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“OVIDIUS “ UNIVERSITY OF CONSTANTA FACULTY OF GENERAL MEDICINE VIth YEAR – ENGLISH http://drddp.wordpress.com/ OBSTETRICS AND GYNECOLOGY Practical exam topics 1. Bony pelvis, side walls A. large pelvis limited by anterior inner wing of iliac bone which form the iliac fossa BITROANTERIAN diameter: 32 cm BICREST diameter: 28 cm BISPINOS diameter: 24 cm Antero-posterior diameter: 19 to 20 cm B. small pelvis (obstetrical pelvis) presents: I. Superior Inlet Transverse diameter -> 13.5 cm Oblique diameter -> 12 – 12.5 cm promonto-suprapubic diameter -> 11 cm Antero-posterior diameter (CONJUGATA VERA) -> 10.5 – 11 cm II. Middle Inlet Sagittal diameter -> 11.5 cm III. Inferior Inlet Lower margin of coccyx -> 9.5 cm and can get till 11-12.5 cm bi-ischial diametre 10cm Pelvimetry diagonal conjugate 12.5 – 13cm bi-ischial diametre 10cm incisura ischiadica 5-6 cm angle of sub-pubic arch 90 degrees 2. Perineum The perineum or perineum is the region of the body between the anus and genitals. In human anatomy, the perineum is a region of the body including the perineal body and surrounding structures. According to some definitions, in females it is located between the vagina and anus and in males between the scrotum and anus. Both men and women can experience the perineum as an erogenous zone that it is sensitive to touch, both of caresses and pressure. That's because the area's musculature is rich in nerves and blood vessels. Tissue under the skin also border area around the prostate gland , a point which is sensitive to sexual stimulation, and therefore also called man - G point. At a birth may tissue of the perineum at the woman stretched too much and crack. 1 To avoid such uncontrolled cracks, or to speed up a slow and the child dangerous childbirth, it happens that the midwife put an incision in the perineum, which is called an episiotomy. If such a cut, or spontaneous fracture , heal poorly, it can affect a woman's sexual prowess. When severe cases it can also lead to fecal incontinence. Terminology It is generally defined as the surface region in both males and females between the pubic symphysis and the coccyx. The perineum is the region of the body inferior to the pelvic diaphragm and between the legs. It is a diamond-shaped area on the inferior surface of the trunk that includes the anus and, in females, the vagina. Its definition varies: it can refer to only the superficial structures in this region, or it can be used to include both superficial and deep structures. The perineum corresponds to the outlet of the pelvis. It is an erogenous zone for both males and females. Perineal tears and episiotomy often occur in childbirth with first-time deliveries, but the risk of these injuries can be reduced by preparing the perineum, often through massage. The anogenital distance is a measure of the distance between the anus and the base of the penis or vagina. Studies show that the human perineum is twice as long in males as in females. Measuring the anogenital distance in neonatal humans has been suggested as a noninvasive method to determine male feminisation and thereby predict neonatal and adult reproductive disorders. 3. Fetal head The fetal head is composed of: face, 2 frontal bones, 2 parietal bones, 2 temporal bones, occipital bone, the wings of the sphenoid Sutures: Frontal, sagittal, coronal, lambdoid Fontanels: the greater (anterior, bregmatic) the lesser( posterior, lambdoid ) the casserian( temporal ) The diamters of the newborn skull The occipitofrontal diameter = 11,5 – 12 cm The biparietal diameter = 9,5 cm The bitemporal diameter = 8 – 8,5 cm. The mobility of fetal head in relation with the vertebral column. Engagement diameters of the fetal head suboccipito-bregmatic diameter- engagement diameter in flexed head presentation = 9,5 cm suboccipito – frontal diameter– sinciput presentation = 11 cm. submento – bregmatic diameter – facial presentation = 9,5 cm. sincipito-mentonier diameter– brow presentation = 13,5 cm. The head circumferences the great circumference – corresponds to the occipito-frontal diameter = 34,5 cm. the small circumference – corresponds suboccipito- bergmatic diameter= 32 – 33 cm. modulation process of the head. 2 4. Clinical diagnosis of the pregnancy There are three degrees of certainty in diagnosis approach: Det finns tre grader av säkerhet i diagnos tillvägagångssätt: - presumptive signs (Amenohrea, breast tenderness, nausea, vomiting, increase skin pigmentation, skin striae), - probable signs (enlargement of the uterus, maternal sensation of uterine contractions or fetal movement, hegar sign, positive urine or serum B-HCG) - positive signs (hearing fetal heart tones, sonographic visualization of a fetus, perception of fetal movements by an external examiner, and x-ray showing a fetal skeleton) a. Amenorrhea It is significant for brutal stop menstruation in a woman of reproductive age with regular cycles in advance, >10 days after the expected date of menstruation Amenorrhea of pregnancy is maintained by estrogen and progesterone secreted by the placenta b. Digestive manifestations Nausea and Vomiting: manifests usually in the morning Other: changes in taste, changes in appetite, heartburn, constipation c. Urinary disturbances Polyuria due to increase in uterus size and pressure on the bladder d. General Manifestations / neuropsychiatric Fatigue, increased temperature e. Perception of fetal movements Pregnant women perceive fetal movements at 16 to 20 f. skin changes skin hyperpigmentation: is explained by stimulation of MSH (melanocyte stimulating hormone) Stretched skin g. Breast modification Dilated superficial veins Fullness, increased pigmentation of nipple region/areola, prominent Montgomery h. Cervix/ vagina Deep-bluish in colour (venous dilatation) Endocervix softens i. Uterus From firm, flattened to soft and globular; Hegar Sign Uterine a. pulsation may be felt at lateral fornix Uterine size by palpation: 6,8,10,12w – at 12w becomes abdominal and just palpable suprapubically Differential diagnosis: uterine tumour, estrogen secreting ovarian tumour j. Braxton-Hick's contractions This involves painless uterine contractions occurring throughout pregnancy. 3 It usually begins about the 12th week of pregnancy and becomes progressively stronger. k. Abdominal changes This corresponds to changes that occur in the uterus, as the uterus grows the abdomen gets larger. Abdominal enlargement alone is not a sign of pregnancy. Enlargement may be due to uterine or ovarian tumors, or edema. l. Positive signs of pregnancy Positive signs of pregnancy are those signs that are definitely confirmed as a pregnancy. They include fetal heart sounds, ultrasound scanning of the fetus, palpation of the entire fetus, palpation of fetal movements, x-ray, and actual delivery of an infant. m. Cervical Changes Goodell's sign. The Goodell's sign is when there is marked softening of the cervix. This is present at 6 weeks of pregnancy. Formation of a mucous plug. This is due to hyperplasia of the cervical glands as a result of increased hormones. 5. Laboratory diagnosis of the pregnancy Tests Utilized To Determine Pregnancy Tests are based on the presence of human chorionic gonadotropin (HCG) in the urine or blood. Urine. This test can be performed accurately 42 days after the last menstrual period or 2 weeks after the first missed period. The first urine specimen of the morning is the best one to use. Blood. Radioimmunoassays (RIA) can detect HCG in the blood 2 days after implantation or 5 days before the first menstrual period is missed. NOTE: HCG levels peak between 50 to 90 days after the last menstrual period. Home pregnancy test kits are easily available and inexpensive. This test allows prenatal care to be started early. Urine tests: Test of HCG (chorionic gonadotrophin hormones) Alpha and beta (glycoprotein) subunit Cross reaction for alpha : LH,FSH, TSH (sharing of alpha subunit) Morning specimen urine; repeat 1-2 weeks if necessary 2 methods ; indirect and direct antibody test Serum HCG produced by synciotrophoblast; peaks at 10weeks; luteotropic & maintains corpus luteum until placental steroidogenesis level is satisfactory False positive: cross reaction to above hormones. Current test using specific beta-subunit Contamination by higher than normal urine protein Ovarian tumour False negative: Technical error Test done too early Abnormalities of pregnancy eg miscarriage Sensitive serum assay : radioreceptor assay or radioimmunoassay Advantage of sensitivity, allowing diagnosis of pregnancy well before the first missed period More expensive,reserved for special indications eg. Ectopic pregnancy,surveillance for molar pregnancy 4 Hormonal Withdrawal Test: Large dose of estrogen/progesterone for 2-3 days. Usually withdrawal bleed after 35days if not pregnant Possible harm; NOT DONE Later Signs After 12 weeks – uterus palpable above symphysis pubis Fetal heart sounds, fetal parts and fetal movement 6. Ultrasound examination in obstetrics First-trimester ultrasound can be done transvaginally or transabdominally and should: Document location of the gestational sac. An intrauterine sac is visible transvaginally as early as 5 weeks' gestation. Document fetal number. Confirm fetal viability. Fetal cardiac activity can be detected transvaginally when the embryo is 5 mm or greater in length (approximately 6 weeks' gestation). Evaluate gestational age. Measurement of the fetal crown-rump length between 6 to 13 weeks' gestation can estimate fetal age within 5 days Evaluate the uterus and adnexal structures. Second-trimester ultrasound is usually performed transabdominally. It is routinely performed between 18 and 20 weeks' gestation for evaluation of fetal anatomy, gestational age, placental location, and amniotic fluid volume. Measurement of cervical length should be