1. Endometriosis
Definition : painful condition caused by growth of endometrial tissue outside the uterus.
Organs of the Pelvic Cavity are the most common locations for the ectopic growths.
Complication : one of the leading causes of Infertility in women.
Define endometriosis?
Most common site of endometriosis is ………
Pelvic organs
Abdomen
All of the above
None of the above
Endometriosis is one of the leading cause of infertility ( true or false )
Most serious complication of endometriosis is …………………..

2. Clinical presentation
Pain
Pelvic
Low back pain
painful sexual intercourse
Dysuria and painful defecation
Painful menstrual cramps
bleeding
Heavy menstruation
Intermenstural spotting
Gastrointestinal bleeding
Fatigue
Mistaken for chronic fatigue syndrome

3. Management Prehospital care is based on the patient's complaint :
If the patient reports severe Pain → provide pain relief with analgesics if allowed in your protocol.
Use dressing or towels as needed to absorb any significant Bleeding.
Let the patient position herself so she is comfortable.
Transport to hospital.
Management of patient with vaginal bleeding ?
Give short account on prehospital care of patient with vaginal bleeding?

4. Pelvic inflammatory disease (PID)
Definition : PID is an infection of the female Upper Genital organs i.e. uterus , ovaries and fallopian tubes.
It affects mainly Young Menstruating Sexually Active females younger than 25 years old
Risk factors include:
The use of an IUD as a contraceptive device.
Frequent sexual activity with multiple partners.
History of previous PID.
Define PID and what are the risk factors for it?
Complete the following :
PID occurs mainly in ………………………………………
3. Choose the correct answer
PID occurs mainly and almost exclusively in
Young virgin more than 25 years old
postmenopausal females
Sexually active young female less than 25 years old
Virgin females less than 25 years old .

5. Pathogenesis of PID Organism enter the vagina with seminal fluid .
It travels up and infects the uterine cavity .
Then it affects both the fallopian tube and ovary .
The infection can spread to abdominal cavity causing peritonitis and pelvic abcess.

6. Pathogenesis of PID

7. Clinical presentation
Pain
1- achy
2- Starts with or after normal menstruation
3- Diffuse and spread to both abdominal quadrants
4- Pain increase with walking and sexual intercourse
Additional symptoms
1- Fever and chills
2- Vaginal discharge
3- Burning micturition
What is the clinical presentation of PID ?
To remember ( any vaginal infection symptoms could be easily memorized by PAIN + DISCHARGE + FAHM)

8. Special notes Symptoms may mimic that of Acute Abdomen .
Complication : septicemia , peritonitis and infertility.
Management :
Address ABCs .
Transport in comfortable position .
No treatment in field for PID , definitive treatment is by antibiotics for 10 – 14 days .
Definitive treatment of PID is …………………………….

9. Vaginitis Vaginitis: infection of vagina which is very common.
Vulvovaginitis : inflammation of both vagina and vulva.
Fungal or yeast vaginitis is one of the most common types .
Yeast vaginal infection is caused by candida albicans fungus .
Vaginitis is ………………………………. While vulvovaginitis is ……………………………………….

10. Pathophysiology of candida vaginitis
Candida albicans is normal bacterial flora .
It inhabits the vagina in small number .
Overgrowth of candida is prevented by normal acidic ph. of the vagina.
Factors that alter vaginal acidity ( decrease ) causes over growth of candida .
Over growth of Candida albicans is caused by factors that ………….. Vaginal ph.:
Increase
Decrease
None of the above .
True or false
Regarding fungal or yeast vaginitis :
The commonest type of vaginitis
Caused by Candida albicans .
Organism causing it is one of normal inhabitant of genital tract
Overgrowth of this microorganism is enhanced by increase vaginal ph

11. Pathophysiology of candida vaginitis
Use of oral contraceptives,
Menstruation,
Pregnancy.
Some antibiotics.
Moisture and irritation.
Stress from lack of sleep, illness, or poor diet.
Immune suppressive diseases such as HIV infection or diabetes.
Risk factors
Enumerate 4 of the risk factors for candida vaginitis?

12. Common symptoms of vaginitis
Vaginitis what ever the causative agent present with common symptoms :
Itching and Irritation ( burning ).
Discharge.
Odor.
Painful intercourse.
Lower abdominal pain.
What are the common presenting symptoms of vaginitis?

13. Symptoms of vaginal yeast infections
Itching and Burning.
Burning on urination.
itchy feeling in the vagina and around the opening.
Thick, white vaginal discharge
Pain during sexual intercourse.
Lower abdominal pain

14. Symptoms of vulvovaginitis
Pain and burning sensation
Itching ( intense itching ) which increase before and the time of menstruation.
Redness and Swelling of the vulva skin.

