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MINISTRY OF HEALTH OF UKRAINE
Bukovinsky State Medical University
“Approved”
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 201_ year
protocol #
T.a.the Head of the department
Professor
________________ O.A. Andriyets
Guidance
practical exercises
"Acute abdomen in gynecology. Diagnosis, differential diagnosis, treatment and
prevention of emergency conditions in gynecology, basic principles and surgical
techniques. "
MODULE 4. Obstetrics and Gynecology
Semantic module 12. Gynecologic disease.
Academic Discipline: Obstetrics and Gynecology
Course: 6
Faculty: Medicine
Specialty: Medicine
Hours - 5.5
Developed by: assist.prof. Berbets A.
Chernivtsi, 2010
Subject. Acute abdomen in gynecology
1. Scientific and methodological basis of the theme. Emergency surgical care is one of the most
pressing problems of practical medicine. The quality of surgical care for acute diseases in obstetrics
and gynecology depends on early diagnosis, physician capacity to make and implement the best
solution. Therefore, lessons must cultivate a high sense of physician responsibility, tenacity and
ability to identify tactics That, or another gynecological pathology that caused the acute abdomen.
2. Study objective: To study the conditions that lead to the development of acute abdomen in
gynecology. Familiar with the tactics of women with impaired ectopic pregnancy, ovarian
apoplexy, ovarian kistomy inverted legs, legs subserous miomatoznoho kink site, etc..
The student must:
2.1. Know:
1. System communication apparatus of the uterus, ovaries.
2. Blood supply of organs.
3. The volume of surgical intervention depending on the cause of acute abdomen.
4. Consistency of treatment of hemorrhagic shock.
5. Pharmacological agents for treatment of bleeding.
2.2. Able:
1. Differentiate causes internal bleeding caused by broken tube pregnancy and ovarian apoplexy.
2. Conduct a differential diagnosis between progressive tube pregnancy and exacerbation of chronic
adnexitis.
3. Use auxiliary diagnostic methods for diagnosis.
4. Make plan of rehabilitation of women operated on ectopic pregnancy.
5. Estimate the amount of blood loss.
6. Make plan bcc recovery.
7. Collect a set of tools for an operation at birth myomectomy submukoznoho miomatoznoho site.
8. Make puncture the abdominal cavity through the rear arch.
2.3. Learn practical skills:
1. Review of cervical mirrors.
2. Bimanualne gynecological research.
3. Puncture the abdominal cavity through the rear arch.
4. Evaluation puncture the abdominal cavity through the rear arch.
3. Educational goal. Formation of the students of professional responsibility for mother and child
vyhovuvannya and consolidate students' basic deontological principles of logical principles in
regard to doctor-patient, physician, doctor, doctor-midwife.
4. Basic knowledge, skills, skills that are required to study subjects (intersubject integration)
Names of previous subjects received skills
Department of Human Anatomy Demonstrating features of phantom buildings ZHSO.
Department of Biological Chemistry physiology schematic depict the hierarchical structure of
neuro-endocrine regulation ZHSO.
Department of Immunology identify normal and pathologically changed parts of uterine tube,
ovary, uterus.
Department of Histology schematic depict the level of damage neuro-endocrine regulation ZHSO.
Department of Normal and Pathological Physiology Demonstrating features of phantom buildings
ZHSO.
Chair of Internal Diseases history taking, conducting surveys fizykalnyh ¬ tion, recognition of
clinical syndromes and symptoms, determining the required volume and sequence ¬ ing test
methods, evaluation methods of paraclinical
5. Plan and organizational structure of educational classes on subjects
Milestones class number and the content distribution time and level of learning control Types
Educational and methodological support
1. Starting from 15%
Structured written work, written and computer test, oral poll for standard list of. Textbooks,
manuals, reference books, atlases, recommendations.
1.1 Organizational issues
1.2 Formation of motivation
1.3 Control of entry-level training (standard controls)
2. Main Stage:
tology, biopsy of the cervix,
colposcopy. 65%
Solution situational problems of practical tasks. Practical training on phantoms, dummies, using inpatient histories, results of studies (x ray) tests and test results.
3. The final stage 20%
Individual control over the implementation of practical problems, situational problems (atypical,
unusual). Using the phantom, dummies, stories stationary patients.
