HR x SV
Cardiac output increased 25 - 30%
– Approximately 1.5 L/min
Catecholamines increased
 Cardiovascular

Total peripheral resistance decreased

– Progesterone
– Placenta
– Prostaglandins
BP is decreased in most normal patients
 Normal Physiologic Changes
Cardiovascular
– Increased blood volume, stroke
volume, and heart rate
– Decreased BP due to lower systemic
vascular resistance
– Normal filling pressures
– Vena cava compression during
third trimester
 Blood Pressure During Pregnancy

Progesterone relaxes smooth muscle

Systolic BP
– No change during pregnancy
Diastolic BP
– Falls at 20 weeks, the rises to near normal
 Physiologic Changes
of Pregnancy
Respiratory System
– Progesterone causes a decrease in airway resistance
Results in a 20 percent increase in oxygen consumption and a
40 percent increase in tidal volume
– Slight increase in respiratory rate
 Respiratory

Rate increased
Tidal volume increased
Minute volume increased
PCO2 decreased = 30 mmHg
Arterial pH increased =7.45
Blood gases
– Compensated respiratory alkalosis
 Renal

Renal blood flow increased

Glomerular flow increased
Creatinine, urea, uric acid decreased
Renal pharmocologic clearance increased
 Normal Physiologic Changes
Pulmonary
– Increased tidal volume, O2 consumption, and
respiratory rate
– Decreased functional residual capacity,
PaCO2, and oxygen
reserve for mother and fetus
 Physiologic Changes
of Pregnancy
Gastrointestinal System
– Hormone levels
– Peristalsis is slowed
Urinary System
– Urinary frequency is common
Musculoskeletal System
– Loosened pelvic joints
Hematologic
– dilutional anemia, slight granulocytosis and
thrombocytopenia, increased coagulation factors
 Hematological Changes in
Pregnancy
Blood volume
– Increases 50%
RBC count increases
– Approximately 30%
– RBC increase is later
Physiological
– Anemia during second trimester
 Terms of Pregnancy

Gravida
– A pregnant woman
Gravida 1 or primigravida
– First pregnancy
Para
– Woman with birth past age of viability
– Age of viability 20 wks or 500 gm
 Terms of Pregnancy

Multiple births count as only 1 para

Stillbirths (past the age of viability) also
count as 1 para
Para 0 or nullipara
– No offspring past the age of viability
Para 1 or primipara
– One offspring past the age of viability
 Para

Para is subdivided in to 4 parts

– Term
– Preterm
– Abortions
– Living
TPAL
 Terms of Pregnancy
Term
– Number of births over 37 weeks EGA
Preterm
– Number of births between 20 weeks and 36 weeks + 6
days
Abortions
– Number of births less than 20 weeks
– Classified as elective or spontaneous
– Common cause of first trimester bleeding
– Miscarriages
Lay term for spontaneous abortion
 Gestation

40 weeks after the fist day of the last normal

menstrual period
– + or – two weeks
– Assumptions
Fertilized 14 days after the first day of the LNMP
Gives birth 38 weeks after fertilization
+ or – two weeks
 Gestation

10 lunar months or 280 days

– + or – two weeks
9 calendar months
– + or – two weeks
 Nagele’s Rule

Calculates the estimated date of birth

– Delivery or confinement (EDC)
Based on the 28 day cycle
Longer or shorter cycles
– Add or subtract days to Nagele’s rule Estimated
Delivery Date (EDD)
 Nagele’s Rule

Determine first day of LNMP

– Eg 3/1/08
– Add 7 days = 3/8/08
– Subtract 3 months = 12/8/08
– Resulting date is the estimated date of birth
+ or – two weeks
 5- MacDonald's Rule

Fundal Height (the distance from the

symphysis pubis joint to the fundus of
uterus) can be a rough estimate of
gestational age.
Typically, from week 24 to week 34, fundal
height in centimetres correlates with weeks
of gestation. For example, at 28 weeks, the
fundus is probably about 28 cm.
 Trimesters of Pregnancy

First trimester
– Weeks 1-13
Second trimester
– Weeks 14-27
Third trimester
– Weeks 28-40
 Fetal Developmental
Milestones
Stages of Fetal Development
– Pre-embryonic
First 14 days following
conception
– Embryonic
15 days to 8 weeks
– Fetal
By 20 weeks fetal heart tones
heard
By 28 weeks, fetus is viable
By 38 weeks, fetus is “term”
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