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Practical Exam
Table of contents
1. History taking in gynecology and obstetrics ........................................................................................ 2
2. Antenatal care – obstetric examination, care schedule, obstetric examination record ..................... 6
3. Prenatal screening tests: non-invasive and invasive ......................................................................... 12
4. Vaginal delivery and labor – initial examination, mother and fetal monitoring, partogram use ..... 27
5. Cardiotocography, ST analysis ........................................................................................................... 43
6. Surgeries and instruments in pregnancy - evacuation of the uterus, surgical abortion ................... 49
7. Surgeries and instruments during labor - forceps, VEX, placenta manual extraction, analgesia ..... 55
8. Pelvic examination in gynecology ..................................................................................................... 65
9. Examination for genital infections, vaginal discharge, infections of the vulva and vagina ............... 71
10. Urogynecology examination, surgeries in urogynecology .............................................................. 74
11. Investigation of the infertile couple, treatment plan, semen analysis ........................................... 85
12. Pediatric gynecology examination, pubertal development, vaginal smear test ............................. 90
13. Gynecologic oncology - ultrasound, clinical staging, breast cancer imaging .................................. 96
14. Pelvic ultrasound in gynecology .................................................................................................... 106
15. Ultrasound scans in pregnancy, dopplerometry ........................................................................... 114
16. Cervical and vaginal cytology, HPV testing and vaccination ......................................................... 127
17. Colposcopy .................................................................................................................................... 131
18. Small gynecological surgeries and instruments - excision, biopsy, endometrial ablation,
hysteroscopy ....................................................................................................................................... 138
19. Laparoscopic gynecological surgeries and instruments ................................................................ 143
20. Abdominal gynecological surgeries and instruments ................................................................... 150
1
1. History taking in gynecology and
obstetrics
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record of all information about person´s health
it is important try to get all and also true information, you should systematically ask question
to get them all
Personal information
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age, family status, number of children, occupation
Why do you need to know?
o age: helps in differential diagnosis (some illnesses typically occur in particular age),
maternal age affect pregnancy, it could affect therapeutic strategy (e.g. preservingfertility therapy in cancer treatment)
o number of children (for example nulliparity is risk factor for some kind of cancer,
multiparity is risk factor for pelvic floor disorders etc.)
o marital status (social status, psychosocial background)
o occupation and employment status(high-risk/low-risk jobs, physical and psychical
stress)
Family history
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which family members?
o parents, grandparents, siblings, children (+father of child in obstetrics)
which illnesses?
o all sever (and relevant),
o e.g. cancer (especial breast cancer and ovarian cancer), congenital disorders,
o diabetes mellitus, cardiovascular diseases, trombophilias,
Why do you need to know?
o some diseases are hereditary (e.g. BRCA gen predisposition)
o some diseases are more common in family
o g. thrombophilia in family could be risk-factor for pregnant patient, because
pregnancy itself cause hypercoagulable state (you can for example recommend
follow-up by haematologist or genetic testing for specific thrombofilic mutations)
Medical history
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all relevant information about patient´s health history and chronical diseases
chronical diseases, trombophilias, cardiovascular diseases (hypertension, stroke, venous
insufficiency, chronic heart failure etc.), liver diseases, kidney diseases, neurological diseases
(epilepsy, sclerosis multiplex), psychiatric diseases…
pregnant patients:
o sometimes you need other specialist´s recommendation for labour
(haemathologiacal treatment during and after labour, contraindication of vaginal
birth etc.)
2
o
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you should ask if any disease had occurred during pregnancy (hypertension, diabetes
mellitus, urinary tract infection etc.)
prescribed medications (with dosage)
surgeries (especially abdominal and gynaecological), you should also find out whether there
were any complications, in case of previous abdominal or pelvic surgeries you should know,
that there is higher risk of adhesions (laparotomy vs laparoscopy? surgeon team?)
accidents all severe accidents especially those which requires surgical treatment or
hospitalisation
allergies: substance and also type of allergic reaction should be recorded (CAVE! common
drug allergies includes antibiotics and disinfection!)
blood transfusion: Where? When? Why? Any complication?
smoking, alcohol, drug abuse
Physiological function
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continence, nycturia, polakisuria, dysuria
Gynaecological history
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menarche
(menopause) + hormonal replacement therapy(when? for how long? which type?
complications)
date and certainty of last menstrual period
length and regularity of menstrual cycle (28/5 means 28 for length of cycle and 5 for length
of menstruation), dysmenorrhoea symptoms
you should ask if any intermenstrual bleeding or spotting had occurred
obstetrical history (look below)
contraception use (when? for how long? which type? complications?/intrauterine device
(when? for how long? complications?)
mammography (screening is recommended for all women older than 45, each two years)
oncological cytology screening (date and result)
HPV vaccination (type of vaccine)
name of general (ambulant) gynaecologist = registrující gynekolog (In the Czech republic
there are ambulant gynaecologists, it is recommended for all women to be registered at
someone´s)
3
Gravidimeter
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Why do you need to know?
o Last period (first day of the last period)
▪ You need to know in which phase of menstrual cycle the patient probably is.
There are illness and conditions typical for each phase of menstrual cycle.
Such as intermenstrual bleeding could mean inadequate hormonal secretion.
Amenorrhea could point to early pregnancy (you should always consider
pregnancy and pregnancy-associated conditions if the patient is in fertile age
(12-55)
▪ The first day of last period is the first way to estimate the expected day of
delivery, you can use Naegele's rule (the result is approximately 280 days (40
weeks) from the start of the last menstrual period), this method is not
accurate, estimated date of delivery (EDD) should be based on ultrasound
examination in first trimester (you can use calculation in case of unobserved
pregnancies etc.)
o Gynaecological illnesses and surgeries (conisation of the cervix, cervical dysplasia
history, inflammatory disease, past surgeries, caesarean section…)
▪ conisation is risk factor for cervical insufficiency (higher risk of preterm birth)
▪ in case of previous uterine surgeries (myomectomy, caesarean section…)
there is higher risk of uterine rupture during pregnancy and during the
labour
4
Obstetric history
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previous obstetric history
o previous pregnancies
▪ abortion (spontaneous/interruption, year, evacuation of uterus? = RCUI
revisio cavi uteri instrumentalis ), complications?
▪ labour and delivery(year, onset of labour, mode of delivery, sex +birth
weight, complications?)
Why do you need to know?
o you can expect different length and course of labour depending on parity
o previous birth weight brings indirectly information of spaciousness of birth canal
o mode of previous delivery inform about imminent complication, indication of
caesarean section in previous pregnancy is essential (primary CS are planned,
indications for example breech position, severe congenital malformation, locked
twins secondary = acute CS, indications such as eclampsia, placental abruption, acute
fatal hypoxia, pathological presentation)
o in case of previous CS you should ask about complication and healing of previous
laparotomy
o complication of previous pregnancies/deliveries/puerperium are very important (for
example: previous preterm birth/preeclampsia/diabetes mellitus are high risk factors
for the same pathologies in ongoing gravidity), previous anal sphincter injury or
previous secondary healing of episiotomy could be important for adequate
management or delivery mode
o previous evacuations of uterus (RCUI,ITP) is risk factor for abnormal adherence of
placenta, residual placental tissue or Asherman syndrome
o previous abortions or stillbirth strongly affect patient´s mental state during
pregnancy and also during labour
history of ongoing pregnancy (ultrasound and biochemical screening results, oGTT result,
Streptococcus agalactiae swab result and compilations of pregnancy /hospitalisations,
bleeding, infections, new medications…/
5
2. Antenatal care – obstetric
examination, care schedule,
obstetric examination record
Prenatal care
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in the Czech republic it is recommended to all women to be registered at some outpatient
gynaecologist’s (called „registrující gynekolog“)
so called “registrující gynekolog” (outpatient gynecologist at whom the patients is registered)
is responsible for prenatal care
pregnancy with low risk factors (appointments each 4-6 weeks, since 34th week of pregnancy
appointments each week)
high-risk pregnancies are followed up more frequently
Regular examinations
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at each appointment during prenatal care
medical history and recognition of high-risk pregnancy
weight of patient, blood pressure
urine testing for protein and sugar
detection of foetal vitality
abdominal examination
bimanual vaginal examination (if required), Bishop score
6
Irregular examinations
The first examination (usually 2-3 weeks after missing period)
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ultrasound scan: confirmation of pregnancy and its intrauterine location, exclusion, or
identification, of multiple pregnancy (and also chorionicity and amnionicity), accurate
identification of gestational age (upon which many obstetrical assessments and decisions are
based, CRL = crown-rump length is used for gestational age estimation), recognition of major
foetal anomalies
7
Week of gestation 11-13 COMBINED FIRST TRIMESTR SCREENING TEST
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combination of ultrasound scan (e.g. nuchal translucency, nasal bone, frontomaxilar angle)
and blood test (markers: PAPP-A, HCG )
main aim is to determinate the risk of chromosomal abnormalities (m. Down, m. Edwards, m.
Patau)
count of foetus, vitality, detection of major foetal abnormalities
screening for preeclampsia
Examinations during first trimester
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filling of pregnancy health record
blood test
o AB0 and Rh group
o antibody screen
o blood count
o HIV, HBsAg, Syphilis antibodies
o glycaemia (after fasting)
8
Week of gestation 18-22 ULTRASOUND SCAN
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biometry (BPD, HC, AC, FL →EFW)
morphology of foetus
localisation of placenta, umbilical cord insertion, count of umbilical vessels
amnionic fluid volume
(screening for preeclampsia – uterine arteries Doppler)
9
Week of gestation 24-28: Oral glucose tolerance test (oGTT)
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after 8 hours of fasting glycaemia of woman is estimated, if avid glycaemia is normal (<5,1
mmol/l) patient drinks 75g of glucose, after 60 minutes and 120 minutes you take another
blood sample for estimating glycaemia
Week of gestation 28 antepartal prophylaxis of RhD isoimmunisation
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all Rh-negative patients should get Anti-D immunoglobulin to prevent isoimmunisation
during the third trimester
Week of gestation 28-34.