3.1 Controlling the final level of training
3.2 motivated the overall assessment of student learning activities
3.3 Informing students about the topic next lesson
5.1. The preparatory phase of this subject knowledge is necessary to further the discipline and
professional obstetrician-gynecologist, primary diagnosis of gynecologic pathology. Familiarization
of students with specific goals and plan lessons. A standardized control entry level training of
students.
5.2. The main phase (content of the topic). Diseases of female genitals, for which there is clinical
acute abdomen, depending on the pathogenesis can be divided into the following main groups:
1. Acute bleeding from external genitalia.
2. Sudden circulatory violation of organs.
3. The gap piosalpinksu (abscess pipes) or piovaru (ovarian abscess with subsequent development
of peritonitis).
Sharp internal bleeding most often arise when disturbed ectopic pregnancy, at least - with ovarian
apoplexy.
Ectopic pregnancy is called pregnancy in which the fertilized egg is implanted and develops in the
cavity of slaying, and outside it.
Frequently this form of pathology tube pregnancy (98-99%). Depending on where the egg implants
tube pregnancy are divided into: Pregnancy in ampulyarnomu (stehinnomu), and interstitial
istmichnomu departments pipe.
Rare forms of ectopic pregnancy:
1. Ovarian pregnancy (intrafolikulyarna, epioforalna) - 0,1-0,7%.
2. Abdominal pregnancy (Willis, pidpechinkova, ureaznoho-rectal cavity, etc.). - 0.3%:
a) Primary - implantation occurs in the abdominal cavity;
b) secondary - implantation occurs in a pipe, and as a result of tubal abortion egg implanted in the
abdominal cavity.
3. Pregnancy rudomentarnoho uterine horn 0,1-0,9%.
4. Shyykova pregnancy (0.1%).
Risk factors of ectopic pregnancy:
a) chronic salpingitis - increases the risk of ectopic pregnancy 7 times;
b) anomalies of uterine tubes - dyvertykuly, additional formations, nedorozvytok.
c) the adhesive process in small tazi as a result of endometriosis or acute appendicitis, infectious
complications after childbirth and abortion;
d) surgical intervention for uterine tube-check 'deviations organosohranyayuschie operations about
ectopic pregnancy;
e) use of the Navy;
e) receiving a mini-piley injection and medroxyprogesteroneThat contribute to reducing motor
uterine tube;
g) artificial insemination;
i) infertility;
s) of women older than age 35 years.
There are progressive ectopic pregnancies and interrupted.
Abandonment can occur as:
1. Tubal abortion.
2. Uterine tube rupture.
Clinic ectopic pregnancy varied and depends on the nature of breaking.
Fallopian pregnancy that develops. Characteristic clinical symptoms are:
- Delay menstruation from several days to several weeks;
- Subjective feelings that arise in pregnancy;
- Pain in one zduhvynnyh areas, which grows with the progress of pregnancy;
- Abdominal pain with palpation of various degree of severity;
- Soft, slightly enlarged uterus, The dimensions of which do not meet the gestational period;
- Volumetric formation in the field of appendages, which in the dynamics of observation increases.
The clinical picture tube pregnancy that was interrupted by burst pipe (typical at implantation
fruitful eggs in istmichnomu interstitial departments and pipes):
- Lower abdominal colic, which irradiyuye shoulder, shoulder (frenikus-symptom) is often
accompanied neprytomnosti.
- BP decrease, PS frequent, low-filling, cold sweat;
- Nausea, vomiting, paleness of skin and mucous cover, cyanosis face;
- Abdominal pain, positive symptom Schotkina;
- At pihvynnomu study reveals significant spotting. Uterus slightly increased its mobility increased
- "floats" in the field determine pastoznist appendages or tumor formation; vault sploschene or
hangs, "Douglas Creek.
The clinical picture tube abortion (with an egg to implant effective ampulyarnomu pipe section):
- A history of delayed menstruation;
- Lower abdominal pain pereymopodibnyy;
- At pihvynnomu study - significant spotting, palpuyetsya slightly enlarged uterus, soft appendages
in the field of tumor formation, painful palpation, limited mobility, sometimes arch sploschene,
expressed his pain slightly.
Diagnosis of ectopic pregnancy:
1. Puncture the abdominal cavity through the rear arch - with ectopic pregnancy, which was
interrupted, receive blood that has not turned up.
2. Laparoscopy and kuldoskopiya - visualizes the uterine tube - cyanotic purple color.
3. Histerosalpinhohrafiya - the typical picture tube - a cavity filled with fluid contrast, has the form
napivmisyatsya.