done by transvaginal ultrasound. The fetal anatomic survey should include, but not to be limited to: Intracranial anatomy with visualization of the lateral ventricles, choroids plexus, thalamus, cerebellum, and cisterna magna. Thorax, diaphragm, heart Visualization of the stomach. Visualization of the kidneys and bladder. Umbilical cord insertion on an intact abdominal wall and determination of the number of vessels of the umbilical cord (normal: two small arteries and one large vein). Upper and lower extremities. Fetal biometry includes: The biparietal diameter is the most accurate measurement of gestational age between 12 and 18 weeks' gestation. The head circumference is measured at the same level as the biparietal diameter. Fetal weight may be estimated by composite measurement of the biparietal diameter, head circumference, femur length, and abdominal circumference. Placental location should be documented Amniotic fluid volume Maternal anatomy. Evaluate the uterus and adnexal structures. Third-trimester ultrasound is approached transabdominally. The indications for thirdtrimester ultrasound are multiple and include estimation of fetal weight and follow-up of fetal growth, evaluation of the amniotic fluid volume, follow-up of a fetal anomaly, determination of fetal presentation, and evaluation of fetal well-being. Fetal weight is estimated as previously described If the estimated fetal weight is below the 10th percentile for the gestational age, the fetus is small for gestational age (SGA) and intrauterine growth restriction (IUGR) is suspected If the estimated fetal weight is above the 90th percentile for the gestational age, the fetus is large for gestational age (LGA) and macrosomia is suspected. Amniotic fluid volume What Should Be Seen In A First Trimester Pregnancy? 5 The site of pregnancy The gestational sac, amniotic cavity including numbers The fetus and viability Any other pelvic masses Earliest sign could be thickened ET > 12mm 4-5 weeks – gestational sac (1-2 mm) 7. Lie, presentations and positions Fetal Lie The relation of the long axis of the fetus to that of the mother Longitudinal lie - found in 99% of labours at term Transverse lie - multiparity, placenta praevia, hydramnios, uterine anomalies Oblique lie: unstable (become logitudinal or transversal) By abdominal palpation, vaginal examination, and auscultation, or by technical means (USG, X-ray) Fetal Presentation The presenting part is the portion of the body of the fetus that is foremost in the birth canal The presenting part can be felt through the cervix on vaginal examination Longitudinal lie -> cephalic presentation -> breech presentation Transverse lie -> shoulder presentation Cephalic Presentation Head is flexed sharply -> vertex / occiput presentation Head is extended sharply -> face presentation Partially flexed -> bregma presenting (sinciput presentation) Partially extended -> brow presentation Breech Presentation Frank breech Complete breech Footling breech Position The relation of an arbitrary chosen point of the fetal presenting part to the Rt or Lt side of the maternal birth canal The chosen point Vertex presentation -> occiput Face presentation -> mentum Breech presentation -> sacrum Each presentation has two positions Rt or Lt Each position has 3 varieties : anterior, transverse, posterior 8. Labor and delivery Childbirth, labor, delivery, is the culmination of a period of pregnancy with the expulsion of one or more newborn infants from a woman's uterus. The process of normal childbirth is categorized in three stages of labour: The shortening and dilation of the cervix, Descent and birth of the infant, Birth of the placenta. When a patient first presents to the labor floor a quick initial assessment is made, using the history of present pregnancy, obstetric history and the standard of medical and social history. Routinely patients are queried regarding contractions, vaginal bleeding, leakage of fluid and fetal movement. 6 Beyond the standard physical examination the obstetric examination includes maternal abdominal examination for contraction and the fetus (Leopold maneuvers), cervical examination, fetal heart tones, and sterile speculum examination if rupture of membranes is suspected. 9. Mechanism of labor in occipital presentation 1. 2. 3. 4. 5. 6. Engagement The biparietal diameter of the fetal head, the greatest transverse diameter of the head in occiput presentations, passes through the pelvic inlet. LOT -> 40% ROT -> 20% OP -> 20% ROP > LOP ROA / LOA -> 20% Descent In nullipara engagement takes place before the onset of labour & further descent may not occur till the 2nd stage In multipara descent begins with engagement It is gradually progressive till the fetus is delivered It is affected by the uterine contractions & thinning of the lower segment Flexion The descending head meets resistance of pelvic floor, Cx & walls of the pelvis -> flexion Internal Rotation Turning of the head from the OT position -> anteriorly towards the symphysis pubis ie. Occiput moves from transverse to anterior 45º Less commonly OT -> posteriorly towards the sacrum 135º Extension When the flexed head reaches the vulva it undergoes extension Æ the base of the occiput will be in direct contact with the inferior margin of the symphysis pubis Crowning Æ the largest diameter of the fetal head is encircled by the vulvar ring The head is born by further extension as the occiput, bregma, forehead, nose, mouth & chin pass successively over the perineum External Rotation (Restitution) After delivery of the head it returns to the position it occupied at engagement, the natural position relative to the shoulders (oblique position) Then the fetal body will rotate to bring one shoulder anterior behind the symphysis pubis (biacromial diameter into the APD of the pelvic outlet) Restitution is followed by complete external rotation to transverse position (occiput lies to next to left maternal thigh) The anterior shoulder slips under the pubis By lateral flexion of the fetal body the post shoulder will be delivered & the rest of the body will follow Occiput Posterior Position Mechanism of labour is identical to OT & anterior varieties The occiput rotate to the symphysis pubis through 135º instead of 90º or 45º If rotation does not occur -> direct occiput posterior or partial rotation -> transverse arrest 10.Mechanism of labor in face presentation Difficult birth, prolonged Engagement the orientation of the presentation with the sincipito-mentonier ( 13,5 cm ) diameter into an oblique diameter of the maternal pelvis complete deflectation – the skull solidarise with the frontal back 7 the presentation reach the surface of the pelvic inlet but the progression is halted because the solidarized fetal head and back brings at the level of the superior straightthe presternosincipital diameter (13,5 cm) with which the engagement is impossible The descent cannot occur unless the flexion of the fetal head occurs, which is possible only if the menton rotates anteriorly in MP Expulsion Occurs by progressive flexion of the head sustained by the menton witch is fixed under symphisis The head expulsion is produced with the face up, showing successively at the vulva:mouth, nose, forehead and the rest of the skull If rotation occurs in MS, the skull stops and the vaginal birth cannot occur by theinclavation of the fetal face Obstetrical conduct Close supervision of labor When progression of the presentation is not optimal → cesarean delivery When doing the engaging and turnover in MP birth can move towards vaginal delivery Newborns have a characteristic appearance - caput succedaneum make a purplish swellingof the lips, nose, cheeks. The head remains in deflected attitude a few days after birth 11.Mechanism of labor in bregmatic presentation The engagement is in an oblique diameter, producing real plastic phenomena → cylindricalaspect of the head Descent and internal rotation are laborious → FP, respectively OS. Expulsion : is achieved in 92% in OS nasofrontal sulcus take fixed under the symphysis and serves as a pivot for the headwhich becomes flexed in order to deliver → will appear at the opening vulva thelarge fontanel, frontal boses, parietal boses, the occiput follows a second time of deflecting , suboccipital region appearing at the rear cornersof the vulva → the face will deliver the head sometimes does not rotate → delivery is performed in oblique or transversediameter The evolution of birth is prolonged Obstetrical approach labor test 12.Mechanism of labor in breech presentation A breech birth is the birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feet first as opposed to the normal head-first presentation. In breech presentation, fetal heart sounds are heard just above the umblicus. The bottom-down position presents some hazards to the baby during the process of birth, and the mode of delivery (vaginal versus Caesarean) is controversial in the fields of obstetrics and midwifery. Though vaginal birth is possible for the breech baby, certain fetal and maternal factors influence the safety of vaginal breech birth. The majority of breech babies born in the United States are delivered by Caesarean section as most obstetricians do not have the required skill set anymore and most hospital policies do not permit vaginal breech birth. 