15. Complication and management
Complication of vaginitis :
Infertility.
Preterm birth.
Endometritis and PID.
Increased risk for STDs.

16. Management Prehospital treatment is supportive.
Definitive treatment of vaginitis is that of the causative organism antibiotics or antifungal .
Vulvovaginitis topical creams(antifungal and steroids cream combination) are added.

17. Bartholin abcess Definition : Inflammation of Bartholin gland .
Pathophysiology :
Bartholin glands opens by two small ducts in lower part of the vagina , it secretes mucous that acts as lubricants during sexual intercourse.
These ducts could become obstructed leading to mucous accumulation and cyst formation .

18. Pathogenesis Cyst is painless swelling .
With time, the fluid within the cyst may become infected, resulting in pus accumulation and abscess formation.

19. Anatomy of Bartholin gland
Bartholin cyst
Bartholin gland

20. BARTHOLIN ABCESS

21. Assessment Clinical presentation :
The Bartholin abscess is usually unilateral.
Patient may report the following:
painful mass.
Swelling and redness of the vulva.
Painful intercourse.
Management :
Drainage ( Marsupialization ) and antibiotics.

22. Complicated ovarian cyst is gynecological emergency
Ovarian cyst : is a fluid-filled sac that forms on or within an ovary.
Types :
Functional cyst .
Follicular cyst.
Corpus luteum cyst.
Polycystic ovarian disease.
Complicated ovarian cyst is
a true
gynecological emergency
What are the definition and types of ovarian cyst?

23. The most common type of cyst.
Functional cyst :
The most common type of cyst.
During the menstrual cycle, the ovaries form tiny sacs (cysts) to hold the oocytes.
Once the oocyte matures, the sac breaks open and releases the oocyte before dissolving.
follicular cyst :
If the sac fails to close after , fluid accumulates inside and the oocyte may form a follicular sac .
Normally disappears within 1 to 3 months.
Functional cyst is commonest type of ovarian cyst ( true or false )

24. Develops if the sac seals itself after release of the oocyte.
Corpus luteum cyst :
Develops if the sac seals itself after release of the oocyte.
Fluid accumulates inside the cyst and continues to grow.
Fertility drugs can increase the incidence corpus luteum cysts.
Polycystic ovarian disease :
Result from repeated and excessive cyst formation with failure of ova release .
Exact etiology is unknown.
Give short account on polycystic ovarian disease ?
Answer :
Result from repeated and excessive cyst formation with failure of ova release.
Exact etiology is unknown.
Pathophysiology and clinical presentation of polycystic ovarian disease :
Increased androgen and decreased estrogen leading to menstrual irregularities acne and excessive hair growth.
Insulin resistance leading to diabetes and obesity.
Increased incidence of hypertension and ischemic heart disease.

26. Follicular And Corpus Luteum Cyst

27. Pathophysiology and clinical presentation of polycystic ovarian disease :
Increased androgen and decreased estrogen leading to menstrual irregularities acne and excessive hair growth.
Insulin resistance leading to diabetes and obesity.
Increased incidence of hypertension and ischemic heart disease.

28. PCOD

29. Clinical presentation of uncomplicated ovarian cyst
Patient with an ovarian cyst may report the following:
Dull, achy pain in the lower back and thighs.
Abdominal pain or pressure.
Nausea and vomiting.
Breast tenderness.
Abnormal bleeding and painful menstruation.
Painful intercourse.

30. PCOD

31. COMPLICATION
REPTURE .
TORSION.
ABCESS FORMATION.

32. Complication of ovarian cyst
Rupture of ovarian cyst
Leads to Internal Hemorrhage And Acute Abdomen.
Signs and symptoms include:
(a) Lower abdominal pain (usually described as sharp).
(b) Abdominal distention and tenderness.
(c) Dizziness , Weakness and Syncopal episode.
Give Short account on clinical presentation rupture ovarian cyst?
Answer :
Rupture ovarian cyst causes internal hemorrhage and acute abdomen.
Presenting symptoms : sharp abdominal pain , abdominal tenderness and distension
( acute abdomen) , weakness , dizziness and syncope ( internal hemorrhage ).