4. Ultrasound - fruitful egg visualizes in uterine tube.
5. Determination of progesterone - with normal early pregnancy in terms of progesterone levels
greater than 25 ng / ml, while ectopic - less than 5 ng / ml.
6. Research content HG - 85% of ectopic pregnancy concentration HCG β-subunit is increased less
than 2 times for 48 hours.
Differential diagnosis is with inflammation, uterine abortion, acute appendicitis.
Differential-diagnostic signs of miscarriage and tubal acute inflammation of uterine appendages:
Number
Serial Tube abortion oophoritis
1. Delayed menstruation 3-5 weeks is not
2. Subjective signs of pregnancy None
3. Body temperature is increased Increased
4. Acute pain of attacking pain developing gradually
5. No unconscious
6. Frenikus symptom-absent
7. Uterus increased the amount of normal size
8. Offset sharply painful uterine cervix is a dramatic shift painful
9. The increase in uterine tube (tistuvata consistency) Both ways applications uterine inflammation
10. No selection Temnokorychnevi
11. Puncture the rear vault - blood serofluid
12. Immunological reaction positive Negative
13. Antiinflammatory effect of treatment ineffective treatment
14. No signs of intoxication. Apparitions of general intoxication.
Treatment. Aborted ectopic pregnancy be rapid surgical treatment. Perform removal of
pathologically altered pipes. When interrupted ectopic pregnancy surgical intervention should begin
not later than 30-40 minutes. after diagnosis. Due to the frequent development of hypovolemic
shock - blood transfusion, protyshokovi measures. As the possible reinfusion avtokrovi.
Conservative operations in pipe pregnancy
Indications - re-tube pregnancy in childless women of reproductive age at the express desire to
preserve uterine tubes. Contraindications massive hemorrhage, a significant gap tube, the "old" tube
pregnancy that was interrupted.
Types of operations:
- Localization of fruitful ampulyarnomu eggs in his department can carefully extruding - Pipe
artificial abortion;
- At a location fruitful eggs in interstitial department conducted uterine tube cutting area and restore
its permeability or salpinhotomiyu.
Indications of laparoscopy in women with ectopic pregnancy:
- Diagnosis of ectopic pregnancy;
- Treatment of ectopic pregnancy at the effective localization of eggs in istmichnomu
ampulyarnomu departments or uterine tube and uterine tube diameter of lesions less than 5 cm;
- The amount of treatment - salpinhotomiya, salpinhektomiya, intraovulyarne input metotryksatu.
When small term ovarian pregnancy ovarian transmitting resection, rarely ovariectomy. Pregnancy
that develops in the secondary corner of the uterus, clamps imposed on the barrier, which connects
the body and horn, the latter cut off the fabric, the remaining league.
In 40-50% of women over the ectopic pregnancy often infertility, repeated ectopic pregnancy,
inflammation. Conducting rehabilitation activities is pathogenetically substantiated. After surgery
patients need to make the complex therapeutic measures aimed at preventing adhesiotomy of 4-5-th
day after the operation conducted hidrotubatsiyi (novocaine, hydrocortisone, proteolytic enzymes).
Hidrotubatsiyi conducted daily (15 procedures in the course of treatment) in combination with
ultrasound. 2 months after surgery appoint induktotermiyu, immunostimulators, proteolytic
enzymes and repeat rate hidrotubatsiyi, 3-4 months treatment is repeated, then transmitting cure and
treatment ozokerite.
Shyykova pregnancy - prevalence 0.1%. Its origin can be caused by deficiency of the mucous
membrane of the uterus or a reduced ability to nidatsiyi fruitful eggs.
Characteristic barrel shape is the cervix, eccentric location of the external eye, the body of the
uterus often smaller than the neck. Bloody appear early and last long.
Treatment: with profuse bleeding due to pregnancy shyykovoyi shows a hysterectomy, with
progression - methotrexate treatment intraovulyatorno or 50 mg/m2 single in / d.
Among the causes of intraabdominal bleeding 0,5-3% of the cases of ovarian apoplexy.
Ovarian apoplexy - pathology associated with the violation of the integrity of ovarian tissue and
bleeding in the abdominal cavity.
Bleeding can occur with ovarian follicular cysts, since the follicle during ovulation, a cyst with a
yellow body and ovarian stroma.