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labs:
o
blood count
Week of gestation 30-32.: 3. ULTRASOUND SCAN
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count of foetus, vitality, position
morphology of foetus
localisation of placenta, umbilical cord insertion, count of umbilical vessels
amnionic fluid volume
Week of gestation 35-37 Streptococcus agalactiae screening
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vagino-rectal swab
Week of gestation 36-37 ultrasound scan
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biometry, dopplerometry (AU, ACM)
10
Since 39th week of pregnancy
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non-stress cardiotocography
Obstetric examination record (in Czech ”těhotenská
průkazka”)
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it is usually filled between 7th-13th week of pregnancy,
it contains
o personal data
o patient´s health history, gynaecological and obstetric history
o estimated term of birth
o laboratory result (blood counts, blood AB0 and Rh group, results for Syphilis, HbsAg
and HIV screening, result of glucose tolerance test, ultrasound examination, weight
gain etc.
o short record of each regular prenatal examination (blood pressure, urinary test for
protein and sugar, presence of oedemas, vitality of foetus, treatment, bishops score
etc.)
o record of other examinations (dentist´s examination, GP examination,
hospitalisations…
11
3. Prenatal screening tests: noninvasive and invasive
Prenatal screening, prenatal diagnosis
Prenatal diagnosis is set of methods and procedures used to diagnose congenital malformations in
the fetus. Systematic screening for developmental defects allows to reduce the number of such
affected newborns or to ensure timely prenatal and postnatal care. The organization of prenatal
diagnostics requires the cooperation of an obstetrician, a genetics clinician or other specializations
(neonatologist, urologist, neurologist, surgeon, radiologist and so on) in the form of the consultation.
The aim of prenatal diagnosis is to the determine the diagnosis of pathological conditions of the
fetus in the earliest possible period. Based on results, it is possible:
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Inform a pregnant woman about the diagnosis and prognosis of the fetus.
Take specific measures concerning, for example, the timing and manner of delivery and
subsequent care.
o Childbirth in a prenatal center followed by urgent cardiac surgery neonatal care in
case of severe congenital heart defects.
o Ensuring the continuity of surgical care in a surgical case to correct the effects of the
fetus (for example - defects of the anterior abdominal wall).
Initiation of prenatal therapy of the fetus
Intrauterine correction of cardiac develop. defects (source:
https://emedicine.medscape.com/article/2109511-technique)
12
Laser coagulation of vascular junction of monochorionic twins (source:
https://www.childrensmn.org/services/care-specialties-departments/fetal-medicine/conditions-andservices/twin-to-twin-transfusion-syndrome/)
13
Intrauterine treatment of obstructive defects of the urinary system using vesicoamnial shunt under
ultrasound control (sources: https://www.chop.edu/conditions-diseases/lower-urinary-tractobstruction-luto and https://www.youtube.com/watch?v=dcUk9WGG6Ao
14
Intra-umbilical transfusion under US control for fetal anemia caused by Rh-immunization (source:
https://rltwnf.tistory.com/m/entry/fetal-blood-transfusion?category=568003)
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Terminate the pregnancy artificially at the request of the pregnant woman in case of an
unfavorable prognosis. It is possible to do so within 24 weeks of pregnancy after performing
a more detailed prenatal diagnosis in collaboration with clinical genetics.
Non-invasive prenatal screening tests
Non-invasive methods of prenatal diagnosis include monitoring of ultrasound and biochemical
markers. Based on the presence or absence of ultrasound markers or changes in level of biochemical
markers related to the dating of pregnancy (calculation according to CRL-crown rump length), we
determine the individual degree of risk of fetal developmental defects. According to the degree of
risk on the basis of screening examination We perform additional examination of other ultrasound
markers or invasive examination with the aim of genetic examination of the fetus (karyotype and
molecular genetic testing).
Biochemical markers
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Substances used to screen for fetal developmental defects produced by the fetoplacental
unit
Their values are different in healthy fetuses Unlike fetuses with chromosomal aberrations
15
Crown-rump length CRL (source: http://pccwellness.org/pcc-salud-family-health-center/14programs-and-services/primary-care/pregnancy-services)
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Biochemical screening in the first trimester
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Exclusion of the most common chromosomal aberrations and their imaginable morphological
defects
Can be performed between 10+0 and 13+6 gestational week
Two biochemical markers and several basic ultrasound markers are examined as standard (PPAP-A,
beta hCG)
1. The combined test consist of examination of PPAP-A and beta hCG levels and ultrasound
measurement of NT - nuchal translucency
2. Combined contingency test complements the examination of the presence of the nasal bone
(NB), doppler examination of tricusoudal regurgitation (TR) and examination of the venous
duct (DV)
Sekvential integrated test – combines the results of combinated test in the first trimester with the
implementation of other biochemical markesr in the second trimester (hCG, u E3, AFP, inhibin A)
17
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In case of determinating the medium risk of chromosomal abrerrations in the fetus, other
markers are addected, in case of their positivity or in case of hign risk, the patient is
recomended to undergo methods of invasive prenatal disgnosis (AMC – amniocentesis, CVS –
chorionic villus sampling)
Ultrasound scan parameters in the first trimester
Ductus venosus- doppler. (b- fyziol., d-revers flow) (source: https://fetalmedicine.org/fmfcertification/certificates-of-competence/ductus-venosus-flow)
NT nuchal translucency + NB (source: https://www.modrykonik.cz/jsem-tehotna/nt/)
18
TSR - Doppler examination trikuspidal regurgitation (source:
https://www.fetalmedicine.org/var/pdf/publications/765.pdf)
The above-mentioned ultrasound markers are associated with other patological conditions in
addition to chromosomal aneuploidis:
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NT - nuchal translucency – heard defects, skeletal dysplasia, muskular dystrophy, central
nervous systém abnormalities, diafragmatics defects, microdeletion syndromes
NB – nasal bone - skeletal dysplasia
TSR - Trikuspid regurgitation – congenitl malformations of the heart
Another parameter of prenatal diagnosis is a measurement doppler signal in the uterine arteries,
witch toogether with markers - PAPP-A, PLGF (placental growth factor - promoting angiogenesis in
the placenta) and MAP (middle arterial preasure) is used to predict the occurence of preeklampsia in
pregnancy. In case of high risk, we reduce this risk by administering acetylsalicylic acid.
19
Doppler - a.uterina in the first trimester (source:
https://www.isuog.org/uploads/assets/uploaded/f4bee12e-1067-4de0-bd8ce4b5d99d1160.pdf)
Between the eleventh and thirteenth week of pregnancy, the detection of further morphological is
possible. Whereas the ability to detect pathology increases with the week of gestation. For clarity,
only some foetal pathologies are listed here: anencephalous, holoprosencephaly, orofacial clefts,
gastroschisis, defects of the uropoetic tract, limb defects.
20
Gastroschisis (first trimester) (source: Prenatální diagnostika vrozených vývojových vad, P.,Polák, J.,
Loucký, V., Tomek)
Anencephalous (first trimester) (source: Prenatální diagnostika vrozených vývojových vad, P.,Polák,
J., Loucký, V., Tomek)
21
Biochemical screening in the second trimester
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The risk of chromosomal aberration is determinate between 15 and 18 weeks of
The set of biochemical tests (triple test, quadruple test) or as a part of an integrated test
(screening evaluating together the parameters from the first and second trimester of
pregnancy)
Triple test- estriol (uE3), beta hCG and AFP combined with the age of the mother.
Quadruple test - estriol (uE3), beta chg., AFP an Inhibin A
Ultrasound examination in the second trimester
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Take place between 18 and 23 weeks of pregnancy when it is possible to rule out some of the
serious developmental defects affecting, for example, the heart, digestive tract, central
nervous system, musculoskeletal system.
We evaluate: fetal biometrics overall morphology including anomalies structure of individual
fetal organs, ultrasound markers of chromosomal aberrations and genetic syndromes,
amount of amniotic fluid, placenta et its location, doppler determination of fetoplacental
flow and echocardiography
ECHO heart assesses cardiac anatomy ventricular system, ventricular and atrial septum, heart
arch and heart rate
Examples of some ultrasonic anomalies:
Spina bifida aperta (source: https://www.lifespan.org/centers-services/fetal-treatment-programnew-england/conditions-we-treat/spina-bifida)
Ren arcuatus (source: https://www.lifespan.org/centers-services/fetal-treatment-program-newengland/conditions-we-treat/spina-bifida)
22
Ultrasound examination in the third trimester
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The aim is to assess foetal growth by foetal biometrics and to establish a weighting estimate
We evaluate: the size off the shape and placement of the internal organs of the foetus,
structure and placement of the placenta, the distance of the placenta from the inner gate of
the cervix and amount of amniotic fluid
Dopplerometry arteria umbilical’s, arteria cerebri media, arteria uterine (assessment of
fetoplacental unit function)
Vasa praevia – bleeding from the umbilical cord occurs when the membrane sac ruptures and the
blood vessels are broken (source: https://twitter.com/elmtreemedical/status/906607900327661570)
Arrows – cervix with a funnel, colour = vessel above the inner gate (source:
https://onlinelibrary.wiley.com/doi/pdf/10.7863/jum.2012.31.6.963)
23
NIPT – Non-invasive prenatal testing
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Non-invasive method of prenatal diagnosis
Isolation of fetal or placental DNA fragments from the mother’s peripheral blood
Allows to determine the risk of selected most common chromosomal aberrations with high
accuracy up to 99 %
NIPT is a screening test, not a diagnostic test.
Variant especially for women with an increased risk of Down syndrome who do not wish to
undergo an invasive test.
In addition, Trisomy 21, it is possible to determine the risk of Trisomy 13 and 18 and
numerical pathologies of chromosomes
Results are available within two weeks
Advantage: non-invasive examination not increasing the risk
Fetal DNA in mother's blood (source: https://fetalmedicine.com/harmony-test)
24
Invasive prenatal screening tests
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Methods used to obtain material for genetic testing of the fetus.