8 Factors predisposing to term breech presentation include: Multiple (or multifetal) pregnancy (twins, triplets, or more) Abnormal volume of amniotic fluid: both polyhydramnios and oligohydramnios Fetal anomalies: hydrocephaly, anencephaly, and other congenital abnormalities Uterine abnormalities. Prior Caesarean sections Contracted pelvis Placenta praevia Congenital malformation of the uterus such as septate or bicornuate uterus Multiparae with lax abdominal wall There are either three or four main categories of breech births, depending upon the source: Frank breech – the baby's bottom comes first, and his or her legs are flexed at the hip and extended at the knees (with feet near the ears); 65–70% of breech babies are in the frank breech position Complete breech – the baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom Footling breech – one or both feet come first, with the bottom at a higher position; this is rare at term but relatively common with premature fetuses Kneeling breech – the baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees; this is extremely rare, and is excluded from many classifications 13.Amnioscopy Examination of a fetus and the amniotic fluid in the lowest part of the amniotic sac using an amnioscope introduced through the cervical canal after dilatation of the cervix Amnioscopy sure about is the fetal position and what state it is amniotic fluid. Amnioscopy also be used to take blood samples from the fetus if there is rupture Results: If yellowish that could indicate the presence of bilirubin, resulting in a blood incompatibility in the event that the pitch is green could warn of the presence meconium, which would result in hypoxia, ie there is a deprivation of oxygen and therefore the possibility of fetal distress is occurring the tone of the amniotic fluid is reddish this would mean that the fetus is dead. procedure The patient is placed in the lithotomy position. “Endoscope inserted through abdomen or in cervix to view fetus and amniotic fluid. Cervix must be dilated to accept 1 finger because scope diameter is approx. 1 cm – the size of an average finger” dr. Tomescu According to the state of the cervix, the largest suitable amnioscope is selected, The suitable speculum applied, then, the selected tube is guided into the cervical canal. The obturator is removed and a light source is inserted so that the amnion sac could be inspected through the intact forewaters. Indications To evaluate for possible fetal hypoxia by noting change in color of amniotic fluid caused by passage of meconium from the rectum of the fetus To secure a fetal scalp blood sample to determine fetal acid–base and blood gases status in the diagnosis of fetal hypoxia and distress Contraindication: Active labour Ruptured membrane 9 Cervical infection or STD. Closed cervix unexplained vaginal bleeding. 14.Amniocentesis An amniocentesis may be performed beyond 15 weeks to obtain a fetal karyotype, once the chorion and amnion have fused. Amniocentesis is also offered to any patient of advanced maternal age (AMA). Amniocentesis involves placing a needle transabdominally through the uterus into the amniotic sac and withdrawing some of the fluid. The fluid contains sloughed fetal cells that can be cultured. These cultured cells can then be karyotyped and also utilized in DNA tests. Early in pregnancy, used for diagnosis of chromosomal and other fetal problems such as: Down syndrome Trisomy 13 & Trisomy 18 Later on, it also can be used to detect problems such as: Infection Rh incompatibility (to examine bilirubin levels after 24 weeks GS) Prediction of lung maturity and fetal maturity studies lecithin-sphingomyelin ratio and phosphatidyl glycerol Decompression of polyhydramnios The common risks are rupture of membranes, preterm labor, respiratory distress, postural deformities, fetal trauma. 15.Clinical and laboratory diagnosis of the membranes rupture Ruptured membranes are signified at any time during pregnancy by either a sudden gush or a steady trickle of clear fluid from the vagina. In a term pregnancy, labor usually follows within 24 hours of membrane rupture. The risk of intrauterine infection (chorioamnionitis) increases if the patient has ruptured membranes for longer than 24 hours, with or without labor. Procedure Pooling. Upon sterile speculum examination, a pool of amniotic fluid may be present and visible at the vaginal vault. Nitrazine test. Testing the fluid with nitrazine paper, which will turn blue in the presence of the alkaline amniotic fluid Ferning. Placing a sample on a microscopic slide, air drying, and examining for ferning. 16.Clinical and laboratory diagnosis of the fetal distress pathological state of the fetus caused by decreased oxygen and nutrients leading to disruption of metabolic activity and fetal growth. It can be installed during pregnancy (Chronic fetal distress) or labor (Acute fetal distress). Etiological factors: Diseases associated in decreased maternal blood oxygen; Vasculo-renal syndrome; Fetal malformations; prematurity; Placenta praevia; Prolabare cord; Dystocia Premature rupture of membranes; Maneuvers to extract the fetus; Diagnostic: Major clinical signs of fetal distress in labor are: Impaired fetal heart rate; Green staining in amniotic fluid 10 More findings: recording fetal heart rate in fetal distress suggests that: heart rate is higher than 180 beats / min heart rate is less than 120 beats / min fetal heart rate is fixed Late decelerations are present in fetal anoxia or variable decelerations in cord pathology. 17.Induction of labor Induction of labor is the attempt to begin labor in a nonlaboring patient, whereas augmentation of labor is intervening to increase the already present contractions. Labor is induced with : Prostaglandins oxytocic agents mechanical dilation of thecervix, and/or artificial rupture of membranes. The indications for induction are based on either maternal, fetal, or fetoplacental reasons. Common indications: postterm pregnancy preeclampsia premature ROM nonreassuring fetal testing intrauterine growth restriction The success of an induction (defined as achieving vaginal delivery) is often correlated with favorable cervical status as defined by the Bishop score. A Bishop score of 5 or less may lead to a failed induction. The total score is achieved by assessing the following five components on vaginal examination cervical dilation Cervical effacement Cervical consistency Cervical position Fetal station Each components is given a score of 0-2 or 0-3. The highest possible score is 13. There are both maternal and obstetric contraindications for the use of prostaglandins. Maternal reasons include asthma and glaucoma. Obstetric reasons include having had more than one prior cesarean section and nonreassuring fetal testing. Labor may also be induced by amniotomy. Amniotomy is performed with an amnio hook that is used to puncture the amniotic sac around the fetus and release some of the amniotic fluid. After the amniotomy is performed, a careful examination should be performed to ensure that prolapse of the umbilical cord has not occurred. When performing amniotomy, it is important not to elevate the fetal head from the pelvis to release more of the amniotic fluid because this may lead to prolapse of the umbilical cord beyond the fetal head. 18.Management of labor and delivery Management Eating or drinking during labour is an area of ongoing debate. While some have argued that eating in labour has no harmful effects on outcomes, others continue to have concern regarding the increased possibility of an aspiration event (choking on recently eaten foods) in the event of an 11 emergency delivery due to the increased relaxation of the esophagus in pregnancy, upward pressure of the uterus on the stomach, and the possibility of general anesthetic in the event of an emergency cesarean. A 2013 Cochrane review pointed out that in recent years, obstetrical anaesthesia has changed considerably, with better general anaesthetic techniques and a greater use of regional anaesthesia and reported "no benefits or harms of restricting foods and fluids during labour in women at low risk of needing anaesthesia." The review suggested "fasting does not guarantee an empty stomach or less acidity" and that "poor nutritional balance may be associated with longer and more painful labours." The review concluded that "women should be free to eat and drink in labour, or not, as they wish." Active management Active management of labour consists of a number of care principles, including frequent assessment of cervical dilatation. If the cervix is not dilating, oxytocin is offered. This management results in a slightly reduced number of caesarean births, but does not change how many women have assisted vaginal births. 75% of women report that they are very satisfied with either active management or normal care. Pain control Non pharmaceutical Some women prefer to avoid analgesic medication during childbirth. They can still try to alleviate labour pain using psychological preparation, education, massage, acupuncture, TENS unit use, hypnosis, or water therapy in a tub or shower. Some women like to have someone to support them during labour and birth, such as the father of the baby, a family member, a close friend, a partner, or a doula. The human body also has a chemical response to pain, by releasing endorphins. Endorphins are present before, during, and immediately after childbirth. Some homebirth advocates believe that this hormone can induce feelings of pleasure and euphoria during childbirth, reducing the risk of maternal depression some weeks later. Water birth is an option chosen by some women for pain relief during labour and childbirth, and some studies have shown waterbirth in an uncomplicated pregnancy to reduce the need for analgesia, without evidence of increased risk to mother or newborn. Hot water tubs are available in many hospitals and birthing centres. Meditation and mind medicine techniques are also used for pain control during labour and delivery. These techniques are used in conjunction with progressive muscle relaxation and many other forms of relaxation for the mind and body to aid in pain control for women during childbirth. The injection of small amounts of sterile water into or just below the skin at several points on the back has been a method tried to reduce labor pain, but no good evidence shows that it actually helps. Pharmaceutical Different measures for pain control have varying degrees of success and side effects to the woman and her baby. In some countries of Europe, doctors commonly prescribe inhaled nitrous oxide gas for pain control, especially as 50% nitrous oxide, 50% oxygen, known as Entonox; in the UK, midwives may use this gas without a doctor's prescription. Pethidine (with or without promethazine) may be used early in labour, as well as other opioids such as fentanyl, but if given too close to birth there is a risk of respiratory depression in the infant. Popular medical pain control in hospitals include the regional anesthetics epidurals (EDA), and spinal anaesthesia. Epidural analgesia is a generally safe and effective method of relieving pain in labour, but is associated with longer labour, more operative intervention (particularly instrument delivery), and increases in cost. Generally, pain and cortisol increased throughout labour in women without EDA. Pain and stress hormones rise throughout labour for women without epidurals, while 12 pain, fear, and stress hormones decrease upon administration of epidural analgesia, but may rise again later. Medicine administered via epidural can cross the placenta and enter the bloodstream of the fetus. Epidural analgesia has no statistically significant impact on the risk of caesarean section, and does not appear to have an immediate effect on neonatal status as determined by Apgar scores. 