Etiology and pathogenesis. At the core of the pathogenesis of apoplexy are the physiological
features of ovarian tissue changes that are in it for the menstrual cycle. Ovulation, increased
vascularization soft yellow body tissues, ovarian premenstrual congestion - all of which can lead to
hematoma formation, breach of coherent tissues and bleeding in the abdominal cavity, whose size
varied - from 50 ml to 2-3 liters. Ovarian apoplexy can cause abdominal trauma, surgery,
inflammation of the pelvic area, violent sexual relations, neuro-psychological trauma, etc.. It can
also be associated with disorders of neuroendocrine processes in women. This confirms the fact that
apoplexy often in the middle of the menstrual cycle or before menstruation, when blood is high
concentration of hormonal prehypophysis. Bleeding from the ovary disease may contribute to blood
clotting in violation of its. Over the past 10-15 years observed increase ovarian bleeding associated
with long-term treatment anticoagulant patients after prosthetic heart valves.
Ovarian gap may occur in different phases of the menstrual cycle, but in most cases - in the 2nd
phase, because in modern literature, this pathology is often defined the term "yellow body gap.
Gap yellow body can occur when uterine and ectopic pregnancy. Approximately 2 / 3 of cases
urazhuyetsya right ovary, due to topographic differences or closeness appendectomy venous
architecture right and left ovaries.
Clinic. Ovarian apoplexy often affects women of reproductive age with two-phase menstrual cycle.
There are three clinical forms of disease: Anemia, pain and mixed.
In the clinical picture is dominated by a form of anemia symptoms intraperytonealnoyi bleeding.
Getting the disease may be associated with trauma, physical activity, sexual intercourse, but can not
begin without knowing why. Acute intense abdominal pain appear in the second half or in mid
cycle. In the third attack women before feeling discomfort in the abdominal cavity, which lasts 1-2
weeks. The pain may lokalizuvatysya lonom over in the right or left zduhvynnyh areas. Often in
pain irradiyuye vidhidnyk, external genitalia, buttocks, may have frenikus-symptom.
Along with the pain attack suputno watching weakness, dizziness, nausea, sometimes vomiting,
cold sweat. When you review draw attention to skin and mucosal pallor, tachycardia at normal body
temperature. Depending on the size of hemorrhage decreases blood pressure. His belly is still soft
and can be somewhat vzdutym. Stress absent abdominal wall muscles. Palpation reveals abdominal
pain Lower overall or in one of zduhvynnyh areas. Signs of peritoneal irritation expressed in
different ways. Percussion in the abdomen can detect the presence of free abdominal fluid. Review
in the mirror: a normal color or pale vaginal mucosa and ekzotserviksa, haemorrhagic discharge
from cervical canal absent. When bimanualnomu study (very painful), determine the normal size
uterus, sometimes painful orbed enlarged ovary. With significant bleeding - navysannya rear and /
or lateral vaginal vault. In clinical analysis of blood - a picture of anemia, white blood changes
dramatically.
Form of pain occurs in cases of apoplexy cerebral tissue nodule or yellow body without bleeding or
with a small hemorrhage in the abdominal cavity. Disease begins acutely with Lower abdominal
pain attacks, which are accompanied by nausea and vomiting on the background of normal body
temperature. No signs of internal bleeding: skin and mucous normal color, pulse rate and size of SC
within the norm. Tongue moist, without overwriting. Abdomen soft, but may be some tension in the
abdominal wall muscles zduhvynnyh areas. Palpation abdomen painful in the lower, more often the
case, determined in the same moderately expressed by peritoneal irritation symptoms. Free fluid in
the abdominal cavity there. Bloody genital tract with no. When domestic gynecology research
identifies normal size uterus, displacement of which causes pain and increased slightly rounded
painful ovaries. Vault sheath remain high. Pathological missing from the vagina. Complete blood
count showing no significant deviations from the norm, sometimes defined moderate leukocytosis
without express shift of neutrophils.
Diagnosis. Diagnosis of apoplexy set on the basis of anamnesis, objective research: percussion and
palpation abdominal, vaginal study. It should be noted that typical symptoms of ovarian apoplexy
no.
Auxiliary Methods: Abdominal puncture through the rear vaginal vault, kuldoskopiya, laparoscopy.
Differential diagnosis should be conducted with diseases such as ectopic pregnancy, acute
appendicitis, ovarian cysts inverted legs, salpingooophoritis and others.