It is performed in case of positive result of a screening test or an increased risk of genetic
damage to the fetus, the consent of the patient is required
We include these methods: AMC – amniocentesis, CVS – chorionic villus sampling,
cordocentesis (blood sample from umbilical cord)
Chorionic villus sampling (CVS)
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Optimal execution time between 11 and 14 weeks
Chorionic villus tissue allows cytogenetic examination and molecular analysis of DNA
The risk of foetal loss is 0,5–1 % within two weeks
It is performed on an outpatient basis with one injection with a strong needle under
ultrasound control
AMC – Amniocentesis
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Optimal execution time between 15 and 22 weeks
Taking 10 to 20 ml of amniotic fluid
We used from peeled epidermal and fibroelastic cells (from the skin, urinary tract, mouth,
respiratory tract and amniotic cavity) for cytogenetic examination and molecular analysis of
DNA
Risk of miscarriage is 1 %
It is performed on an outpatient basis with a single injection with a thin needle under
ultrasound control
Cordocentesis-collection of fetal blood from the umbilical cord
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Optimal method after 20 weeks of pregnancy
By puncturing the umbilical vein, we obtain fetal blood for genetic, biochemical,
hematological and microbiological examination.
Cytogenetic examination is performed from fetal blood lymphocytes
Collection of 2 to 4 ml of fetal blood with a thin needle under ultrasound control
The risk of fetal loss within two weeks is 1-2%
It is performer on an outpatient basis.
Picture of cordocentesis (intra-umbilical transfusion) page two
25
CVS - chorionic villus sampling (source: Prenatální diagnostika vrozench vývojových vad, P.,Polák, J.,
Loucký, V., Tomek)
AMC - Amniocentesis (source: Prenatální diagnostika vrozench vývojových vad, P.,Polák, J., Loucký,
V., Tomek)
26
4. Vaginal delivery and labor –
initial examination, mother and
fetal monitoring, partogram use
At the outpatient clinic, we treat pregnant patients from the viability limit of the fetus to the end of
pregnancy (23 + 0 - 40-42 Weeks OF pregnancy)
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Prematurity < 37 + 0
Term pregnancy 37 + 0 - 40 + 0 (41+6)
post term pregnancy is defined as pregnancy that has extended to or beyond 42 weeks
of gestation (294 days), or estimated date of delivery (EDD) + 14 days (ACOG, 2004).
However, for the needs of the recommended procedures of the Czech Gynecological
Society, post-term pregnancy is defined for more than 40 + 0 weeks of gestation
Upon arrival, the patient hands over a pregnancy card to a midwife, who finds out basic information
about the patient, examines the urine in an orienteering biochemistry, listens to fetal heart sounds
(possibly connects to a CTG monitor), measures the patient's blood pressure / pulse / temperature.
The doctor continues the examination - takes anamnesis, performs gynecological (in mirrors,
bimanual examination - determines the cervix score, external palpation - situs, position of the fetus
and ultrasound examination, plans the next check or another intervention.
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Pregnancy card - see practical question no. 1 + 2
History - see practical question no. 1 + 2
The patient brings morning urine with her - we will perform an orientation biochemical
examination
27
source: photos of GPK FN and LF MUNI Brno
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Blood pressure measurement
source: photos of GPK FN and LF MUNI Brno
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Listening to fetal echoes (auscultation) - through the abdominal wall of the mother with a
hearing aid, ultrasound device, cardiotocograph
28
source: photos of GPK FN and LF MUNI Brno
source: photos of GPK FN and LF MUNI Brno
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Cardiotocography (CTG) is a technical means of recording the fetal heart beat and the uterine
contractions during pregnancy. The machine used to perform the monitoring is called a
cardiotocograph, more commonly known as an electronic fetal monitor (EFM) - see practical
question no. 5
29
source: photos of GPK FN and LF MUNI Brno
source: photos of GPK FN and LF MUNI Brno
30
Objective examination
The external examination has a given sequence, which we should respect.
We investigate externally in the following order:
1.
2.
3.
4.
Aspects (scars, striae gravidarum …)
Palpation
Auscultation - see above
Measurement
source:
https://www.wikiskripta.eu/w/Zevn%C3%AD_vy%C5%A1et%C5%99en%C3%AD_(porodn%C3%AD_as
istence)#/media/File:Aspekce_t%C4%9Bhotn%C3%A9.png
Palpation (palpation of the uterus + fetus)
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External palpation examination – shape of uterus (The primigravid uterus is ovoid in shape
compared to the multigravid uterus, which is a rounded shape), distance from the symphysis
to the uterine fundus (SF in cm), height of the uterine fundus - evaluated by the number of
fingers by which the fundus (= FD) is far from the xiphisternum, the umbilicus and the
symphysis pubis. Palpate of the abdomen for number of fetus, fetal position and situs.
Fundal Palpation
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Both hands are gently placed around the fundus to determine contours of the fetus. Aids
determination of presentation, whether cephalic or breech. This will aid diagnosis of the lie
and presentation of the fetus
31
Lateral Palpation
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Hands are placed at umbilicus level on either side of the uterus. Gentle pressure is used with
each hand to determine which side offers the greatest resistance. ‘Walking’ the fingers over
the abdomen can also locate the position of the back and distinguish fetal body
parts.1Location of the fetal back can help determine the fetal position.
Pelvic Palpation
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Identifies the level and side of the occiput and sinciput when the presentation is vertex. In a
normal vertex presentation the head is flexed and the sinciput will be palpated at a higher
level than the occiput. Pawlik’s maneuver should only be used if necessary to judge size,
flexion and mobility of the head.1This will help identify fetal position, degree of flexion and
how many fifths of the presenting part is palpable above the pelvic brim. Assess engagement
of the presenting part of the fetus (defined as no more than 2/5ths palpable above the pelvic
brim). If the head does not engage (3 or more fifths above the pelvic brim) in a primigravid
woman at term, it may indicate malpresentation or cephalopelvic disproportion (CPD).
However, non-engagement is not definitive of CPD. Risk factors should be discussed with the
woman.
Auscultation
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Locate the fetal heart by identifying the fetal position and presentation. Use of a hand held
Doppler allows the woman to hear the fetal heart rate (FHR). Identify the maternal pulse.
The maternal pulse should be identified to confirm the abdominally detected rate is that of
the fetus, not the woman. Auscultate the fetal heart rate for one minute and record in the
woman’s medical record. The fetal heart rate varies according to gestational age and activity.
Report any deviation or irregularity in the FHR to the medical staff. A reassuring heart rate is
between 110 and 160 beats per minute, with no irregularities.
Documentation
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Document the findings from the abdominal examination, including inspection, palpation and
auscultation of the FHR in the woman’s medical records.
For example:
Baby in vertex - or 'head' down position.
1. Assessing the height of the fundus (lower area of the baby) - seeing how many
fingerbreadths below the xiphisternum (bottom of the woman’s sternum bone) the baby is
laying.
2. Assessing the size of baby and feeling for the baby's back and limbs.
3. Pawlik's grip - the lower part of the uterus is grasped to determine the presenting part.
4. Pelvic palpation to determine the position of the baby's head.
5. Measuring the height of the fundus, which generally corresponds to the number of weeks of
gestation.
6. Listening to the baby's heartbeat.
32
Baby in breech position - or 'bottom' down position.
1. Checking the height of the fundus (the highest point of the uterus). At 20 weeks, this
measurement is taken from the belly button. When the pregnancy is at term (37-40 weeks),
it is taken from the lower end of the woman's sternum bone (the xiphisternum).
2. Assessing the baby's position and size. Feeling for the baby's head, back and limbs.
3. Using ‘Pawlik's grip’ to check that the baby's buttocks are in the pelvis.
4. Listening to the baby's heartbeat
source: https://www.betterhealth.vic.gov.au/health/servicesandsupport/pregnancy-antenatalchecks-of-your-baby
33
Gynecologic examination
•
Gynecological examination in mirrors (vaginal speculum) - evaluation of external genitalia
(scars, warts, sexually transmitted diseases, ulceration…), vagina (fluorine, color, growths,
bleeding, mucus, amniotic fluid, spaciousness), cervix (shape - conical, cylindrical, external
gate), amniotic fluid outflow, blood, smooth, furrowed, ulceration, exophytes…)
source: photos of GPK FN and LF MUNI Brno
•
Methodology: hold the lower mirror with the right hand, the upper mirror with the left hand.
Then we carefully pass through the introitus, observing the vaginal walls. We get to the
cervix, which we stop and observe, or we take material for examination (amniotic fluid,
secretion from the posterior vaginal vault, secretion from the throat, secretion from the
vagina).
Premature amniotic fluid outflow at term (preterm) – how we check it ?
•
•
•
Macroscopic visualization in the vagina cavity or from the cervix during gynecological
examination
microscopic examination - ferning of the dried
alkalinity of the fluid reaction - as determined by Nitrazine paper confirm the diagnosis (in
the Czech republic we perform Temesvary solution/reagent). Blood contamination of the
incator´s paper and ferning of cervical mucus may produce false-positive results. Pooling of
fluid is by far the most accurate for diagnosis of ROM. If all fluid has leaked out as in early
PROM, an ultrasonographic examination may then show absence of or very low amounts of
amniotic fluid in the uterine cavity.
34
source: photos of GPK FN and LF MUNI Brno
•
Specific examination by PROM test (Premature Rupture of Fetal Membranes; Amnisure):
biochemical markers – imunochromatic detection of insulin-like growth factor binding
protein-1 (IGFBP-1) insulin-like growth factor binding protein-1 (IGFBP-1) whose
concentration in amniotic fluid is 100-1000 times higher than in the mother's serum. Under
normal circumstances, IGFBP-1 is not present in the vagina. After rupture of the amniotic
sacs, amniotic fluid with a high concentration of IGFBP-1 mixes with vaginal secretion. The
detection limit is 25 micrograms / liter, this concentration gives a weakly positive result in 5
minutes. Concentrations of IGFBP-1 in the extracted sample higher than 50 micrograms/liter
give a strongly positive result. We use it advantageously for lower weeks of pregnancy.
source: http://m.blog.daum.net/tae0mang/7267041
•
•
Determination of pH using indicator paper - the pH of the vagina is in the range of 4.5 to 6.0,
the pH of amniotic fluid between 7.1 and 7.3.The method is not commonly used, it is loaded
with low specificity.