19.Episiotomy. Perineum repair Definition An is epiostomy an incision of the perineum made to enlarge the vaginal outlet to facilitate delivery. It is made at the end of the second stage of labor just before delivery, when indicated. It increases the area of the outlet for the fetal head during delivery, particularly in assisted deliveries with forceps or the vacuum extractor. Function An episiotomy is used to prevent major perineal lacerations. Prophylactic episiotomy has been advocated to prevent pelvic relaxation, although this has never been proven. Types Median or medialy. This incision should be one-half the length of the distended perineum and is cut vertically in the midline of the perineal body. Advantages: less blood loss, easier to repair, more comfortable during healing Disadvantage: possible occurrence of inadvertent cutting or extension into the anal sphincter and rectum. It is important to recognize and repair this complication during repair of the episiotomy so that rectovaginal fistula does not result. Mediolateral . This incision of the perineum, at a 45-degree angle to the hymenal ring, extends laterally to the anus onto the inner thigh, allowing more room than a median incision. Advantage: more room with less risk of injury to the rectum and sphincter Disadvantages: more difficult to repair, more blood loss, more discomfort during healing There are four degrees of vaginal or perineal lacerations: First-degree lacerations involve the , perineal skin, and vaginal mucosa. Second-degree lacerations involve the skin, mucosa, fascia, and muscles of the perineal body Third-degree lacerations involve the anal sphincter. Fourth-degree lacerations involve the rectal mucosa to expose the lumen of the rectum. indications: large size baby preterm baby breech delivery direct -occipitio posterior Perianal Repair : First and second degree repair : Some first degree tears will not require suturing and second will require one or two interrupted suture ,non –locking suture technique to oppose each layer (vaginal epithelium, perineal muscle and skin) is associated with less short term pain. Third and fourth repair: Adequate muscle relaxation with regional or general anesthesia is essential. As the anal sphincter (levator ani muscle) is normally in a state of tonic 13 contractions. A suture is made in order to bring the muscle ends together, using an absorbable synthetic suture if possible to do it as subcutaneous stitch. 20.Complications of the IIIrd stages of labor AND 21.Complications of the IVth stages of labor Abnormal placental Placenta acreta describe any placental implantation there is abnormal adherence of placenta villous placental penetration time of the superficial portion of the myometrium. Placental increta is characterized by invading myometrium curled across its thickness. Placenta percreta is characterized by invasion of myometrium and overcome it, reaching up to serous. Retained placenta The placenta remains inside the uterus for longer than 30 minutes after delivery of the baby, usually due to one or more of the following: Uterine contractions may be inadequate to expel the placenta The cervix might have retracted too fast and partially closed, trapping the placenta in the uterus The bladder may be full and obstructing placental delivery. Postpartum hemorrhage (PPH) is the loss of more than 500 ml of blood following delivery of the baby. Most bleeding comes from where the placenta was attached to the uterus, and is bright or dark blood and usually thick. PPH occurs when the uterus fails to contract well, usually due to: Partially separated placenta (it remains partly attached to the uterine wall Completely separated placenta, but retained inside the uterus Atonic uterus; the muscular wall of the uterus could not contract powerfully enough to arrest the natural bleeding which occurs when the placenta separates. Uterine inversion The uterus is pulled ‘inside out’ as the baby or the placenta is delivered, and partly emerges through the vagina. Etiology factors predisposing Strong traction on the umbilical cord Relaxation of uterine fundus Traction on the bottom of the uterus by placental weight Maneuvers by pressing the bottom of uterine placenta acreta 22.Manual extraction of the placenta The diagnosis of retained placenta is made when the placenta does not deliver within 30 minutes after the infant. Procedure: The retained placenta may be removed by manual extraction. A hand is placed in the intrauterine cavity and the fingers used to shear the placenta from the surface of the uterus . If the placenta cannot be completely extracted manually, a curettage is performed to ensure no products of conception (POC) are retained. Causes of retained placenta include: Weak or insufficient uterine contractions: 14 Uterine anomalies: Hormonal Causes: During childbirth, the hormone oxytocin is released into the blood. Oxytocin is responsible for uterine muscle contractions. Complication lose a large amount of blood severe infection fertility issues. 23.Manual and instrumental curettage of the uterine cavity Dilation (or dilatation) and curettage (D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). It is a therapeutic gynecological procedure as well as a rarely used method of first trimester abortion. D&C normally refers to a procedure involving a curette, also called sharp curettage. However, some sources use the term D&C to refer more generally to any procedure that involves the processes of dilation and removal of uterine contents, which includes the more common suction curettage procedures of manual and electric vacuum aspiration. Procedure An illustration of a Dilation and Curettage The first step in a D&C is to dilate the cervix, usually done a few hours before the surgery. The woman is usually put under general anesthesia before the procedure begins. A curette, a metal rod with a handle on one end and a sharp loop on the other, is inserted into the uterus through the dilated cervix. The curette is used to gently scrape the lining of the uterus and remove the tissue in the uterus. This tissue is examined for completeness (in the case of abortion or miscarriage treatment) or pathologically for abnormalities (in the case of treatment for abnormal bleeding). Clinical uses D&Cs are commonly performed for the diagnosis of gynecological conditions leading to 'abnormal uterine bleeding'; to resolve abnormal uterine bleeding (too much, too often or too heavy a menstrual flow); to remove the excess uterine lining in women who have conditions such as polycystic ovary syndrome (which cause a prolonged buildup of tissue with no natural period to remove it); to remove tissue in the uterus that may be causing abnormal vaginal bleeding, including postpartum retained placenta; to remove retained tissue (also known as retained POC or retained products of conception) in the case of a missed or incomplete miscarriage; and as a method of abortion that is now uncommon. In contrast, D&C remains 'standard care' for missed and incomplete miscarriage in many countries despite the existence of alternatives currently used for abortions. Because medical and non-invasive methods of abortion now exist, and because D&C requires heavy sedation or general anesthesia and has higher risks of complication, the procedure has been declining as a method of abortion. The World Health Organization recommends D&C as a method of surgical abortion only when manual vacuum aspiration is unavailable. Most D&Cs are now carried out for miscarriage management and other indications such as diagnosis. Hysteroscopy is a valid alternative to D&C for many surgical indications from diagnosis of uterine pathology to the removal of fibroids and even retained products of conception. It poses less risk because the doctor has a view inside the uterus during surgery, unlike with blind D&C. 15 Medical management of miscarriage and medical abortion using drugs such as misoprostol and mifepristone are safe, non-invasive and cheaper alternatives to D&C. Complications Complications may arise from either the introduction or spreading of infection, adverse reaction to general anesthesia required during the surgery or from instrumentation itself, if the procedure is performed blindly (without the use of any imaging technique such as ultrasound or hysteroscopy). One risk of sharp curettage is uterine perforation. Although normally no treatment is required for uterine perforation, a laparoscopy may be done to verify that bleeding has stopped on its own. Infection of the uterus or fallopian tubes is also a possible complication, especially if the woman has an untreated sexually transmitted infection. Another risk is intrauterine adhesions, or Asherman's syndrome. One study found that in women who had one or two sharp curettage procedures for miscarriage, 14-16% developed some adhesions. Women who underwent three sharp curettage procedures for miscarriage had a 32% risk of developing adhesions. The risk of Asherman's syndrome was found to be 30.9% in women who had D&C following a missed miscarriage, and 25% in those who had a D&C 1–4 weeks postpartum. Untreated Asherman's syndrome, especially if severe, also increases the risk of complications in future pregnancies, such as ectopic pregnancy, miscarriage, and abnormal placentation (e.g.placenta previa and placenta accreta). According to recent case reports, use of vacuum aspiration can also lead to intrauterine adhesions. 