Anemic form apoplekiyi has great similarities to the clinic excited ectopic pregnancy. Absence of
delay cycles and other subjective and objective signs of pregnancy inclined levers in favor of
apoplexy, but rather their relative dovedenist. Helps determine the differential diagnosis chorionic
gonadotropin and laparoscopy, but their conduct is not required because the presence of internal
bleeding leads to emergency laparotomy, during which the final diagnosis is established and.
The painting recalls the pain clinic forms of acute appendicitis, which happens ovarian apoplexy, so
patients can be sent to the surgical hospital. When appendicitis not communication with the phases
of the menstrual cycle. Epigastric pain begins with a plot, then migrates to the right zduhvynnu.
Nausea and vomiting are more sustainable. Rising body temperature. I get a sharp pain in a pointMak and other Burneya syptomy appendicitis. Stress the anterior abdominal wall muscles right
zduhvynnoyi plot significantly expressed. It also defined clear symptoms of peritoneal irritation.
Internal research shows no gynecologic pathology of the uterus and appendages. Complete blood
count quite revealing: leukocytosis, neytrofiloz shift formula right. In doubtful cases, you can spend
puncture the abdominal cavity through the rear arch. When you receive blood or apoplexy
serosanguineous liquid.
Appendicitis requires absolute surgical treatment, while apoplexy - available conservative therapy.
In unclear cases, the diagnosis can be established by laparoscopy and the absence of such
opportunities effectively bow in favor of appendicitis and to establish an accurate diagnosis during
laparotomy.
First Aid. In cases of massive internal bleeding start against manifestations of hemorrhagic shock:
puncture or catheterization of veins and fluid infusion polihlyukinu, reopoliglyukinu, zhelatynolyu,
albumin or 5% glucose solution and 0.9% sodium chloride solution. Eliminating pain intravenous
analgesics (1-2 ml 1% solution of morphine hydrochloride, 1-2 ml of 1-2% solution promedolu, 2-4
ml 50% solution of aspirin). At falling blood pressure - glucocorticoids (hydrocortisone 1000-15000
mg, 200-300 mg prednisolone, dexamethasone 30-40 mg), dopamine 2 mcg / (kh.hv). Warm
patients, urgent hospitalization ambulances to gynecological hospital.
Qualified and specialized help. The method of treatment depends on the degree of intraperitoneal
bleeding. Anemic form of the disease requires surgical treatment. If the gap appeared yellow body,
it should be sutured hemostatic Z - like seams, imposed within the healthy ovarian tissue. Sculpt
cloth yellow body should not be to prevent abortion.
The most typical operation is resection of the ovary. Ovariectomy performed in cases when the
whole ovarian tissue destroyed and there imbibitsiya blood. In cases of ovarian bleeding
complicates long-term anticoagulant therapy after prosthetic heart valves for reliable hemostasis
forced to carry out removal of appendages. Prevention of bleeding from the ovary yellow body,
remaining in such women experiencing or recommended in such cases, suppression of ovulation
requires the appointment of trombohennymy properties.
Form of ovarian apoplexy pain without clinical signs of progressive internal bleeding can be treated
conservatively. Appoint calm, cold on the underbelly and hemostatyky: 12.5% solution etamzylatu
(dytsynonu) in 2 ml of 2 g. / Day intravenously or intramuscularly; adroksonu 0.025% solution of 1
ml per day subcutaneously or intramuscularly, vitamins, 10% solution of calcium chloride to 10 ml
intravenously. Conservative terpiya should be in the hospital round the clock under the supervision
of medical staff.
Apoplexy ovary in women suffering from blood diseases with defects of haemostasis (Autoimmune
thrombocytopenia, Villyebranta disease, etc.) should be cured by conservative. After consulting
hematologist in transmitting specific therapy for underlying disease: Corticosteroids,
immunosuppressive agent - with autoimmune thrombocytopenia, infusion or Kriopretsipitat
antyhemofilnoyi plasma - Villyebranta disease, etamzylat (dytsynon) - in both cases.
Sudden circulatory violation of organs, usually caused by:
1. Inverted legs and ovarian cysts fibromatoznoho site.
2. Necrosis miomatoznoho site.
The frequency of such complications as inverted legs of ovarian cysts, is 6,0-8,5%.
Factors that contribute to the development of this complication:
1. Physical tension.
2. Sudden movements.
3. Increased intestinal peristalsis.
Clinic: When inverted legs broken power tumor cysts, and consequently developing symptoms of
acute abdomen: Acute pain, accompanied by pallor, nausea, cold sweat emergence even vomiting;
- There are peritoneal signs (painful and swollen abdomen with palpation, a pronounced symptomSchotkina Blyumberha in the area of tumor);
- PS - frequent, intense;
- Body temperature rises.