Ultrasound examination – maximal vertical pool (MVP) or Amnion fluid index (AFI)
• Management: When confirming amniotic fluid outflow, the patient is always admitted to
hospital.In the case of term pregnancy in a negative culture examination of
Streptococcus agalactiae (performed in the 35-37th week of gestation by the registering
gynecologist), an expecting approach is possible for about 24 hours, unless spontaneous
35
•
contractile activity occurs, childbirth is induced (most often prostaglandins).The
antibiotic barrier is started intravenously (penicillin intravenously, in case of allergies
clindamycin iv) 18 hours after amniotic fluid outflow, continued with administration until
delivery.If the culture is SAG positive, an active approach is indicated (according to the
cervix score pre / induction of labor), the ATB diaphragm is started intravenously
immediately, the administration is continued until delivery.
Secretion from the posterior vaginal vault - for examination of fibronectin, which may
predict the risk of premature birth in a shortened cervix (in the case of the gray zone or
in the management of corticosteroids to induce fetal lungs mature)
source: photos of GPK FN and LF MUNI Brno
source: photos of GPK FN and LF MUNI Brno
36
•
Secretion from the cervix, vagina - microbiological examination
source: photos of GPK FN and LF MUNI Brno
•
Pelvic examination – bimanual - the right hand performs a vaginal examination, the left
hand holds the uterine fundus
Bishop's score, also known as cervix score is a pre-labor scoring system to assist in predicting
whether induction of labor will be required. It has also been used to assess the likelihood of
spontaneous preterm delivery. The total score is calculated by assessing the following five
components on manual vaginal examination by a trained professional:
•
•
•
•
•
Cervical dilation in centimeters
Cervical effacement as a percentage
Cervical consistency by provider assessment/judgement
Cervical position
Fetal station, the position of the fetal head in relation to the pelvic bones
37
source: http://www.porodnice.cz/porod-a-z/porodni-cesty
The Bishop score grades patients who would be most likely to achieve a successful induction. The
duration of labor is inversely correlated with the Bishop score; “A Bishop score of 9 conveys a high
likelihood for a successful induction. For research purposes, a Bishop score of 4 or less identifies an
unfavorable cervix and may be an indication for cervical ripening.”
Bishop score. Source: https://en.wikipedia.org/wiki/Bishop_score
38
Cervical effacement. Source: http://www.lubusky.com/clanky/110.pdf
Cervical dilatation (cm). Source: http://www.lubusky.com/clanky/110.pdf
Source: http://images.slideplayer.cz/7/1987724/slides/slide_41.jpg
Cervical position. Source: http://www.lubusky.com/clanky/110.pdf
39
•
Amnioscopy: is an invasive exam employed to visualize the forebag of the amniotic sac and
to look out for meconium staining. (Not used it)
source: http://www.porodnice.cz/tehotenstvi-a-z/amnioskopie
Ultrasound examination of the fetus - see practical
question no.3
•
•
•
•
Vitality (fetal heart rate, heart rate, fetal movements)
Fetal position
Fetal biometrics - measurement of biparietal diameter of the head = BPD, circumference of
the head = HC, measurement of the circumference of the abdomen = AC, measurement of
the femur = FL - the device software calculates the weight estimate of the fetus
Placental location - Dopplerometry – Cervicometry
source: http://www.porodnice.cz/tehotenstvi-a-z/amnioskopie
40
source: photos of GPK FN and LF MUNI Brno
•
•
Fetal Biophysical profile according to Manning (condition of fetal condition - CTG +
ultrasound examination within 30 minutes, after the introduction of Doppler measurement is
rather a historical matter)
Measurement of the pelvis - pelvimetry - the correct external dimensions of the pelvis
indicate the normal shape and size of the pelvis for the permeability of the head / buttocks
of the fetus
o distantia bispinalis ≥ 25 cm, between the spina iliaca anterior superior of both sides
o distantia bicristalis ≥28 cm, between the iliac crista of both sides
o distantia bitrochanterica ≥ 31cm, between the trochanter major of both sides
o Baudelocque external conjugate - 19-21 cm, between L5-S1 and the upper edge of
the symphysis (measured on the left side with the left lower limb flexed)
Theoretically, pelvimetry may identify cephalo-pelvic disproportion, which is when the capacity of
the pelvis is inadequate to allow the fetus to negotiate the birth canal. However, a woman's pelvis
loosens up before birth (with the help of hormones).
source: photos of GPK FN and LF MUNI Brno
41
•
•
•
•
•
•
Laboratory blood + urine samples:
o Blood count, coagulation - Biochemical examination
o Urine + sediment
o Gestotic screening for preeclampsia: to exclude or confirm preeclampsia (uric acid,
total protein, albumin, urine collection - determination of proteinuria, alb / creatinin
or total proteinuria/ creatinine, urea, creatinine, liver tests, sflT / PlGF ratio (up to
36t.g), blood count, coagulation
o Hepatopathy: liver tests: ALT, AST, ALP, bilirubin direct, bile acids
o Premature amniotic fluid outflow < 37 + 0: blood count, coagulation, biochemistry
(CRP), vaginal and urine microbiological examination
o Premature birth: blood count, coagulation, biochemistry (CRP), vaginal culture, urine
Part of the mother's care is planning the timing of childbirth due to the circumstances of the
mother (internal diseases, diseases caused during pregnancy - gestational diabetes,
hepatopathy, gestational hypertension, preeclampsia) + fetal (VVV defects, hypotrophy,
placental insufficiency, fetal position, placental placement)
Induction of labor in a healthy mother and eutrophic fetus with physiological
cardiothocoraphy is between 41-42 weeks of pregnancy; we use prostaglandins E2, E1 most
often in the form of tablets (gel), they are applied intracervically or in the posterior vaginal
vault according to the type of preparation
Preinduction of labor - preparation of an immature cervix score before the induction itself,
with the cervix closed we use Dilapany, with a mature finding - Hamilton's touch
Indication for planned caesarean section / primary / iterative
Clinical and laboratory examinations in the provision of prenatal care are divided into:
o regular (performed at each visit to the pregnancy clinic)
o irregular (performed only in the specified week of pregnancy).
The most commonly used drugs in obstetrics:
1.
2.
3.
4.
5.
6.
uterotonics (oxytocin 2IU, 5IU methylergometrine, carbetocin, carboprost)
tocolytics (hexoprenaline, atosiban)
supportive medication (MgSo4, Mg.lactici)
antibiotics (PNC G, cefazolin, amoxiclav, clindamicin, clarithromycin…)
analgesics, spasmoanalgesics (paracetamol, diclofenac, buscopan, papaverine supp….)
antihypertensives (methyldopa, metoprolol, verapamil, dihydralazine, labetalol)
42
5. Cardiotocography, ST analysis
We use cardiotocography (CTG) and ST analysis (STAN) for monitoring the fetal heartbeat and the
uterine contractions during pregnancy and labour in order to identify fetuses at risk of significant
hypoxia and to assess fetal wellbeing.
Cardiothoracicography
The principle of this method is the recording of the fetal heart action and its changes due to the
hypoxia as well as other factors (uterine contractions, umbilical compression, infection etc...). All
these information are recorded on a cardiotocogram. Our devices also monitor the mother's heart
rate and fetal movements.
Cardiotocograph
1. Probe monitoring uterine contractions and the mother'sheartrate
2. Probe monitoring the heart rate and movements of the fetus
There are two options of the monitoring
a. External probe attached to the mother's abdomen
b. Internal probe - scalp electrode placed on the head of the fetus
source: https://bedmed.com.br/cardiotocografia-fetal-quando-e-onde-realizar/
43
source: http://matterhatter.com.au/publicly-funded-homebirth-and-birth-centres-how-theyconnect-to-the-maternity-care-revolution/ctg-im80136/
Fyziologický CTG záznam
44
The basic concept of CTG
Assessment of CTG results in three main components:
Basal frequency (BF) refers to the mean level of fetal HR. The normal basal frequency of a full term
fetus ranges from 110 – 160 beats per minute. Fetal tachycardia is BF ≥160 BPM, fetal bradycardia is
BF ≤ 110 BPM.
Variability is composed of two components: short-term and long-term variability.
•
•
Short-term variability - changes in the fetal HR between each cardiac cycle.
Long-term variability - composed of acceleration or deceleration waves (oscillations). We
distinguish variable decelerations, early decelerations and late The presence of accelerations
on the CTG record indicates good compensation and sufficient reserves of the fetus.
Otherwise, the CTG monitor is assessed as non-reactive and the condition requires further
examination.
Both variability components are linked to each other. They form a coherent cardiac rhythm
circuit - cardiotocogram. A numerous expression of long-term variability: normal variability 5-25 BPM; decreased - 3-5 BPM; absent - ≥ 2 BPM; increased ≥ more 25 b/min.
The presence of normal variability and stable basal frequency implicates adequate cardiac work
regulated by the nervous system, cardiac conducting system and myocardium which is not affected
by hypoxia.
On the record of uterine activity, we evaluate the frequency and duration of contraction and their
correlation with possible decelerations.
Example of physiological CTG record: Basal frequency between 130-140 beats per minute. Variability
in the range of 5-25 (approximately 10). Decelerations are not present. We observe numerous
accelerations.
Example of physiological CTG record
Example of pathological CTG record: Basal frequency approximately 180 beats per minute
(tachycardia). Variability less than 5. Numerous decelerations. Accelerations absent.
45
Example of pathological CTG record
In the Czech Republic, we use FIGO CTG classification published in 2015. CTG record can be
evaluated as physiological (values mentioned above), suspect or pathological. The criteria are
following:
•
•
•
Normal: No hypoxia or acidosis; no intervention necessary to improve fetal oxygenation
state.
o Baseline 110–160 bpm
o Variability 5–25 bpm
o No repetitive decelerations
Suspicious: Low probability of hypoxia/acidosis, warrants action to correct reversible causes
if identified, close monitoring or adjunctive methods.
o Lacking at least one characteristic of normality, but with no pathological features.