24.Transverse lie. Internal version Definition At the end of pregnancy or during of labor, champ of pelvic inlet is not fetal head or fetal breech Variety shoulder right in dorso-anterior shoulder left in dorso-anterior shoulder right in dorso-posterior shoulder left in dorso-posterior Etiology Mistake of accommodation: the grand cause of transverse position is multipara (relax of uterine wall) Other cause can hydramnios, previa tumor, shortness umbilical cord Uterine malformation Internal Version (is an obstetric procedure wherein the fetus is turned within the uterus such that one or both feet present through the cervix during childbirth. It is used most often in cases where the fetus in transverse lie or in another abnormal position in the uterus) the foot is grasped and pulled gently and continuously into the birth canal Indicaations: intrauterine to transfere the transverse lie to breech only in twin delivery in cephalic presentation multipara with small baby conditions for internal version: membrane must be intact full dilatation of the cervix 16 normal maternal bony pelvis a live fetus general anesthesia for uterine relaxation Causes of transverse: multipara polyhydramnios short cord 25.Fetal extraction ??? 26.Caesarian section Cesarean section is delivery of a viable fetus through an abdominal incision (laparotomy) and uterine incision (hysterotomy). Indications Contraindications to labor Placenta previa Vasa previa Previous classic cesarean section Previous myomectomy with entrance into the uterine cavity Previous uterine reconstruction Malpresentations of the fetus Active genital herpes infection Dystocia and failed induction of labor Cephalopelvic disproportion, failure to descend, or arrest of descent or dilation Failure to progress in normal-size infant, usually because of fetal malposition or posture Failed forceps or vacuum extractor delivery Certain fetal malformations that may obstruct labor (i.e.,large hydrocephalus,sacrococ-cygeal tumor) Emergent conditions that warrant immediate delivery Abruptio placentae with antepartum or intrapartum hemorrhage Umbilical cord prolapsed Nonreassuring antepartum or intrapartum fetal testing Intrapartum fetal acidemia, with intrapartum scalp pH of less than 7.20 Uterine rupture Impending maternal death Types of cesarean operations Cesarean operations are classified according to the orientation (transverse or vertical) and the site of placement (lower segment or upper segment) of the uterine incision. Low transverse (Kerr). The low transverse uterine incision is the preferred incision and the one most frequently used today. Low vertical (Sellheim). The vertical incision begins in the noncontractile lower segment but usually extends into the contractile upper segment. Classic incision (Sanger). The classic incision is a longitudinal incision in the anterior fundus. Procedure Anesthesia. Most often, anesthesia is regional (spinal or epidural), but it can be inhalational (general) as dictated by the individual situation. Surgical techniques Abdominal incision The abdominal incision maybe midline, paramedian, or Pfannenstiel. Uterine incision 17 The pregnant uterus is palpated and inspected for rotation. The type of uterine incision is selected depending on development of the lower uterine segment, presentation of the infant, and placental location. Complications Common postoperative complications include the following conditions: Endomyometritis. Postoperative infection is the most common complication after cesarean section. Urinary tract infection Wound infection Thromboembolic disorders Cesarean hysterectomy Uterine rupture in future pregnancies 27.Postpartum period in caesarian section - Considerations. The risks of a vaginal birth after cesarean section, when performed in the proper setting, are less than the risks of a repeat cesarean section. A previous vaginal delivery is the best prognostic indicator for success. Women with nonrecurring indications (e.g., breech presentation, fetal distress, or hemorrhage) have higher success rates than women with recurring indications (e.g., previous cephalopelvic disproportion or failure to progress) Prerequisites No maternal or fetal contraindications to labor Previous low transverse cesarean section, with documentation of the uterine scar Informed consent regarding risks and benefits of repeat cesarean and vaginal birth Personnel able to perform emergency delivery and appropriate facility Contraindications. The risk of vaginal birth after cesarean section in multiple gestations and breech presentations has not been determined. Previous classic uterine incision Maternal or fetal contraindications to labor Trial of labor declined by mother Previous low vertical scar, unless absence of upper segment extension is well documented History of more than two prior cesarean sections Extra informations: As more than 30% of deliveries are now by cesarean, wound care and pain management in these women are a common component of postpartum care. Local wound care and observation for signs of wound infection or separation are part of routine care. Wound infections include cellulitis or a wound abscess. Wound separations can be at the level of the skin or subcutaneous tissue or deeper at the level of the rectus fascia known as a wound dehiscence. Pain is usually managed with opioids that can contribute to a postoperative ileus or constipation. Patients on opioids should therefore be prescribed stool softeners and occasionally laxatives. NSAIDs should be used concomitantly for the cramping pain caused by uterine involution. Patients have usually received a first- or second generation cephalosporin during the cesarean section as prophylaxis against infection. Although it is routine in many institutions to give additional dosages, this has never been shown to further decrease the risk of infection. 28.Forceps application These are metal instruments used to provide traction , rotation , or both to the fetal head. Simpson: used for traction only Kjelland : used for head rotation and traction Piper : used for the after – coming head of a vaginal breech baby 18 Barton : used to deliver the head in occiput transverse position with a platypelloid pelvis Indication Prolonged second stage : may be because of dysfunctional labor, this is the most indication for forceps Avoid the maternal pushing : like in cardiac , pulmonary or neurologic disorders Breech presentation: shorten time to deliver the head of a vaginal breech fetus. Prerequisites Clinically adequate pelvic dimensions Experienced operator Full cervical dilation Engaged fetal head Orientation of fetal head is certain Complication Maternal : lacerations to the vagina , cervix , perineum and uterus Fetal- neonatal : soft tissue injury caused bu incorrectly placed forceps blades 29.Normal puerperium This period of 4 to 6 weeks starts immediately after delivery and ends when the reproductive tract has returned to its nonpregnant condition. Involution of the uterus. The uterus regains its usual nonpregnant size within 5 to 6 weeks, shrinking from 1000 g immediately postpartum to 100 g. Breastfeeding accelerates involution of the uterus because stimulation of the nipples releases oxytocin from the neurohypophysis; the resulting contractions of the myometrium facilitate the involution of the uterus. Involutional changes of the renal system. The puerperal bladder has an increased capacity and a relative insensitivity to intravesical fluid pressure. Anatomic changes, such as the dilation of the calyces, renal pelvis, and ureters, that are characteristic of pregnancy may persist as long as 8 weeks postpartum. Cardiovascular changes. The changes that occurred during pregnancy (e.g., increases in heart rate, cardiac output, and blood volume) generally return to baseline by approximately 6 weeks postpartum Blood. A marked leukocytosis occurs during and after labor. Ovulation and menstruation Nonlactating women. The first menstrual flow usually returns within 6 to 8 weeks after delivery, with ovulation occurring at 2 to 4 weeks postpartum. Lactating women. Ovulation is much less frequent in women who breast feed compared with those who do not. The first menstrual flow may occur as early as the second month or as late as the 18th month after delivery. Amenorrhea during lactation is due to a lack of appropriate ovarian stimulation by pituitary gonadotropins. 