GYNECOLOGIC EMERGENCIES

Dr. KUSUMA ANDRIANA SpOG

CASE

Ny. R 27 th, dtang dg keluhan nyeri perut bawah 24 jam ini. Amenore 7 minggu dan memakai pil KB tak teratur.

Dari DP : nyeri tekan ¾ RLQP/ Bimanual : massa kisitk di adnexa D

diameter 4-5 cm nyeri, uterus membesar ~ 7 mgg

CASE STUDYDari Presentasi klinis kemungkinan :1. Ruptured ectopic pregnancy2. Adnexal torsion3. Ovarian hemorrhage4. Ovarian rupture

Differential Dx: Acute Pelvic Pain

Gynecologic OriginInfection

Acute salpingitis (PID) Tubo-ovarian abcess (TOA)

Complications of Pregnancy Ectopic pregnancy Septic abortion Post-partum or post-abortion endometritis Post-medical abortion sepsis

Differential Dx: Acute Pelvic Pain

Gynecologic OriginAdnexal Accidents

Ovarian torsion Ovarian rupture Ovarian hemorrhage

Other Gynecologic Problems Flare of symptoms from endometriosis Ovulation (mittelschmerz) Dismenore

Differential Dx: Acute Pelvic PainNon-Gynecologic Origin

GastrointestinalAppendicitis or appendiceal abcessInflammatory bowel disease

Urinary TractAcute cystitis or pyelonephritisUreteral stone

OrthopedicLumbo-sacral muscle spasmLumbar disc disease

PIDDefinisi

Infeksi serius dan difuse dan sering mengenai banyak organ

Prevalensi1 – 3 % wanita yg dtg ke IRD mengalami PIDUsia 15 – 44 th

Etiologi1/3 kasus ok GO1/3 kasus GO + mixed infeksi (Chlamydia)1/3 kasus infeksi campuran bakt aerob dan

anaerob

PATHWAY GO or Non GO

PIDFaktor risiko

Multiple partner sexUterine & cervical instrumentation

Biopsi endometrial HSG IUD

Pembersih vaginaBakterial vaginosis

PID

SIGN & SYMPTOMNyeri pelvis (100%)Febris 39˚C ( 40 %)Pe ↑ LeuIrreg vag bleed or

dischaegeTakikardia, mual,

muntahFluor purulent ↓

KRITERIA DXHARUS ADA

Abdominal tenderness Adnexal tenderness Cervical tenderness

HARUS ADA MIN 1 Kultur bakt (+) Suhu > 38 ˚C Leu > 10.000 Pus (+) dari

kuldosentesis or laparaskopi

TOA

MANAJEMEN PID

Dasar Dx Ax, DP, USG dan labPlan Dx

Lab DL, kultur servik, pemeriksaan GramImaging USG : cairan bebas di cav

DouglasiSpecial test laparaskopi PPV : 65 – 90 %

Tentukan Dx berdasarkan kriteria Dx

MANAJEMEN PIDNon farmakologi

Diet TKTPAktivitas bed rest, Rwt jalan if infeksi ringan

FarmakologiRawat jalan

Ceftriaxone 250 mg i.m singel dose + Doxycline 2 x 100 mg p.o 14 hari With or wihout

metronidazol 2 x 500 mg selama 14 hariRawat inap

Cevotetan 2 x 2 g i.v or Cefoxitin 4 x 2 g i.v + Doxycline 2 x 100 mg p.o or i.v 14 hari Untuk mixed infeksi Clindamycin 3 x 900 mg iv +

gentamycin 2 mg/kg BB dosis awal dilanjut 1,5 mg /kg 3x/hr

MANAJEMEN PID

FOLLOW UPMonitoring

MRS if di DD KET * Nullipara / Hamil Appendisitis * Ileus paralytic HIV * Suhu > 39 ˚C IUD * TOA Leuko > 20.000 or < 4000

KomplikasiInfertile faktor tuba : risk 40 % bila 3 x PIDKET risk 4 xKronik abdominal painRuptura TOA + septic syok kegawatanRisk Kematian : 0,29 dari 100.000

ADHESION

ADHESI HEBAT

SPASME TUBA

PERITONITIS

ADHESI DI CAV DOUGLASI

OVARIAN TORSION

DefinisiTerpluntirnya sebagian atau all adnexa shg

menyebabkan iskemik dan infark jaringanPrevalensi

Ditemukan 2 – 3 % gynecologic operative emergenciesUsia

Sekitar 20 tahunanEtiologi

Spontan terpluntir ok pembesaran ovarium ( 50 – 60% kista or tumor)

Faktor RisikoAdanya mass di ovairum, tuba atau paratubaRisiko meningkat pada kehamilan or post induksi

ovulasi

OVARIAN TORSION

Sign & SymptomNyeri unilateral yg hebat dan hilang timbulMual & muntah 60 – 70 % kasus

DiagnosisAx, DP, imagingLab :

Tes kehamilanImaging

USG

DDKET *Kista pecahRuptur corp luteumAdnexal abcessApendisitis akutSmall bowell obstr

MANAJEMENLaparatomi citoDiet : TKTPObat

AB post opAnti nyeri Anti nyeri TDK BOLEH diberikan

sampai Dx tegak dan kondisi Px stabil

Menstruation

MittelschmerzAbdominal pain

and crampingMay start any time

during ovulationAffects

approximately 20 percent of women

Pain is usually not severe.

DISMENOREKeadaan nyeri saat menstruasi (segala usia)

Respon sistemik- Backache- Kelemahan- Diaporesis- Anoreksia, mual, muntah- Diare, pusing- Penurunan konsentrasi

JENISDismenore Primer- Timbul 6bln-2thn setelah menarche- Sembuh setelah berusia 25 thn/setelah melahirkan pervaginam

Dismenore SekunderEndometriosis, peradangan pervik, ca uterus, ca ovarium, akseptor IUD

TREATMENT

A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, opinion, or case series.

EndometriosisPathophysiology

Endometrial tissue grows outside the uterus. Organs of the pelvic cavity are the most common

locations for growths.One of the leading causes of infertility

EndometriosisAssessment

Symptoms include: Pain Dysuria Very heavy menstrual periods Bleeding between periods

EndometriosisManagement

Prehospital care is based on signs/symptoms. If the patient reports severe pain:

Provide pain relief. Use dressing or towels as needed.

ENDOMETRIOSIS

MYOMA UTERI

Vascular occlusion necrosis, infectionTorsion of a pedunculated fibroid acute painMyometrial contractions to expel the myomaRed degenration acute painHeaviness fullness in the pelvic area Feeling a massIf the tumor gets impacted in the pelvis pressure on nerves back pain radiating to the lower extremities

Dysparunea if it is protruding to vagina