Pathological: High probability of hypoxia/acidosis, requires immediate action to correct
reversible causes, adjunctive methods, or if this is not possible expedite delivery. In acute
situations, delivery should happen immediately.
o Baseline <100 bpm
o Reduced or increased variability or sinusoidal pattern
o Repetitive late or prolonged decelerations for >30 min, or >20 min if reduced
variability (decelerations are defined as repetitive when associated with >50%
contractions)
o Deceleration >5 minutes
ST analysis (STAN)
STAN is a system for fetal surveillance that displays the FHR and information resulting from the
computerized analysis of ST interval of the fetal ECG. This system is based on ECG changes
determined by the myocardial adaptation to oxygen deficiency. STAN expands the spectrum of
information of the fetal wellbeing in connection with anaerobic metabolism. STAN is helpful
46
especially in births with a higher risk of occurrence of fetal hypoxia. The basic principle of the method
is the calculation of the T/QRS ratio and the analysis of the ST segment on the fetal ECG.
Device
•
•
Probe monitoring uterine contractions
Scalp electrode recording ECG and CTG of the fetus
source: https://medlineplus.gov/ency/imagepages/9324.htm
source: https://www.slideshare.net/conyeije/st-segment-analysis-stan-for-intrapartum-electronicfetal-monitoring
47
Record of the STAN
The CTG curve is displayed, below which the current values of the T/QRS ratio are recorded (crosses).
If there is a significant change, the device marks the "ST event" that appears on the monitor.
Example of CTG record (source: https://www.slideshare.net/conyeije/st-segment-analysis-stan-forintrapartum-electronic-fetal-monitoring)
STAN events
There are three types of events:
1. Episodic T/QRS rise - an increase in the T/QRS ratio lasting less than 10 minutes. An episodic
T/QRS rise usually indicates a period in which the fetus has to utilise anaerobic metabolism
but has recovered.
2. Baseline T/QRS rise - an increase in the T/QRS ratio lasting more than 10 minutes. It usually
indicates that the fetuses utilizing anaerobic metabolism for an extended period of time.
3. Biphasic ST - reflects a downward-sloping ST segment. The grade of the biphasic ST events
corresponds to the situation where hypoxia is occurring but the fetus either has not yet had
time to respond with anaerobic metabolism.
48
6. Surgeries and instruments in
pregnancy - evacuation of the
uterus, surgical abortion
Commonly used instruments
American forceps (tenaculum) – This single bite tool used to grasp cervix and pull it caudally towards
the vaginal introitus.
American forceps (tenaculum)
Uterine sound – This long instrument with blunt tip is used at the beginning of each vaginal
procedure to determine the length of the cervix and uterus. It has marking on it for measurement.
Uterine sound
49
Hegar cervix dilator – a straight metal long instrument, used for gradual dilatation of the cervix, can
cause perforation of uterus if too much force is used.
Hegar cervix dilator
Vaginal speculum – tool used to visualize the vagina, vaginal walls and cervix. There are different
types, e.g. Scherback vaginal speculum, bottom spoon with weight:
Vaginal speculum
Uterine curette – This tool is used in vaginal operations such as revision of the uterine cavity and
separated abrasion, to evacuate the contents of the uterine cavity (when reviewing the uterine
cavity) or to scrap endometrial cavity to obtain or histological sample (abrasion of the cervix and
uterine body)
Uterine curette
50
Evacuation of the uterus = surgical abortion = revision
of uterine cavity
is a gynecological procedure to remove content of uterine cavity after spontaneous incomplete
abort, inducted abort in 2nd semester or missed abortion.
•
•
•
•
Performed in general anesthesia, the patient lies in the gynecological position, disinfection of
vulva and vagina. Uterine sound is used to measure the length of the uterus.
Gynecologist gently dilatates the cervix by Hegar dilators, remembering not to put too high
pressure to prevent perforation of uterine body, and respects the ante/retroflexion of the
uterus. The revision of uterine cavity by curette to remove uterine content.
Transabdominal ultrasound should be done after procedure to check that uterine cavity is
empty. Uterotonics should be also administered, Oxytocin i.v. or Methylergometrin iv.
Complications: perforation of the cervix or uterus, injuries to the surrounding organs intestine, omentum, bladder
Revision of uterine cavity
Cerclage
Cerclage is a gynecological operation, treatment of an incompetent cervix by putting a stitch around
cervix to prevent miscarriage or preterm birth.
51
•
•
•
•
Diagnosis of incompetent cervix is performed by cervicometry (transvaginal ultrasonographic
imaging of cervix length)
Normal cervical length is 25 to 50mm between 14-30th week of pregnancy. Shorter cervix
might predict risk of preterm birth.
Cervical length - closed part of the channel of the throat, normally T-shape,
Funneling – presence of open portion of cervix, starting from internal os of cervix. Usually,
we measure funnel length and then closed part of cervix. Funneling might be in Y, V, U shape.
U represents the most concern.
Cerclage. Source: https://sonoworld.com/images/FetusItemImages/articleimages/maternal_conditions_that%20affect_the_fetus/cx-incom_quintero_files/cx-draw.gif
Types of cerclage:
•
•
•
Preventive (selective): in asymptomatic women based on previous medical history and risk
factors (women with multiple pregnancy, miscarriages in the 2nd trimester or a history of
premature birth).
Therapeutic: in women with randomly detected throat incompetence between 14-24th week
of pregnancy
Emergency: rescue procedure to prolong pregnancy to a viable gestation in women
presenting in the 2ndtrimester with cervical dilatation and bulging fetal membranes
Cerclage sec. Mc. Donald
•
•
•
Conditions: vital fetus, absence of signs of infection or uterine contractions.
Contraindications: vaginal bleeding, amniotic drainage, congenital fetal defect incompatible
with life, uterine contractions or signs of vaginal or intra-amnial infection.
Performed under general anesthesia, the patient lies in Trendelenburg's position. The
obstetrician carefully puts circular suture around the cervix, usually starting at number 12
and finishing at number 1. When its done, local antibiotics might be administered, such as
Clindamycin, Entizole.
52
•
•
After performing the patient rests in bed under possible application of tocolysis
Removal of the suture: between the 36th and 38th week of pregnancy or with premature
rupture of amniotic water, bleeding, signs of infection and uterine aktivity
Cerclage sec. Mc. Donald
Formation of cervix after cerclage, we can see length of cervix is 34.9 mm, cerclage is seen as 2 bright
spots:
53
Cerklage failure: hyperechogenic shadow is noticeable - stitch and total dilation of the cervix
U-shaped cervical funneling
54
7. Surgeries and instruments
during labor - forceps, VEX,
placenta manual extraction,
analgesia
Obstetric analgesia
Ideal obstetric analgesic
•
•
•
•
•
•
strong analgesic effect
safe for mother and child
easy to administer
predictable effect
patient controlled dosage
without effect on uterine contractions
Non-pharmacological methods
•
•
•
psychological support (reduction of anxiety, tension, pain, support of self-confidence)
bath (warm water stimulates cutaneous nerve endings which cause pain relief)
hypnosis etc.
Pharmacological methods
Opioids
•
•
•
advantage: strong analgesics
disadvantage: breathe centrum deprivation, urinary retention, bradycardia of foetus,
breathe depression of new-born
examples:
o nalbuphin – agonist-antagonist of opiod receptors with good analgesic effect, it has
ceiling effect (lower risk of overdosing)
o fentanyl – used for epidural analgesia and also can be used as Patient Controlled
Analgesia (PCA)
o remifentanil – ultrashort acting opioid, used for PCA, there is risk of cardiovascular
depression, so mother and foetus should be monitored if used
Naloxon
specific antagonist for opioids
initial dose 0,4–2 mg
55
Nonopiod analgetics
• examples:
o paracetamol
o NO in mixture with oxygen 50/50 (Entonox) – analgesic effect starts 50 second after
inhalation, so patient has to start inhalation about 30 seconds before the contraction
is expected, it has also euphoric and relaxing effect
o butylskopolaminium (Buscopan) – it is also spasmolyticum, so it can affect on cervix
dilatation
CAVE!
nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated during the III. trimester!
explanation: their effect on induction of prostaglandins could lead to premature closure of
ductus arteriosus
Regional analgesia
Topic/mucosa
•
•
local anaesthetics (lidocaine, trimecain, bupivacaine, etc.) in spray or gel
usage: catheterisation of urinary bladder, local analgesia for stitching slight wound
Infiltration anaesthesia
•
administration of local anaesthetic before episiotomy or before stitching
Pudendal nerve block
•
•
•
transvaginal or transcutaneous anaesthesia of n. pudendum
disadvantage: practice of technique required, special equipment (special needle with guide is
safer – it limits the depth of penetration and minimize tissue injury)
advantage: better analgetic effect, probably the most convenient type of anaesthetics before
obstetrical operations or episiotomy
Paracervical block
•
•
•
•
•
infrequently (rare) use
it could provide pain relief during the first stage of labour or theoretically an option for
spastic/rigid state of cervix during the labour
block of utero-vaginal plexus
complications: systematic absorption, foetal bradycardia
disadvantage: continual monitoring of patient and foetus (risk of bradycardia) is necessary
Neuroaxial block
Epidural analgesia
•
•
must be perform by anaesthesiologist
side effects: hypotension, nausea, vomit, pruritus, it might affect motoric nerves, urinary
retention, ( theoretically breathe centre attenuation)
56
Obstetrical operations
Forceps delivery
Operative vaginal delivery using obstetric forceps is procedure designed to expedite vaginal delivery.