Vaginal study reveals a tense, sharply painful ovarian tumors, limited mobility.
When symptoms gradually inverted expressed less dramatically, then they appear, then disappear.
Ovarian cysts is inverted:
- Full (3600 on the kink and more);
- Partial (less than 3600).
Treatment:
- Operational;
- Kistektomiya typical operation (in case of tumor necrosis is required abdominal drainage).
Differential diagnosis of inverted legs cyst is disturbed ectopic pregnancy, appendicitis.
Necrotic changes in fibromatoznyh nodes associated with circulation disorder (compression of
vascular obliteration) observed in 7-10% of cases.
If necrotic node hematogen lymphogenous or gets infected, then comes the maturation of tumor.
Clinically necrosis fibromatoznyh nodes revealed a sharp pain in abdomen, fever to 390S, chills,
symptoms pelvioperytonitu (tension in the anterior abdominal wall hipohastriyi, positive symptomSchotkina Blyumberha, bloating, gas delay). In the blood - leukocytosis, accelerated ESR.
Diagnosis necrosis fibromatoznoho node set based on: Anamnesis (available fibromyoma uterus),
the clinical picture (pain below the stomach, fever, phenomena pelvioperytonitu), vaginal study (a
fibromatoznyh nodes, node palpation pain, tension it), additional methods (laparoscopy, ultrasound
scanning).
If there is necrosis fibromatoznoho node is operative treatment - amputation or hysterectomy with
removal of uterine tubes (can be a source of infection) in women who at 40, and ovaries removed.
If necrosis fibromatoznoho site arose during pregnancy, the pregnant must hospitalize and observe.
When poured pain and increase uterine tone should be made tokoliz and transfusion therapy.
Indications for surgery are high fever, leukocytosis growth, symptoms of general peritonitis.
Depending on the pregnancy (28 weeks or longer) perform caesarean section with subsequent
hysterectomy.
At earlier gestational perform hysterectomy or amputation. Only when the surface subserous
location or site availability subserous node on the stem of necrosis without collapse of the node
(internal necrosis) can take a chance on a more conservative intervention - removal of this node
(node enucleation) with preservation of the uterus and pregnancy. Abdominal cavity in such cases
must be drenuvaty 3-4 days. Note that this operation is directed at maintaining pregnancy, often
leads to an increase in uterine contractile activity, resulting in spontaneous abortion or premature
delivery.
The picture of acute abdomen may occur if the legs perekturi pidocherevynnoho (subserous)
miomatoznoho site.
When research identifies pihvynnomu painful formation of dense consistency associated with
cancer.
Treatment: surgical - myoectomy nadpihvynna or amputation of the uterus, if there are other
components.
Clinic of acute abdomen caused by rupture of purulent mishkopodibnyh formation may be preceded
by symptoms such as congestion, fever, nausea, vomiting, increased numbers of leukocytes, ESR,
Le-shift formula to the left. In gynecological screening bolyuvannya defined tumor capsule
formation of dense and blurred. When you increase the symptoms of acute abdomen are threatened
rupture piosalpinksu (piovaru) with effusion of pus in the abdominal cavity and is likely to splash
the development of peritonitis.
Diagnosis.
Diagnosis is established on the basis of:
1. A history of prolonged course of inflammation oophorectomy with frequent aggravation.
2. Sudden sharp start, which is sometimes accompanied by symptoms of shock.
3. Standard is likely to splash pictures of peritonitis.
4. Results Gynecological research, in which show tumor, painful work of art with blurred contours.
Treatment.
Methods of surgical intervention in piosalpinksah piovariumah and individual:
- Young women with unilateral process should take adneksektomiyu;
- In old age - nadpihvynna amputation or extirpation of the uterine appendages.
In the absence of effusion in the abdomen and is likely to splash phenomena peritonitis abdominal
cavity sew up tightly.
When spilled peritonitis transmitting abdominal drainage channels through the side and leave
mikroiryhatory for input of antibiotics and peritoneal dialysis.