30.Pathological puerperium The most common complications include hemorrhage, genital tract infections, urinary tract infections, and mastitis. Postpartum hemorrhage is defined as a blood loss in excess of 500 mL during the first 24 hours after delivery. Causes Failure of compression of blood vessels at the implantation site of the placenta because of: An atonic uterus due to general anesthesia; overdistension of the uterus from a large fetus, hydramnios (excess amniotic fluid), or multiple fetuses; prolonged labor; very rapid labor; high parity; or a 19 labor vigorously stimulated with oxytocin. The most common cause of postpartum hemorrhage is uterine atony. Retention of placental tissue, as seen in placenta accreta, a succenturiate placental lobe, or a fragmented placenta Trauma to the genital tract because of: Episiotomy Lacerations of the cervix, vagina, or perineum Rupture of the uterus Coagulation defects,as seen in hypofibrinogenemia or thrombocytopenia Management should be directed at the underlying cause(s) Vigorous massage of the uterine fundus for uterine atony Use of uterine contracting agents for uterine atony Oxytocin Prostaglandin Methylergonovine Manual exploration of the uterine cavity for retained placental fragments or uterine rupture Inspection of the cervix and vagina for lacerations Curettage of the uterine cavity Hypogastric artery ligation; embolization of the uterine vessels; and, rarely, hysterectomy Puerperal infection is defined as any infection of the genitourinary tract during the puerperium accompanied by a temperature of 38 c or higher that occurs for at least 2 of the first 10 days postpartum, exclusive of the first 24 hours. Prolonged rupture of the membranes accompanied by multiple vaginal examinations during labor is a major predisposing cause of puerperal infection. Pelvic infections Endometritis (childbed fever), the most common form of puerperal infection, involves primarily the endometrium and the adjacent myometrium. Parametritis, infection of the retroperitoneal fibroareolar pelvic connective tissue Thrombophlebitis results from an extension of puerperal infection along pelvic veins. Urinary tract infections are common during the puerperium because of: Trauma to the bladder from a normal vaginal delivery A hypotonic bladder from conduction anesthesia Catheterization. Management Antibiotics should be administered. Broad-spectrum antibiotics, which include anaerobic coverage, are recommended for those pelvic infections in which identification of the offending organism is impossible. 31.Cardinal symptoms in gynecology: pain Pain 1. Spontaneous acute pain a. without fever: In case of acute pain in pelvis without pain in a young women who had a normal menstrual cycle (without abnormalities) the doctor think first about a rupture because of an ectopic pregnancy it can also be acute torsion or an ovarian cyste. b. with fever: Pelvic pain with fever we think first about salpingite (appendicite can also be evocated). 2. Intermenstruel syndrome: (in the middle of the cycle) Pelvic pain irradiate to the vulva and vagina ; sometimes to the lower back and all the abdomen can be associated with nausea and vomiting ;with leukorrhea and vaginal bleeding. 20 Occure usualy in the ovulation periode between 12and 16 days it can last from few hours till 48 hours. 3. Dyspareunia Pain wich occure in sexual act in womens it can be superficiel or deep with the penetration it can be primary (the first act)or secondary(in all the sexual acts) It can be caused about: Vaginal infections :mycoses; herpes;tricomonas vaginalis… malformations ;hormonal deficiencies endometriosis vaginal dryness (decresing of oestrogene in premenaupose) And it can be psychiatrique desease the treatment is related with the pathologie. 4. Vaginismus The vaginismus is a involontary contracture wich is spasmodic of the musculature of the vulva and the perineum it occurs during the penetration in the vagina and stop it or make it very painfull.we call it primary if occurs in the first sexual act or secondary if its appear after a period of time of normal sexual acts. No gynocological exam is possibl . Sometimes the etiologie is organic: local erosions vulvovaginitis menopause herpes or eczema of the vulva hemorroidaire anal fissure or no. But In the most of the cases its psychological desease. 32.Cardinal symptoms in gynecology: bleeding Bleeding an abnormal condition in which blood is passed from the vagina other than during the menses or abnormality in menses. It may be caused by abnormalities of the uterus or cervix, an abnormal pregnancy, endocrine abnormalities, abnormalities of one or both ovaries or one or both fallopian tubes, or an abnormality of the vagina. Abnormal Uterine Bleeding Defined as alteration of normal flow Dysfunctional uterine bleeding (DUB) is most common cause of abnormal uterine bleeding prior to menopause Heavy, prolonged or inter-menstrual Terms used in abnormality menses Menorrhagia: excess menstrual bleeding Hypomenorrhea: decreased menstrual bleeding Polymenorrhea: increased frequency of menstruation Metrorrhagia: uterine bleeding in between menstruation Etiology Organic: coagulopathies, liver/renal disease, drugs (steroids, chemo & Coumadin), obesity and endocrine abnormalities (thyroid, diabetes & adrenal) Uterine: leiomyomas, polyps, endometrial hyperplasia, PID, IUD, pregnancy, cancers & endocrine active tumors Non organic: persistent ovulatory failure, the most common cause is the continuous acyclic estrogen production leading to anovulation and endometrial proliferation DUB is the most common cause of bleeding in adolescent & young adults Dysfunctional Uterine Bleeding Pathology is excluded Most patient anovulatory May be related to hypothalamic-pituitary axis resulting in continued estrogenic stimulation of the endometrium 21 The endometrium outgrows its blood supply partially breaks down bleeding occurs in irregular manner Organic causes (thyroid, adrenal must be excluded) Diagnosis - based on: history absence of ovulatory temperature changes low serum progesterone result of endometrial sampling in the older woman Post Menopausal Bleeding always abnormal and is Cancer until proven otherwise requires a Definitive Diagnosis and if chronic, re-evaluate Every Year Diagnosis History: Previous customary cycles, episode of irregular bleeding, heavy bleeding Exam: Pelvic for possible sites of internal bleeding (vaginal / rectal), uterine or adnexal enlargement Endometrial biopsy may be required Possible D&C and hysteroscopy may be helpful. 33.Cardinal symptoms in gynecology: amenorrhea Defined as failure of menarche by age 16 regardless of development or the absence of menstruation for 3-6 months after menarche Two different types: primary & secondary Primary Amenorrhea Failure of development by 14 years of age Failure of menses by 16 years of age regardless of development Secondary to chromosomal (Turners 45XO) genital agenesis/congenital abnormalities (absent vagina or imperforated hymen), failure of pituitaryovarian axis Secondary Amenorrhea Failure to menstruate for 3-6 months or 3 cycles after menarche Ovarian failure most common i.e.: menopause, but can be premature Outflow tract obstruction Etiology: Causes divided into ovulatory and anovulatory Ovulatory: results from anatomic genital abnormalities with normal hormonal function Reproductive Outflow Disorders: Mullerian agenesis - absence of either vagina or uterus Imperforated hymen Vaginal and uterine aplasia Cervical stenosis Intra-uterine adhesions (Asherman’s syndrome naturally or surgical etiology) Anovulatory: in which both ovulation and menses are absent (is most common) Ovarian Disorders: Chronic anovulation/ Autoimmune disorders/Gonadal dysgenesis/Premature ovarian failure Pituitary Disorders: Hyperprolactinemia/ Various tumors/ Pituitary insufficiency Hypothalamic Disorders: Functional- Exercise, stress anorexia/ obesity/ Neoplastic lesions Diagnosis Exam: Neuro for possible intracranial lesions, Pelvic (limited external in adolescent)Secondary sex characteristics pregnancy testing (hCG) / measurement of hormone levels {Prolactin,TFT (T3/T4/TSH) ,LH/FSH, Estrogen/progesterone} 22 progesterone challenge: - If bleeding occurs, the cause is chronic anovulatory or oligo-ovulatory -If no withdrawal bleeding, the cause is either a low estrogen state of anatomic Treatment Aims to correct any underlying disorder and minimize excess androgenic effects Depends on the basic cause Goal to induce menstrual flow 3-4 /year Surgical - for any lesion/tumors/defects 80-90% of CNS or pituitary tumors will need resection Absent genital: cosmetic surgery, but will never be functional Pharmacological - wide range usually long term Hypothalamic disorder - behavior or lifestyle changes Treat any hypothyroid and hyperprolactinimia with surgery &/or Parlodel. 34.Cardinal symptoms in gynecology: vaginal discharge Vaginal discharge is a fluid produced by glands in the vaginal wall and cervix that drains from the opening of the vagina. The amount and appearance of normal vaginal discharge varies throughout the menstrual cycle. An increase in the amount of vaginal discharge, an abnormal odor, colour, consistency of the fluid, or pain that accompanies vaginal discharge can all be signs of infection or other disorders. The normal pH in vaginal secretions is usually <4.5 Examples Thrush (Yeast Infection): the most common non-sexual acquired infection, usually caused by candida species, gives a thick, white, lumpy discharge,that looks like cheese. often associated with marked vulval itching. Bacterial Vaginosis: usually caused by Gardnerella vaginalis,produces a watery,fishysmelling discharge.pH >5 Trichomoniasis: causes a vaginal discharge that is yellow-green, foamy, and bad smelling Diagnosis Speculum examination Vaginal culture for bacterial or candidiasis Gram stain to determine the relative concentration of lactobacilli The affirm test -> to detect the bacteria ‘trichomonal vaginitis’ Testing of vaginal fluid for pH, odor Treatment Antibiotics: Metronidazole, usually for 7 days. 35.Cervical and endometrial neoplasm – screening, HPV-CIN, Pap smear Pap Smear is a screening test used for the detection and diagnosis of various infections, abnormal hormonal activities, and pre-cancerous and cancerous processes in the endocervical canal. Characteristics: It is an excellent test, but not perfect in preventing cervical carcinoma detect treatable premalignant lesions not a good test for glandular lesions, which are the most common form of uterine cancer In taking a Pap smear, a speculum is used to open the vaginal canal and allow the collection of cells with a plastic spatula and small brush from the outer opening of the cervix of the uterus and the endocervix. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by sexually transmitted human papillomaviruses. The test may also detect infections and abnormalities in the endocervix and endometrium. 23 Conditions for conducting Avoid sexual intercourse 24 hours before sampling takes place outside the period, outside local infection and preferably in the mid-cycle speculum is inserted without lubricant or disinfectant Material: Spatula, small brush, glass slides fixative - alcohol-ether in equal or spray Abnormal Results: include: Squamous cell abnormalities (SIL) Atypical squamous cells of undetermined significance Low-grade squamous intraepithelial lesion Atypical squamous cells High-grade squamous intraepithelial lesion Squamous cell carcinoma Glandular epithelial cell abnormalities Atypical Glandular Cells not otherwise specified Endocervical and endometrial abnormalities can also be detected, as can a number of infectious processes, including yeast, herpes simplex virus and trichomoniasis. However it is not very sensitive at detecting these infections, so absence of detection on a Pap does not mean absence of the infection. Classification of Pap Class I- absence of abnormal or atypical cells Class II-a - atypical cytology but no evidence for malignancy Class III-a - cytology suggestive but inconclusive for malignancy Class IV-a - cytology strongly suggestive for malignancy Class V-a - cytology conclusive for malignancy 36.Vaginal smear Vaginal Smear (Wet Mount) Smear taken from the vaginal mucosa for cytological analysis It is used to find the cause of vaginitis or vulvitis Indications May be considered in case of vaginitis symptoms such as: vaginal itching, burning, rash, odor, or discharge It may assist in suspicion of vaginal yeast infection, trichomoniosis, and bacterial vaginosis Method Is not done during menstrual period, because menstrual blood can affect the results Vaginal irrigation, tampon use or sex (disrupting the pH) should be avoided for 24 hours before the test Antibiotics treatment is not administered at least 8 days before. The sampling is done with the patient in lithotomy position. A speculum is used to facilitate use of a swab or spatula to sample fluid inside the vagina. The sampling procedure may cause some discomfort and minor bleeding, but otherwise there are no associated risks. The sample is then smeared upon a microscope slide and is observed by wet mount microscopy by placing the specimen on a glass slide and mixing with a salt solution. 37.Colposcopy is a medical diagnostic procedure to examine an lighted, magnified view of the cervix and the tissues of the vagina and vulva. It is done using a colposcope, which provides an enlarged view of the areas, allowing the physician to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. 24 The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them. EXTRA: is a binocular operating microscope with magnification of between 5- and 20 times. It has been used to examine the cervix in details to identify CIN and pre-clinical invasive cancer. Indications Most patients undergo a colposcopic examination to further investigate a cytological abnormality on their pap smears. Other indications for a patient to have a colposcopy include: assessment of diethylstilbestrol (DES) exposure in utero, immunosuppression such as HIV infection, or an organ transplant patient an abnormal appearance of the cervix as noted by a primary care provider as a part of a sexual assault forensic examination done by a Sexual Assault Nurse Examiner Procedure Colposcopy is performed with the patient in dorsal lithotomy position. A speculum is placed in the vagina after the vulva is examined for any suspicious lesions. The cervix is first examined for abnormal vessel patterns known to be associated with premalignant and malignant lesions of the cervix. To assist in the identification of abnormal vessels, the cervix may be washed with normal saline and may be viewed through a green filter, which highlights the blood vessels as black lines. 3 to 5% acitic acid to the area highlight CIN as white compaired with the pink of the squamous epithelium Colposcopic direct biopsy will be taken from the most abnormal areas of the epithelium to confirm the Diagnosis Lahm-schiller test will be used and biopsy for the suspected areas Following any biopsies, an endocervical curettage (ECC) is often done. Complications Significant complications from a colposcopy are not common, but may include bleeding, infection at the biopsy site or endometrium, and failure to identify the lesion. 38.Lahm-schiller test is a medical test in which iodine solution is applied to the cervix in order to diagnose cervical cancer (squamous cell carcinoma). Lugol's iodine solution is applied to the cervix under direct vision. Stratified squamous epithelial cells are rich in glycogen and stained by iodine fixation in brown, whereas abnormal areas, such as early cervical cancer, do not take up the stain, and appearing as white areas with net margins - Iodine negative areas. Lahm-Schiller's test is not specific for cervical cancer, other iodine-negative areas include: ectopia, erosions, ulcers, dysplasia, areas of inflammation, neoplasms. The abnormal areas can then be biopsied and examined histologically. 39.Biopsy Biopsy is the procedure to collect a sampling of tissue for histopatholgical examination and diagnosis Vulvar Biopsy Is done in order to collect tissue from the suspected lesions, i.e: infectious origin, dystrophic or neoplastic at the vulva. Biopsy is performed under local anesthesia with lidocaine 1%. Using forceps biopsy Selected fragment is cut with a scalpel Haemostasis is achieved by applying a silver nitrate pencil, termocoagulare or often by applying suture. 25 Vaginal Biopsy It is achieved by selecting a biopsy forceps fragment from vaginal lesion and cut it with knife. The maneuver often requires local anesthesia with lidocaine 1% and followed with hemostasis. Suspicion of cancer (squamous cell carcinoma, adenocarcinoma) Cervical Biopsy a sample from the cervix is collected and analyzed by histopathology. If suspicious lesions invisible to the naked eye indicates taking colposcopic control after application of acetic acid and Lugol's solution (Lahm-schiller test) Cervical conization refers to a biopsy of the cervix in which a cone-shaped sample of tissue is removed from the mucous membrane. Conization may be used either for diagnostic purposes, or for therapeutic purposes to remove pre-cancerous cells. Conization of the cervix is a common treatment for dysplasia following abnormal results from a pap smear. Side effects of the treatment may include cervical stenosis with a resulting severe endometriosis Endometrial Biopsy a small sample is collected from the lining of the uterus using dilation and curettage D&C, then collect a small sample with a syringe or suction. The test is done to find the cause of: Abnormal menstrual periods (heavy, prolonged, or irregular bleeding) Bleeding after menopause Bleeding from taking hormone therapy medications Thickened uterine lining seen on ultrasound Abnormal pap test The test is usually done in women over age 35. Abnormal results can be: Endometrial cancer or precancer (hyperplasia) Uterine fibroids, Uterine polyps, Infection, Hormone imbalance Complications Infection / Making a hole in (perforating) the uterus or tearing the cervix (rarely) Prolonged bleeding / Slight spotting and mild cramping for a few days. 40.Bioptic curettage It is a painless and easy routine screening of the endometrium avoiding dilation and traction of the uterus neck It can be performed on the cervix and uterus with the help of anesthetic general or local Uses: miscarriage, menstrual irregularities and biopsies Endometrial biopsy by aspiration without dilation This method of endometrial sampling easier and less painful than curettage of the uterine cavity prior to expansion Indication detection of malignancy or endometrial hyperplasia follow up patients on hormone therapy for endometrial hyperplasia diagnosis of luteal failure development of endometrial tissue cultures Contraindications: Inflammation of the cervix or uterus Endocervical curettage Indication 26 for determining the extent of endocervical CIN diagnosis of endocervical polyps, glandular hyperplasia, a chronic endocervical diagnosis of endocervical glandular dysplasia, CIS, or invasive carcinoma setting behavior therapy in women with cervical dysplasia Contraindications: in pregnant women Fractional uterine curettage Is a useful diagnostic and therapeutic method, frequently used in gynecology. The main purpose of fractional uterine curettage is obtaining endometrial tissue for diagnostic and histopathological endocol Indication unusual bleeding or abnormal uterine origin whose causes were not detected by routine examinations removing debris and placental ovulare for incomplete abortion before a hysterectomy for a benign condition in order to exclude the coexistence of malignancy microscopic examination of the endometrium is useful for retrospective diagnosis of ovulation. 