Types of forceps
Design
•
•
crossed, g. Simpson, Breus, Kjelland, Wrigley´s,
parallelg. Shute forceps
Use
•
•
•
outlet: foetal head is localised in pelvic outlet, it means head reached the perineal floor and
is visible at the vulva (forceps Simpson)
low-cavity/mid-cavity: head engaged, leading point is above station +2 but not above the
ischial spines(forceps Kjelland)
high: head is localised in pelvic inlet, head is not engaged, this procedure is forbidden (non
lege artis)
Conditions for forceps delivery
•
•
•
•
•
•
there is no suspicion of kephalopelvic disproportion
suitable presenting part –vertex (or after-coming head in breech position)
cervix fully dilated, ruptured membranes
head at least engaged
o head engaged: station 0, during vaginal examination the leading edge of the skull lies
below ischial spines (BPD is at ischial spines an it means that BPD is below pelvic
inlet), because of leading edge you can touch only lower third of symphysis
head is fixed in pelvis (means that it is not possible to pushed the head up between uterine
contractions)
there is no foetal contraindication (known illnesses such as osteogenesis imperfecta,
haemophilia etc.)
Indications for the use
Foetal (the most common)
•
foetal distress or acute hypoxia during the second stage of labour
Maternal
•
•
•
•
delay in the second stage of labour
exhausted or uncooperative patient
poor maternal effort, poor uterine contractions
acute maternal conditions in situations where conditions for forceps delivery are
accomplished and delivery must finished immediately (eclampsia, strong bleeding,
unconsciousness etc.)
57
Description of simpson forceps (the most used forceps Czechia)
Forceps delivery
1. examination of patient in lithotomy position to get the exact knowledge of foetal
position and station and to be sure that there is no contraindication for operative
vaginal delivery
2. disinfection of vulva, local anaesthesia, urinary catheterization (to be sure the
bladder is empty) mediolateral episiotomy
3. application of forceps
•
left blade always first
58
4. forceps should lock with ease
•
if you have any problem locking the forceps, you should remove them and apply again both
forceps again!
5. pilot traction
•
between uterine contractions apply tentative traction to be sure that forceps are not slipping
59
6. traction
•
•
traction should be applied in coordination with uterine contractions and maternal expulsive
efforts
J shape of pelvis must be followed during the traction
source: https://obgynkey.com/forceps-delivery/
60
7. removing the forceps
•
•
•
thumb of the left hand opens forceps
remove the right and then the left forceps
finish the delivery of shoulders and whole foetus
Complications of forceps delivery
•
•
•
•
•
•
slipping which could cause severe trauma of birth canal or foetal head
maternal injuries (vaginal rupture, perineal rupture)
if the traction is too quick the risk of shoulder dystocia is increased
late impact – pelvic floor disorders
neonatal trauma (bruising, grazes, kefalhematoma, subdural haemorrhage, intracranial
haemorrhage, impressive fracture of skull, facial nerve palsy
failure of forceps delivery – in this case you should finished the delivery with another
strategy (VEX, C-section)
VEX (ventouse delivery)
Vacuum extractor is tractor instrument used to expedite vaginal delivery. It adheres to the baby’s
scalp by suction (vacuum).
Popis vakuumextraktoru
•
•
•
suction cup – diameter 30–60 mm
traction part with handle
source of suction (hand pump or electric suction-making device)
61
Indications for the use
Foetal (the most common)
•
•
foetal distress or acute hypoxia during the second stage of labour
sincipital presentation
Maternal
•
•
•
•
delay in the second stage of labour
exhausted or uncooperative patient
poor maternal effort, poor uterine contractions
acute maternal conditions in situations where conditions for forceps delivery are
accomplished and delivery must finished immediately (eclampsia, strong bleeding,
unconsciousness etc.)
Conditions for vex delivery
•
•
•
•
•
•
•
there is no suspicion of kephalopelvic disproportion
suitable presenting part (occipital or sincipital presentation)
cervix fully dilated, ruptured membranes
head at least engaged
o head engaged: station 0, during vaginal examination the leading edge of the skull lies
below ischial spines (BPD is at ischial spines an it means that BPD is below pelvic
inlet), because of leading edge you can touch only lower third of symphysis
head is fixed in pelvis (means that it is not possible to pushed the head up between uterine
contractions)
there is no foetal contraindication (known illnesses such as osteogenesis imperfecta,
haemophilia etc.)
gestation age > 36th (if EFW > 2500g you can consider using VEX before 36th week, but not
younger than 34th week of gestation)
o notice that prematurity contraindicate using of VEX!
62
Ventouse delivery
1. Examination of patient in lithotomy position to get the exact knowledge of foetal
position and station and to be sure that there is no contraindication for operative
vaginal delivery
2. Disinfection of vulva, local anaesthesia, urinary catheterization (to be sure the
bladder is empty) mediolateral episiotomy (episiotomy is not required)
3. Care should be taken, in applying the cup to the foetal scalp, to exclude vaginal
skin from the edges of the cup. The spot where you should apply the cup is called
flexion point.
Flexion point
ideal spot for applying the cup, it is 3 cm forward of the posterior fontanelle on sagittal suture
when the cup is applied on the flexion point, the foetal head will remain flexed and synclitic
under traction
63
4. Sweep a finger around the cup to ensure that there are no intervening vaginal or
cervical tissues between the cup and the foetal scalp
5. Apply suction
6. Downward traction applied along the pelvic curve
7. Cancel the suction and remove the cup
•
•
•
•
maximal suction vacuum 80 kPa
vacuum-assisted delivery should be achieved with no more than 3 sets of pulls and a
maximum of two cup detachments or pop-offs
total vacuum application time should be limited to 15 minutes
in case of failure of VEX delivery you should finished the delivery with another strategy
(Forceps, C-section)
Complications of forceps delivery
•
•
•
•
•
neonatal trauma (bruising, grazes, kefalhematoma, subdural haemorrhage, intracranial
haemorrhage)
maternal injuries (vaginal rupture, perineal rupture)
if the traction is too quick the risk of shoulder dystocia is increased
late impact – pelvic floor disorders
failure of VEX delivery
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8. Pelvic examination in
gynecology
Basic principles
•
•
•
•
•
•
gynecological examination should take place in adequate premises
in the case of a gynecologist - a man, the presence of a nurse is always necessary
at the patient's request to allow the presence of an accompanying person
children are examined in the presence of a legal guardian
the basis of a successful examination is a well-taken medical history
part of the general gynecological examination is also a senological examination
Senological examination
•
•
•
•
•
preventive examination in women over 25 years of age with a positive family history, as well
as symptomatic patients (screening mammography performed from 45 years of age)
We monitor: lumps, arched areas, thickening of the skin, drawn-in areas, nipple shoving,
scaling, persistent itching of the breast, unusual secretion, discharge or bleeding,
enlargement of the lymph nodes
When examining for better orientation, we use the division of breasts into 4 quadrants
(lower inner and outer, upper inner and outer quadrant) + nipple area
o individual quadrants are examined from the periphery to the nipple, which we
examine separately
o A nipple area
o the most common occurrence of pathological finding is in the upper outer
quadrant area and the area under the nipple
o in case of positive finding an addition of radiological methods is necessary as well as
and biopsy verification
▪ describe size, borders, ambient mobility, soreness and bleeding
the patient should be instructed to self-examine the breasts
Self-examination of breasts
65
o
o
o
o
o
perform regular every month, ideally just after menstruation (breasts are softer, less
sensitive, without tension)
examination should be performed standing up in front of the mirror
we use inspection and then palpation
we take three tummy of middle fingers
we proceed in bits and bits with small rings
Examination of the abdomen
•
•
•
•
patient is placed in a supine position, knees slightly flected
when palpation, first a small palpation , then a deep palpation
with localized pain, the area will be the last to be examined
we evaluate intestinal activity by auscultation
Pelvic examination
•
examination is carried out on the gynecological chair
66
•
•
•
•
•
•
semi-seated patient, slightly flexed lower extremities
examination with gynecological mirrors is carried out before bimanual examination (we
avoid possible cause of arterial bleeding)
after correct positioning of the patient
we first examine the external genitalia (we evaluate pubic hair, leukoplakia, inflammatory
coatings, skin morphs, Bartholin gland area)
if the patient is virgine – we do not examine mirrors, introduce a vaginoscope – we observe
sources of bleeding, discharge, arching of the vaginal wall
if the patient is not virgine we introduce gynecological speculum
o the possibility of using disposable or re-sterilizable
o most often we use Kristeller mirrors (left)
o or Cusco mirror (right) – the advantage is a free hand after fixing the position of the
mirror – often used for colposcopy or biopsy collection (knips)
67
•
The technique of correctly introducing Kristeller's mirrors
•
when introducing mirrors, we observe:
o abnormalities of the hanging apparatus (cystocele, rectocele, uterine prolapse)
o urethra mouth - redness, inflow, neoplasms
o vagina - discharge and its character , source of bleeding, laceration, stranded objects
o cervix – physiologically has a circular shape – we can observe – polyps, neoplasms
with introduced mirrors it is possible to supplement – colposcopy examination,
microbiological smears (sampling kit - above) collection of bioptic material
•
68
Bimanual palpation examination
•
•
when using lubrication gel, we introduce one to two fingers into the vagina
movements of the cervix may be painful
o scuff – deposits of endometriosis may be palpable, especially in the area of the
rectovaginal septum or the area of the sacrouterine ligaments
o cervix – we evaluate the length, soreness
o uterine body - size, position, soreness
o adnexa – in physiological findings they are not palpable – in pathology there may be
palpable resistance – cysts, carcinomas, sactosalpinx
▪ soreness especially in adnexitis
•
if the virgo patient can be examined similarly per rectum
69
•
possibility of additional method is rectovaginal examination
o we introduce the index finger into the area of the vagina, lubricated intermediary
into the rectum
•
after completing of the physical examination, we add other additional methods –
sonography, laboratory sampling, hCG urine testing....
70
9. Examination for genital
infections, vaginal discharge,
infections of the vulva and vagina
Vaginal disorders are among the most common reasons for visiting a gynecologist.
The most common symptoms of a vaginal infection are: itching, burning, discharge (vaginal fluor),
dyspareunia, dysuria, abdominal pain.