5.3. Control issues:
1. System communication apparatus of the uterus, ovaries.
2. Blood supply of organs.
3. The volume of surgical intervention depending on the cause of acute abdomen.
4. Consistency of treatment of hemorrhagic shock.
5. Pharmacological agents for treatment of bleeding.
5.4. Final stage. Current assessed each student during class, standardized final control, the analysis
of student, announced evaluation of each student and set in the ledger of student visits and.
Informing students about the topic next classes and teaching methods for preparing for it.
6. Materials methodological support classes:
Venue: study rooms, viewing room gynecological department, office of functional diagnosis,
manipulation, visualization study, women's consultation.
Equipment: Study table, slides, case histories or extracts from them, mirrors, tweezers, subject
glasses, skull X-rays, histerohramy, packaging hormones, microscope, a set of glasses with klityka,
diagnosis and treatment ppohonadotropnoyi Perk, Diagnosis and treatment hiperhonadotropnoyi
Pernod vaginal epithelium (four estrogenic saturation degree). A set of control questions, situational
problems, tasks for students' independent work.
6.1. Appendices. Means for control:
Control issues:
Case problem.
1. Etiology, pathogenesis and classification of ectopic pregnancy.
2. Clinical manifestations of progressive ectopic pregnancy and its methods of diagnosis.
3. Clinical manifestations of ectopic pregnancy interruption and its methods of diagnosis.
4. Clinical differences ectopic pregnancy, which was interrupted by breaking through the uterine
tube and pipe abortion.
5. Differential diagnosis of ectopic pregnancy and acute appendicitis.
6. Methods of surgical treatment of ectopic pregnancy.
7. Indications for conservative treatment tube pregnancy.
8. Methods of conservative treatment tube pregnancy.
9. Shyykova pregnancy. Diagnosis and treatment.
10. Etiology, pathogenesis of ovarian apoplexy.
11. Clinical features of different forms of ovarian apoplexy and their treatment.
12. Differential diagnosis of ovarian apoplexy and acute appendicitis.
13. What leg cysts (anatomical and surgical)?
14. What treatment is necessary to identify patients with inverted stem tumor?
15. Cause of power fibromatoznoho site.
16. Symptoms characteristic of power in violation of the site.
17. Tactics necrosis fibromatoznoho doctor on site.
18. Perform differential diagnosis between pregnancy clinic broken tube and inverted foot cysts.
19. Perform differential diagnosis of clinical manifestations of necrosis miomatoznoho node and
exacerbation of chronic adnexitis.
20. Clinic diagnosis of birth submukoznoho miomatoznoho site. Tactics.
21. Clinic diagnosis of acute abdomen caused by rupture piosalpinksu, piovariumu.
B. Objectives for the self
Number 1. Patient M., 13, entered the gynecological department with complaints of heavy spotting
of the genital tract, weakness, dizziness. From the notes transferred diseases measles, mumps, flu,
frequent sore throats. Periods of 12 years, the rhythm is not installed. Ill 15 days ago, when the
genital tract appeared spotting after 2 months. delay. In the following days intensyvyst increased
bleeding, there were weakness, dizziness. Overall condition patients during moderate. Pulse - 96
beats / min, SC - 80/70 mmHg Tongue moist, clean. Patient moderate fatness, poorly developed
mammary glands. Pathology of the heart and lungs do not. Blood test: Hb - 50 g / l, erythrocytes 2200000. When rectal-abdominal study: Tapered neck, smooth body of the uterus in normal
position, a small, movable, painless. Adnexa on both sides are not detected. With abundant cracks
sexual spotting with clots.
Diagnosis. Treatment plan. Measures for prevention of uterine bleeding.
Number 2. Patient L., 36, came to the gynecological department with complaints of heavy spotting
of the genital tract. From the notes transferred diseases measles, influenza, malaria. Suffering from
chronic hepatoholetsystytom. Periods of 13 years, once established, without features. Last normal
menses, 5 weeks ago. Sex life - with 24 років. Delivery - 2, abortion - 2, without uskladen, 2 years
ago to introduced intrauterine contraceptive spiral. Ill 2 days ago when, after a short delay
menstruation to sexual spotting appeared in large quantities. Overall condition the patient is
practically unchanged. Pulse - 80 beats / min. rhythmic. Skin and visible mucous membranes
slightly pale. Well-developed breasts. Overview dzerkalax: vagina full of blood clots. From the
cervical canal streams flowing blood. Neck clean. Two-research: vagina as a woman in a cylindrical
neck, external eye misses fingertip. Uterine body in the correct position, slightly larger, thick,
movable and painless. Adnexa on both sides is increased. Vault free.