33. associated with nausea and vomiting. Requires surgery.
Ovarian torsion :
Occurs when the cyst reaches a considerable size causing the ovary to twist which impair its blood supply .
Clinical picture :
Sudden onset of severe unilateral lower abdominal pain that may radiate to the back or thigh
associated with nausea and vomiting.
Requires surgery.
What is clinical presentation and definitive management of ovarian torsion?
Answer
Clinical presentation :
Presents with sudden onset of severe unilateral lower abdominal pain that may radiate to the back or thigh
Associated with nausea and vomiting.
Definitive treatment : requires surgery.
The following about ovarian torsion is true or false :
One of the complication of ovarian cyst ( true )
True gynecological emergency ( true )
occurs when the cyst reaches considerable size causing the ovary to twist and cutting its blood supply. ( true )
Definitive line of treatment is bed rest and antibiotics. ( false )
Presents with diffuse vague abdominal pain. ( false )

34. Called Tubo-ovarian abcess .
Abcess formation
Called Tubo-ovarian abcess .
Patient with A Tubo-ovarian Abscess present with :
Severe abdominal pain.
Guarding , tenderness and rebound tenderness
Abdominal distention
Nausea and vomiting
Fever , headache , anorexia and malaise .
Any of these conditions, may be complicated with internal hemorrhage.
1- Complication of ovarian cyst include :
Answer :
Rupture
Ovarian Torsion
Abscess formation causing tubo- ovarian abscess
2-Tubo-ovarian abscess is true gynecological emergency , what is clinical presentation of this emergency?
Severe abdominal pain
Guarding and rebound tenderness
Nausea and vomiting
Abdominal distention
Fever

35. Management of complicated ovarian cyst
Ensure adequate airway and give high flow oxygen .
Check signs of Shock and give an IV fluid via large bore cannula.
Anticipate vomiting
Keep the patient in left lateral pain .
Give analgesic if allowed
Transport rapidly and inform hospital about your diagnosis and patient condition.
Reassess vital signs regularly during transport.
What is the proper management of complicated ovarian cyst?

36. Prolapsed uterus
Definition : drop of the uterus from its normal position into vagina .
Etiology : occurs due to weakness of muscles and ligaments holding uterus in its position which may be due to :
age .
Child birth .
Obesity .
Low estrogen levels .
Complete the following :
Uterine prolapse occurs due to ………………………. Of the muscle and ligaments holding uterus in its position which may be due to …………………… , ………………………… and ……..
……………………………….
Prolapsed uterus is ……………………….

37. STAGES OF UTERINE PROLAPSE
There are Four Stages of prolapse :
1st Degree : cervix drops into the vagina.
2nd Degree: cervix sticks out of the opening of the vagina.
3rd Degree : cervix is outside of the vagina.
4th Degree : the entire uterus is outside the vagina.
Write in front of column ( B ) what is suitable from column ( A):
( 1 ) 1ST degree prolapse Cervix is outside of the vagina ( )
( 2 ) 2nd degree prolapse The entire uterus is outside the vagina ( )
( 3 ) 3rd degree prolapse The cervix drops into the vagina ( )
( 4 ) 4th degree prolapse Cervix sticks out of the opening of the vagina( )

38. Uterine prolapse

39. Clinical presentation
Vaginal , pelvic pain and Low back pain,.
Dysuria and Incontinence.
Infection and bad smelling discharge.
Varying degrees of feeling like something is falling out of or bulging from their vagina.

40. Management Prehospital treatment is limited to:
Pain management and Treatment for shock if present
Do not replace any tissue and Cover with warm, moist dressings.
Do not let the patient walk.
Definitive treatment includes devices to hold the organs in place or surgery.

41. Toxic shock syndrome Form of septic shock .
Commonly seen in menstruating female using tampons.
Caused by group A streptococci and staphylococcus aureus .
Clinical presentation :
Fever , headache
Anorexia , malaise
Vomiting and may be syncopal attack.

42. Management High-flow supplemental oxygen IV therapy
Pressors if necessary
Cardiac monitoring
Rapid transport is indicated.

43. Sexual assault
Rape is a crime, and police involvement should be expected.
The rule of the paramedic is to manage the medical aspects of the case and act as the patient supporter.
If possible, a female rape victim should be given the option of being treated by a female paramedic.

44. Assessment of rape victim
Professionalism, kindness, and sensitivity are important.
Do the following:
Limit any physical examination to a brief survey for life- threatening injuries.
Examine the vaginal area only if there is evidence of bleeding.
Do everything possible to protect the patient's privacy.
Examine the patient with a minimum of people present.

45. Management Do not cut through any clothing or throw away anything
Place bloodstained articles in separate paper (not plastic) bags.
Discourage the patient from:
Cleaning herself up
Using hand sanitizer
Changing clothes
Moving her bowels
Rinsing out her mouth