Diagnostic methods:
•
•
•
•
•
•
anamnestic data collection
gynecological pelvic exam
evaluation of vaginal pH
whiff test (amine test, KOH test)
microscopic examination of a native or stained vaginal swab specimen
bacterial culture of vaginal and cervical swab
71
Evaluation of vaginal pH
The examination is performed using a pH indicator paper by applying it to the lateral wall of the
vagina in its upper third. The introduced vaginal specula must not be lubricated with gel or water, as
this could affect the resulting pH value (alkaline environment).
A normal vaginal pH level is acidic: 3,8 – 4,5.
Whiff test (amine test, KOH test)
The test is performed with 10% potassium hydroxide (KOH). Potassium hydroxide is a base (alkalis).
Biogenic amines – putrescine, cadaverine and tyramine - are released in an alkaline environment.
These amines have a typical fishy odor. The whiff test is positive in case of bacterial vaginosis and
trichomonas vaginal infection.
In practice, the test can be performed on a slide. After adding several drops of 10% potassium
hydroxide to a sample of vaginal discharge on a slide, we can smell a typical fishy smell in case of
positive test.
The 10% KOH solution can also be used for vaginal microscopy too. Here, KOH serves as a solvent that
quickly dissolves all the components of the specimen, but the yeast retains its original shape, thanks
to the rigid cell wall. In other words: KOH kills bacteria and cells from the vagina, leaving only yeast
for easier detection of a yeast infection.
Vaginal microscopy (a vaginal wet mount/wet prep)
Microscopic examination of the native or stained specimen directly in the outpatient clinic almost
disappeared from clinical practice. However, this examination is irreplaceable in the diagnosis of
vaginal disorders. A sample of vaginal discharge is observed mostly by wet mount microscopy. The
speculum is inserted into the vagina to help see the area. A sterile, moist cotton swab is inserted into
72
the vagina to obtain a sample of vaginal discharge. Afterwards the specimen is placed on a glass slide
and mixed with a salt solution. In the microscopic image we can observe: epithelium, lactobacilli, rodshaped bacteria, cocci, leukocytes, Trichomonas, yeast, mycelia, clue cells. The disadvantage of
vaginal microscopy is its longer learning curve, ie the time in which the doctor is able to learn the
method.
Microbiological culture (bacterial culture of vaginal
swab)
This examination is not performed routinely. Some microorganisms require a special environment for
their growth and are difficult to detect in routine clinical practice. Others, on the other hand, are part
of the normal vaginal microflora. Therefore, simple cultivation may not correctly identify the
pathogen causing the patient's problems. Cultivation should be performed, especially in case of
recurrent infection, suspicion to Trichomoniasis (special medium required) or in case of streptococci
detection.
Diferenciální diagnostika:
Infection
pH
discharge
Microscopic image
Whiff
test
Candida
vulvovaginitis
(Yeast infection)
≤4,5
thick white, curdy, „cottage
cheese-like“, odor free
Yeast, mycelium
-
Bacterial colpitis
(aerobic vaginitis)
thick sticky yellow, rotten
>4,5
odor
Lots of bacteria a white
blood cells, absence of
lactobacilli
-
Clue cells – squamous
epithelial cell with bacteria
adherent on their walls
+
moving Trichomonads,
white blood cells
±
significant numerical
superiority of lactobacilli
-
Bacterial vaginosis
(anaerobic)
Trichomoniasis
Lactobacillosis
thin grey, white or green,
adherent, foul-smelling
≥5,0
„fishy“ vaginal odor (worse
after intercourse)
frothy, greenish, foul>5,0
smelling, adherent
profuse thick white, occur
<4,5 regurarly - more manifested
before menses
73
10. Urogynecology examination,
surgeries in urogynecology
The aim of examination methods in urogynecology is to determine whether a woman is truly
incontinent, eliminate the transient urinary incontinence (cystitis, medication, etc.), and to rule out
other serious causes of urinary incontinence (malignant process in the true pelvis, neurological
disease). In case of confirmed urinary incontinence, using urogynecological examination it is possible
to determine the specific type of incontinence the patient is suffering from.
In addition to urogynecological examination the anamnesis, targeted questions, voiding diary and
standard questionnaires are an integral part of the examination.
Urinalysis
Can be performed by using urine reagent strips (dipstick) (e.g. OctaPhan) – lower accuracy, or
standard laboratory urinalysis with high accuracy, including urine sediment examination. We are
especially interested in: Leukocytes, Erythrocytes, nitrogenous substances, pH, possibly the presence
of bacteria in urine. In case of suspicion to bacterial infection, it is advisable to perform urine
specimen culture.
Physical examination
•
•
•
•
gynecological (pelvic) examination – vaginal discharge, inflammation, descensus or pelvic
organ prolapse (cystocele, rectocele), uterine deformities – myomatosis etc.…
skin lesions – dermatitis, decubitus (bedsore)
abdominal examination
basic neurological examination
Clinical diagnostic tests
Clinical tests serve as basic examination methods in the hands of a urogynecologist. These tests can
be performed using very basic equipment.
•
•
•
Stress test (cough test) – performed by filling the bladder with sterile fluid (300 ml). Patient
is standing or is in the lithotomy position (Marshall test), while directly visualizing the
urethra, the patient is instructed to cough. Leakage of urine during cough means a positive
test result.
Marshall-Bonney test – performed by placing an index finger and the second finger on either
side of the bladder neck, to support the proximal urethra. The patient is instructed to
perform Valsalva or cough → the absence of leakage with bladder neck elevation confirms
stress urinary incontinence due to urethral hypermobility
Q-tip test – the sterile lubricated cotton swab is placed in the urethra to the level of bladder
neck. Afterward the patient in lithotomy position is asked to cough or perform Valsalva
maneuver. In normal patient the angle of Q-tip (cotton swab) is less than 30 degrees from
the horizontal and will remain at the same angle during Valsalva maneuver. In patients with
urethral hypermobility angle exceeds 30 degrees from horizontal (stress incontinence).
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•
Pad-weight test – the weight of pad is determined prior and after the normal daily activities.
The urine leakage is assessed by the gain of weight.
Urodynamic examination methods
The most accurate methods for diagnosing lower urinary tract dysfunction.
Filling cystometry
Cystometry is invasive urodynamic study used to describe relationship between the pressure and the
volume of the bladder.
The intravesical pressure itself is given by the sum of two pressures, namely the detrusor pressure
and intra-abdominal pressure. The examination is performed by inserting one catheter into the
rectum (measuring intra-abdominal pressure) and the other catheter into the bladder (measuring
intravesical pressure). The catheter inserted in the bladder is double-channel * - one channel is used
to measuring the bladder pressure, the other one is used to fill the bladder with irrigation fluid
(typically saline solution)
* at our department of urogynecology we are using a triple-channel (triple-lumen) catheter with one
extra channel for measuring the pressure in the urethra. Using triple-lumen catheter we can perform
not only filling cystometry, but also the profilometry (see below) at the same time.
Detrusor pressure (true bladder pressure: bladder muscle pressure) = intravesical pressure – intraabdominal pressure
The following parameters are evaluated during filling cystometry:
Detrusor sensitivity: during filling bladder with fluid patient is asked to report
•
first desire to void
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•
•
normal desire to void
strong desire to void
As soon as the patient notices the particular desire to void, she reports it, at the same time the
volume of the bladder is recorded.
Detrusor activity: recorded as a curve in the cystometry graph. Detrusor pressure during filling
should be very low with no involuntary contractions (only minimal increase of intravesical pressure).
Detrusor overactivity is defined as involuntary detrusor contractions during filling.
Detrusor (cystometric) capacity: normal capacity in adults is 350-500 ml.
Bladder compliance: relationship between the change in bladder volume and the change in detrusor
pressure.
Filling cystometry - results
The normal cystometrogram curve
Using filling cystometry, we can detect the following disorders:
Detrusor sensitivity disorders
•
•
hypersensitivity – acute / chronic cystitis, bladder tumor
hyposensitivity – neurogenic disorders (spinal cord injury, diabetes)
Activity disorders
•
hyperactivity - increased contractility (OAB, Parkinson, multiple sclerosis)
Pathological capacity
•
•
reduced capacity – cystitis, bladder tumor
increased capacity – neurogenic disorders, chronic obstruction of the lower urinary tract
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Uroflowmetry
Uroflowmetry is noninvasive diagnostic method used to measure the flow of urine during voiding.
The examination is performed using a uroflowmeter, which is basically a specially designed toilet.
The toilet is equipped with a rotating disc, on which a stream of urine falls during urination. This disk
is braked by the falling urine – the rotating disc measures the power necessary to maintain a
constant rotation, since urine tends to slow down the speed of the disc, the additional power reflects
the urine flow rate.
Another method of measurement is that the specially designed toilet with the funnel is connected to
the digital uroflowmeter – an accurate measuring device with high-precise weighing sensor that
measures the amount of falling urine over time. This type of device is available at our department of
urogynecology. The output of the examination is an uroflow curve on which we can evaluate:
•
•
•
•
•
continuous or intermittent flow
maximal flow
average flow
voiding volume
total voiding time
In a healthy patient, the uroflow curve is continuous, uninterrupted, and smooth. The normal value
of the maximum flow rate greater than 15 ml / s.
With reduced detrusor contractility, the curve is flattened, and urination takes longer. This can be
caused eg. by detrusor decompensation during prolonged lower urinary tract obstruction.
Intermittent uroflow curve indicates significant obstruction of the lower urinary tract.
Uroflowmetry – results:
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In the following three uroflow curves recorded by uroflowmetry, there is a significant difference.
The first one is normal uroflow curve in a healthy patient. The patient voided the entire volume of
urine for approx. 13 seconds. The total voiding volume is 549 ml. The average flow rate is 37 ml / s.
The second uroflow curve is pathological – the curve is flat, the average flow rate is 3.7 ml / s. The
total voiding volume is 228 ml, for a total voiding time of 58 seconds. It is caused by reduced
contractility of the detrusor based on pelvic organ prolapse.