Diagnosis. Treatment plan, treatment options Discharge in ambulatory umovax.
№ 3. Patient N., 31, entered the clinic with complaints of spotting, which appeared 3 weeks ago.
From the notes transferred diseases measles, influenza, pneumonia and appendectomy. Periods of
14 years, labor - 2, abortion - 1, without complications. Last menstruation started 3 weeks ago and
did not end until now. Bloody periodically increasing or decreasing. Overall condition is
satisfactory patient. Pathology of the internal organs were found. Review in the mirror: mucous
vagina and cervix clean. Select spotting, dirty appearance, dark. With two-handed study of vaginal cylindrical neck, eye closed. The body of the uterus in normal position, slightly larger, dense,
ruxome, painless. Adnexa not palpating, parametriyi free. Infiltrates in small tazi not. The patient
appealed for help in women's consultation, where together with symptomatic treatment (contractile
means vikasol, calcium gluconate) were conducted more tests for functional diagnostic tests. Basal
temperature curve has monofaznyy The character, a symptom of the pupil to the 10 th day was, KPI
8-10-12-16-22-day meet 18, 24, 30, 31, 33%.
Diagnosis. What additional test should be. Treatment plan. Write drugs. Admission Schedule
medicines.
№ 4. Patient P., 43 years, with menstruation 13 years, once established, were scheduled for 3-4 days
in 28 days. Small 2 delivery, gynecological diseases were not. Over the past two years, said
lengthening the menstrual cycle to 40-45 days, and then having uterine bleeding. Vaginal research:
Cervix cylindrical shape is changed, the external eye closed, uterus a little more the norm, dense
surface is smooth, ruxoma, painless, appendages on both sides without features. Select spotting,
dirty (10 days).
Diagnosis. Assign the test treatment.
Tests
1. Female 23 років asked the gynecologist complaining of heavy spotting with genital tract after
delays mestruatsiyi for 8 weeks. During examination of the body of the uterus enlarged to 12 weeks
of pregnancy, bleeding from the tissue elements, reminiscent of bubbles. What additional test is
most appropriate?
A. Ultrasound.
B. X-ray examination.
C. Immunological test for pregnancy.
D. Laparoscopic examination.
E. Determination of human chorionic gonadotropin.
2. Ovarian apoplexy in most cases occurs in:
A. The first phase of the menstrual cycle.
The second phase of the menstrual cycle.
3. In which part of uterine tube is fruitful egg upon the termination of ectopic pregnancy by bursting
pipes?
A. mural.
V. Istmichniy.
S. Ampulyarniy.
The proper response to the test:
1-A 2-B 3-B.
7. Tasks NDRS
1. And perform a bibliographic search on "Use of endoscopic techniques in the treatment of
inflammatory diseases ZHSO.
2. Writing papers on the issue.
3. Plan review of literature.
4. Production of tables, slides, drawings.
8. Literature
8.1. General:
1. Bodyazhyna VI Obstetrics. / VI Bodyazhyna, KN Zhmakyn, AP Kyryuschenkov. - M., 1998. - S.
285-296.
2. Aylamazyan EK Obstetrics. / E.K Aylamazyan. - C-Pererburh, 1998. - S. 245-256.
3. Nicholas L. Gynecology. / LV Nicholas. - Medicine, 1985. - S. 342-355.
4. Gryshchenko VI "Gynaecology. / VI Gryshchenko. - Berlin: Basis, 2000.
5. Order number 582 of Health of Ukraine "On approval of clinical protocols for obstetric and
gynecological care.
MORE:
1. Aylamazyan А.К. Neotlozhnaya екстремальных condition to aid in lead researches. / EK
Aylamazyan, Y.T. Ryabtseva. - N. Novgorod: Izd NHMA, 1996. - S. 30-34.
2. Markin LB Emergency surgical care in obstetrics and gynecology / LB Markin, JP Snows, BM
Ventskovskyy .- Lviv: Svit, 1992. - S. 60-63.
3. Stepankovskaya GK Handbook of Obstetrics and lead researches / H.K. Stepankovskaya, LV
Tymoshenko, E.T. Mikhailenko. - K.: Health, 1997. - S. 410-412.
4. Anishchenko VM Encyclopedia semeynoho physician. / VM Anishchenko, GA Belytskaya, AS
Efimov .- 2 vol. - K.: Health, 1995. - Kn. 1. - S. 25-37.