Gynecology and Obstetrics - Birger Breumwww.handout.dk

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Gynecology and Obstetrics
Anatomy and physiology
What are the organs of the female reproductive system?
What do they look like - size and shape
How are they connected?
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Anatomy and physiology
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Anatomy and physiology
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Anatomy and physiology
What is the purpose of the uterus?
What is the purpose of the ovaries?
How does the egg (secondary oocyte) get to the uterus?
Where does the egg meet the sperm cells?
What happens after fertilisation?
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Anatomy and physiology
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Birth Control
Guess (hopefully qualified) what we see in this video.
Female Sterilization
What other forms of birth control do you know?
Male condom, female condom, diaphragm,
spermacides (gel, foam...). birth controll pill, nuvaring,
IUD, injectable contraception (solid og fluid)......
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Pathology - what can go wrong?
Cancer
Infection
Cysts
Torsion
Fibroma
Polyps.....
Pregnancy related
Bleeding
Pain
Nausia
Abortion (&missed abortion)
Ectopic pregnancy
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
What do we want to know?
Description of pain. Where in the cycle? Is she pregnant?
Is she (or has she been) sexually active?
Temperature? Urinetest for (HCG, Leukocytes, Nitrate)
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 1
Pain started suddenly, 20 hours ago, varies, pain gets worse
when moving around, started diffusely, now worst in lower
right abdominal quadrant. Period 2 weeks ago. She has not
been sexually active for the last three months.
Temperature 38,4 C. Urinetest: HCG negative, 2+
Leukocytes, Nitrate negative)
Appendicitis, Cystitis or PID?
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 2
Pain started slowly, a few days ago, varies, pain gets worse
when moving around, low in the middle og the abdomen.
Period 2 weeks ago. She has not been sexually active for the
last three months.
Temperature 38,4 C. Urinetest: HCG negative, 2+
Leukocytes, Nitrate positive)
Cystitis!
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 3
Pain started suddenly, 20 hours ago, varies, pain gets worse
when moving around, started diffusely, now worst in lower
right abdominal quadrant. Trying to get pregnant, but started
to bleed around 3 weeks late (usually has irregular
menstruation), the bleeding was yesturday.
Temperature 37,4 C. Urinetest: Leukocytes negative, Nitrate
negative) Should we take HCG?
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 3
Pain started suddenly, 20 hours ago, varies, pain gets worse
when moving around, started diffusely, now worst in lower
right abdominal quadrant. Trying to get pregnant, but started
to bleed around 3 weeks late (usually has irregular
menstruation), the bleeding was yesturday.
Temperature 37,4 C. Urinetest: HCG positive, Leukocytes
negative, Nitrate negative)
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 3
Pain started suddenly, 20 hours ago, varies, pain gets worse
when moving around, started diffusely, now worst in lower
right abdominal quadrant. Trying to get pregnant, but started
to bleed around 3 weeks late (usually has irregular
menstruation), this was yesturday.
Temperature 37,4 C. Urinetest: HCG positive, Leukocytes
negative, Nitrate negative)
Abortion? Extra uterine pregnancy? VIDEO 3
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
A clinical case
22 year old female, goes to the ER due to abdominal pain.
Case 4
Pain started suddenly, 20 hours ago, varies, pain gets worse
when moving, started diffusely, now worst in lower right
abdominal quadrant. Trying to get pregnant, but started to
bleed around 3 weeks late (usually has irregular
menstruation), this was yesturday.
Temperature 37,4 C. Urinetest: HCG positive, Leukocytes
negative, Nitrate negative)
But ultrasound yesturday: Normal pregnancy!
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Early pregnancy diagnostics problems
• Symptyms of spontanious abortion are: Bleeding and pain,
but one or both might not be present (asymptomatic)
•
• Symptyms of extrauterine pregnancy are: Bleeding and
pain, but one or both might not be present (asymptomatic)
•
• Around 20% of normal pregnancies bleed one or more
times.
•
• Around 20% of normal pregnancies have pain or more
times.
• SOLUTION:
• Ultrasound and S-HCG
•
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Some later pregnancy conditions/problems
•
•
•
•
•
•
•
•
•
•
•
Nausia
Hypertension, before or because of pregnancy
Preeklampsia (hypertension, protein in urine...)
Diabetes, before or because of pregnancy
Obesity
Astma
Infections do usually not harm foetus. Exceptions
(rubella, toxoplasmosis, Group B streptococs....)
Bleeding
Intra uterine growth retartion
Abortion/foetal death
Medicine-changes needed.(Myxoedema, depression)
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Normal delivery
Children that are born between the 36th and 39th week
(38 and 41 weeks after the Last Menstrual Period) are
considered as being normal term deliveries.
Statistically, only 2/3 of all children are born within the 3
weeks around the calculated date of birth and around 80 %
within a month around the predicted date of birth.
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Normal delivery
Delivery proceeds in three periods:
• Dilatation period
• Expulsion or press period (subdivided into 4 phases)
• After-birth period
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Normal delivery
During delivery the infantile head has to conform to the
various pelvic sections.
In the expulsion period the first 3 phases describe the
development of the head while phase 4 that of the shoulders,
whereby the head rotates 90° back again.
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Normal delivery
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Normal delivery
Press Period Problems (Expulsion problems)?
Consider the 3 Ps
Power (or Push or Pattern of contractions)
Pelvis (not large enough?)
Passenger (Babysize, baby orientation)
Usually a comPnation (combination) of the three
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Pathological delivery
Helping the baby along:
Enforsing contractions: oxytocin-drip
Direction and force: vacuum extraction/Forceps
Manual manipulation
Alternative route.
Operation: C-section
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Pathological delivery
Post partum bleeding
Fysiological (normal bleeding) 300-500 ml
Pathological >500 ml
Imediate action (operating theater) >1000 ml
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Pathological delivery
Bleeding >500 ml is patological.
Consider:
Tonus: Atonia
Tissue: in uterus (placenta/clots)
Traume: Tears
Thrombin: Koagulation - maybe secondary to bleeding
Bleeding > 1000 ml: Intrauterine palpation, tears in
collum, vagina and perineum – Operating theater
Match-test, Hgb, plateles, factor 2-5-7, APTT - perhaps.
DIC-screening
Birger Breum, MD, OB/GYN. 14/10-2010
Gynecology and Obstetrics
Pathological delivery
Treatment
Call help: obstetrician, midwife in charge,
healtcareworker
Empty bladder
Uterus massage and compression.
Observations (Respiration, BP, pulse, i.v. fluids,
estimated bloodloss, diuresis and medicin).
Trendelenburgs
IV acces 2 large - Bloodmatch
NaCl 2 liter, Plasma expanders 500 - 1000 ml. Oxygen
Medicin
Intrauterine palpation.
Birger Breum, MD, OB/GYN. 14/10-2010
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