41.Hysterometry Hysterometry is a maneuver that measures the length of the uterine cavity and cervical canal Can be done in certain conditions: is made only in the first cycle, in the absence of local infection and pregnancy first practice vaginally cough for determining the uterus position Hysterometry is used in cm (Meigs), which has a concave curvature of the gradient. The maneuver involves disinfection of the cervix and vagina with an antiseptic solution Procedure Upper lip of the cervix is caught with Pozzi forceps and traction exert a slight decrease for anteflexed uterus. The Hysterometry is inserted into the vagina and into the cervical canal with a slight push motion without force. Introducing of the Hysterometry should not be either painful or difficult. Normal uterine cavity total length is 70-75 mm in nulliparous and 75-80 mm in multiparous. If hysterometry cannot enter the uterine cavity, the following are taken into account: a poor technique, an abnormality of the cervix, or a spasm at this level. 42.Hysterosalpingography Hysterosalpingography is an x-ray of the uterus and fallopian tubes that involves the injection of contrast (dye) through the cervix. Uses: to see the structure of the uterus and fallopian tubes and to determine if there is any blockage or other problems, it’s usually as a part of infertility examination Abnormal results may indicate any of the following: Developmental disorders of the structures of the uterus or fallopian tubes Intrauterine adhesion Obstruction of the fallopian tubes Presence of foreign bodies Scarring Tubal adhesions Uterine tumors or polyps Risks allergic reaction infection like endometritis and salpingitis perforation of the uterus 27 Contraindicated vaginal bleeding pelvic inflammatory diseases (PID) 43.Ultrasound in gynecology Ultrasound of the uterus In longitudinal section the uterus is a pear-shaped mass with greater upper extremity, echogenic, homogeneous, with regular contours. In cross section appears as a more oval uterus, myometrium is homogeneous, poorly echogenic, and measures typically 2-3 cm. The endometrium is poorly visible in the first week after menstruation, then appearing as a low echogenic band that thickens progressively up to menstruation. Uterine cavity, usually virtual, are viewed as a fine linear echoes the union of the two girls endometrial. Pathological changes of the uterus can be confirmed by echocardiography. malformation, endometrial polyp, endometrial cancer Uterine fibroids less echogenic than the myometrium, are easily detected and measured, especially subserosal and earlier. Endometrial hyperplasia translates into an area of endometrial thickening. Intrauterine collections are viewed as a hypoecogenic areas in the uterine cavity. Intrauterine pregnancy is confirmed by the presence of ovular sac surrounded by an echo trophoblastic, and an embryo, after 6 weeks of amenorrhea abdominal and after 5 weeks of amenorrhea intravaginal probe. Ultrasound of the ovaries Ovaries, most commonly latero-uterine, measuring 25-35 mm in length and 12-20 mm thick. Ovarian pathology that can be appreciated at ultrasound is represented by serous cysts, mucous, dermoid tumor or cancer. Fallopian tubes, which normally can’t be clear in ultrasound, they may be pathological cases such as: tubal pregnancy, hydrosalpinx, hematosalpinx, pyosalpinx. Indication of Ultrasound suspected intrauterine pregnancy; suspicion of ectopic pregnancy; differential diagnosis between uterine fibroids and an ovarian pathology; indication of organic or functional origin of adnexal masses; specifying the structure of a liquid or solid tumor examination of obese patients, which is inconclusive vaginal cough; monitoring of ovulation induction treatment 44.Uterine curettage Dilation and curettage (D&C) is a brief surgical procedure in which the cervix is dilated and a special instrument is used to scrape the uterine lining. Reasons for Dilation and Curettage Remove tissue in the uterus during or after a miscarriage or abortion or to remove small pieces of placenta after childbirth. This helps prevent infection or heavy bleeding. Diagnose or treat abnormal uterine bleeding. A D&C may help diagnose or treat growths such as fibroids, polyps or endometriosis, hormonal imbalances, oruterine cancer. A sample of uterine tissue is viewed under a microscope to check for abnormal cells. 28 After a D&C, there are possible side effects and risks. Common side effects include: Cramping Spotting or light bleeding perforation 45.Termination of pregnancy - voluntary or therapeutic Therapeutic abortion is the intentional termination of a pregnancy before the fetus can live independently An abortion may be performed whenever there is some compelling reason to end a pregnancy. Women have abortions because continuing the pregnancy would cause them hardship, endanger their life or health, or because prenatal testing has shown that the fetus will be born with severe abnormalities. Abortions are safest when performed within the first 6 to 10 weeks after the last menstrual period. Complications from abortions can include: uncontrolled bleeding infection blood clots accumulating in the uterus a tear in the cervix or uterus missed abortion where the pregnancy continues incomplete abortion where some material from the pregnancy remains in the uterus. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Cervical screening is a way of preventing cervical cancer from developing, and diagnosing the disease at an early precancerous stage. In the USA, cervical screening is usually performed using the Pap test (or 'smear test'), The Papanicolaou test (also called Pap smear, Pap test, cervical smear, or smear test) is a method of cervical screening used to detect potentially pre-cancerous and cancerous processes in the endocervical canal (transformation zone) of the female reproductive system. Unusual findings are often followed up by more sensitive diagnostic procedures, and, if warranted, interventions that aim to prevent progression to cervical cancer. The test was invented by and named after the prominent Greek doctor Georgios Papanikolaou. In taking a Pap smear, a speculum is used to open the vaginal canal and allow the collection of cells from the outer opening of the cervix of the uterus and the endocervix. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by sexually transmitted human papillomaviruses. The test remains an effective, widely used method for early detection of pre-cancer and cervical cancer. The test may also detect infections and abnormalities in the endocervix and endometrium. In general, in countries where Pap smear screening is routine, it is recommended that females who have had sex seek regular Pap smear testing. Guidelines on frequency vary from every three to five years. If results are abnormal, and depending on the nature of the abnormality, the test may need to be repeated in six to twelve months.[4] If the abnormality requires closer scrutiny, the patient may be referred for detailed inspection of the cervix by colposcopy. The patient may also be referred for HPV DNA testing, which can serve as an adjunct to Pap testing. Additional biomarkers which may be applied as ancillary test with Pap test are evolving. Human papillomavirus (HPV) is a DNA virus from the papillomavirus family that is capable of infecting humans. Like all papillomaviruses, HPVs establish productive infections only in keratinocytes of the skin or mucous membranes. While the majority of the known types of HPV cause no symptoms in most people, some types can cause benign papillomas (such as warts [verrucae] or squamous cell papilloma), while others can in a minority of cases lead to cancers of the cervix, vulva, vagina, penis, oropharynx and anus. HPV has been linked with an increased risk of cardiovascular disease. In addition, HPV 16 and 18 infections are a cause of a unique type of oropharyngeal (throat) cancer. More than 30 to 40 types of HPV are typically transmitted through sexual contact and infect the anogenital region. Some sexually transmitted HPV types may cause genital warts. Persistent infection with "high-risk" HPV types different from the ones that cause skin warts may progress to precancerous lesions and invasive cancer. HPV infection is a cause of nearly all cases of cervical cancer. However, most infections do not cause disease. Most HPV infections in young women are temporary and have little long-term significance. Seventy percent of infections are gone in one year and ninety percent in two years. However, when the infection persists in 5% to 10% of infected women there is high risk of developing precancerous lesions of the cervix, which can progress to invasive cervical cancer. This process usually takes 10–15 years, providing many opportunities for detection and treatment of the 29 pre-cancerous lesion. Progression to invasive cancer can be almost always prevented when standard prevention strategies are applied, but the lesions still cause considerable burden necessitating preventive surgeries, which do in many cases involve loss of fertility. In more developed countries, cervical screening using a Papanicolaou (Pap) test or liquid-based cytology is used to detect abnormal cells that may develop into cancer. If abnormal cells are found, women are invited to have a colposcopy. During a colposcopic inspection, biopsies can be taken and abnormal areas can be removed with a simple procedure, typically with a cauterizing loop or, more commonly in the developing world by freezing (cryotherapy). Treating abnormal cells in this way can prevent them from developing into cervical cancer. Pap smears have reduced the incidence and fatalities of cervical cancer in the developed world, but even so there were 11,000 cases and 3,900 deaths in the U.S. in 2008. Cervical cancer has substantial mortality in resource-poor areas; worldwide, there are an estimated 490,000 cases and 270,000 deaths each year. HPV vaccines (Cervarix and Gardasil), which prevent infection with the HPV types (16 and 18) that cause 70% of cervical cancer, may lead to further decreases. http://drddp.wordpress.com/ 30