The third curve shows repeated interruptions during urination. However, during urination itself, there
is a relatively significant increase in flow due to an increase in abdominal pressure - the patient must
push hard to urinate a portion of urine. Such a curve is typical in severe lower urinary tract
obstruction - in men, for example, in prostate hyperplasia, in women, it may be caused by excessive
correction of the urethrovesical junction after surgery for stress incontinence (TVT, TVT-O…).
78
Uroflowmeter
Specially designed toilet used during uroflowmetry. Below the toilet is a funnel, which points to a
prepared tank, which lies on an accurate measuring device with high-precise weighing sensor. The
device measures the weight of falling urine and records it over time. The result of the measurement
is a uroflow curve represents the amount of urine urinated in ml per time in seconds (see above).
Detail of a measuring device. After urination, the mark on the tank shows the total amount of
excreted urine.
79
Urethral Pressure Profilometry
Profilometry is used to examine the function of the urethral sphincters by measuring intraluminal
pressure along the length of the urethra with the bladder at rest. The study is done by inserting a
catheter equipped with pressure sensors into the urinary bladder.
This catheter is automatically withdrawal through the urethra at a constant rate of speed. During the
withdrawal, the pressure is measured along the entire urethral length as well as in the bladder. The
result of the study is the urethral pressure profile, which is an image of the spatial pressure
distribution in the urethra. The second output is the length of the urethra.
Standard profilometry is usually followed by stress profilometry.
The procedure is basically same, but in addition to the standard profilometry, the intravesical
pressure is also measured during the stress maneuvers – in most cases during the coughing. The aim
of the study is to confirm stress incontinence. If the value of the intravesical pressure is higher than
the value of the maximum urethral pressure during coughing, urine leakage occurs, which confirms
the stress incontinence. It is recommended to perform the examination with half the filling of the
bladder.
Urethral closure pressure – difference between urethral and intravesical pressure
80
Equipment necessary for filling cystometry and urethral pressure profilometry
A: Gynecological examination chair with a special equipment (marked X in the picture) processing
automatic withdrawal of catheter during profilometry
B: Computer equipped with software providing measurement, saline solution (marked nr. 1), sockets
for connecting each catheter (marked nr. 2)
A – catheter measuring intra-abdominal pressure, catheter is inseted into the rectum during filling
cystometry
B – triple-channel cathteter, each channel has his own special function
1. urinary bladder filling (filling cystometry)
2. intravesical pressure measuring (filling cystometry)
3. urethral pressure measuring (profilometry)
81
Catheter detail: A – catheter inserted into the rectum (intra-abdominal pressure)
B – three-way catheter inserted into the urethra and bladder (see above)
Pressure-Flow Studies
Invasive examination requiring good patient cooperation. This study is used to evaluate detrusor
activity during micturion. During the examination it is simultaneously recorded urine flow
(uroflowmetry) and intravesical pressure. The result is a pressure-flow curve. The study is performed
by inserting a catheter into the bladder that measures intravesical pressure. The catheter is inserted
into the bladder through the urethra or transabdominally by a suprapubic approach (highly invasive).
In case of transurethral approach, the catheter is as thin as possible, but there is still some reduction
in urethral flow. Based on the results, it is possible to diagnose lower urinary tract obstruction,
decreased or increased detrusor contractility.
Imaging methods
Ultrasound imaging
Ultrasound imaging is fundamental part of urogynecological examination. It is necessary sometimes
to perform both, transvaginal and transabdominal ultrasound. Using ultrasound, it is possible to
assess deviations from normal anatomy, evaluate UVJ and urethral stability, assess the postmiction
residuum, locate TVT position, assess the anal sphincter morphology and function and many more.
Furthermore, using introital ultrasound, especially using 3D and 4D ultrasound imaging of true pelvis
it is possible to display and assess urogenital hiatus, levator function, levator damage et cetera.
82
Introital ultrasound examination using abdominal 3D / 4D probe – it is possible to evaluate the size of
urogenital hiatus and damage (avulsion) of levator ani muscle
Imaging of the anal sphincter using transvaginal ultrasound:
M - mucosa, IAS – internal anal sphincter, EAS – external anal sphincter, * - the anal canal
83
Cysto-urethroscopy
Cysto-urethroscopy is used in case of suspicion to bladder pathology (tumor, diverticulum), or when
hematuria is present. It is performed by urologist in most cases.
Intravenous urography – extraurethral incontinence, fistula
Magnetic resonance
MR is advanced imaging method, mostly used in the evaluation of pelvic floor disorders and
assessment of levator avulsion. MR is used especially in complicated patients, prior to repeated
operations or in clinical trials. MR imaging of the pelvic floor is more accurate than ultrasound
imaging but is far more expensive. In most cases the 4D ultrasound imaging of the true pelvis is quite
sufficient.
Other methods
Video urodynamics
Video urodynamics is a combination of urodynamic examination method and imaging method
(ultrasound, X-ray). Using this method, it is possible to assess the anatomical conditions in the true
pelvis and performing a functional urodynamic examination at the same time.
Electromyography
Electromyography is used to assess the activity of the striated urethral sphincter.
84
11. Investigation of the infertile
couple, treatment plan, semen
analysis
Basic procedure in infertility management
Examination is planned into ovulation so as not to disrupt the early development of the embryo
!!
Tubal factor as the cause of sterility is in 30 % of women
CAVE! Obstruction of the contrast agent may be caused by transient muscle contractions
It uses only passive assessment of patency - no diagnostic test can evaluate tubal physiology
Therapeutic potential - the fallopian tubes can be unblocked by removing cellular detritus
Methods:
Ultrasound sonohysterosalpingography (SONO HSG) with contrast agent
•
•
•
•
The most commonly used, when the result is unclear surgery can be indicated (laparoscopy,
hysteroscopy)
The contrast agent contains hydroxymethylcellulose and glycerol, when mixed with water it
forms a foam. Mixing takes place in two interconnected syringes and foam is formed as it
passes through the narrow part. The foam is applied through a catheter into the cervix and
to the uterine cavity, where it is to pass through the fallopian tubes to the periovarial space.
The patency of the fallopian tubes is evaluated using vaginal ultrasonography, the probe is
inserted when foam is applied
Advantage: The examination is performed on an outpatient basis without the need for
analgesia or anaesthesia and lasts up to about 10 minutes, it is affordable and time-saving.
Disadvantage: the result is influenced by the acoustic properties of the tissues, anatomical
conditions, the quality of the ultrasound device, the experience of the sonographer, the
patient's reaction to the application of a contrast agent
85
•
Contraindications: suspected pregnancy, uterine bleeding, inflammation, cancer of the
genital tract
Using EX EM foam kit:
https://www.youtube.com/watch?v=bcPQ-_K0aR0
Laparoscopic chromopertubation
•
•
•
•
Indication: when surgical laparoscopy in small pelvis (cysts, fibroids) is done in women
planning pregnancy, or in the cases of unclear findings in sonoHSG
After insertion of the laparoscopic instrument into the abdominal cavity and visualization of
the uterus and adnexa, we apply a blue dye (Patent blau) through the cervix. In a
physiological finding, it passes through the uterine cavity into the fallopian tubes and flows
into the abdominal cavity. Thanks to the established optics, we can observe the passage of
the dye and we are able to evaluate the permeability of the fallopian tubes.
Advantage: possibility to achieve higher pressure for contrast application than with
sonoHSG, possibility of surgical procedure - removal of adhesions, sactosalping
Disadvantage: the need for general anaesthesia, surgical risk
Chromopertubation – in the fallopian tube on the right (1st controlled) the patency is clearly visible,
in the left fallopian tube there is a suspicious obstruction, which at the end of the application is
partially released and a small amount of dye passes through the fallopian tube:
https://www.youtube.com/watch?v=WQXYm6yeM_c
Transvaginal hydrolaparoscopy
•
•
•
•
unusual method, used only in some workplaces
A trocar is inserted into the Douglas cavity through the posterior vaginal wall and the
abdominal cavity is filled with an aqueous solution, optics are then inserted into the trocar
and direct visualization of the peritoneal cavity is possible, fallopian tubes, ovaries and uterus
is visible, then chromopertubation is added
Advantages: direct visualization of the abdominal cavity and fallopian tubes with ovaries,
absence of skin incisions, abroad and as an outpatient procedure under local anaesthesia, or
as one day surgery
Disadvantages: poorer clarity, especially with adhesions in the pelvis, impossibility of
surgery, risk of injury to the pelvic organs
The difference between transvaginal hydrolaparocopy and abdominal laparoscopy:
https://www.youtube.com/watch?v=95Dy5dOIkzQ
X-ray hysterosalpingography:
•
•
•
•
method historically used before the development of sonography, hysteroscopy and
laparoscopy
an X-ray contrast agent is applied to the uterus with a Shultz apparatus through the cervix,
and we take 1-2 images.
Disadvantages: radiation exposure of the patient and staff, procedure is very unpleasant and
painful for the woman
Contraindications: iodine allergy, pelvic infections, pregnancy
86
Hysterosalpingogram with normal findings (source MEDCHROME))
When examining patients, we should not forget about the possibility of vagal irritation by
manipulating the cervix, and especially in patients with cardiac disease we must be careful.
Semen analysis
Basic examination of male fertility
Decreased male fertility contributes to the fertility disorders of the couple in about 40-50%
We determine the number, movement, functional properties and morphological features of
sperm
Ejaculate collection by masturbation is done after 3-7 days of sexual abstinence
•
•
•
•
We measure volume, pH, colour, consistency and viscosity in the sample
pH change: higher than 7.8 sign of infection, lower than 7.0 may indicate seminal tract
obstruction
We microscopically examine the number, movement and morphology of sperm, the
presence of other elements (leukocytes, detritus…)
Microscopic examination: phase contrast microscope, standardized conditions, currently the
Makler chamber is mostly used
87
Sperm morphology:
Length approx. 50–60 μm, head approx. 3x4x5 μm
Reference values according to WHO 2010
•
•
•
•
•
•
•
•
•
Sperm concentrations: 15 mil / ml and above
Total sperm count: 39 miles or more
Ejaculate volume: 1.5 ml and more
pH 7.2, and more
Movement: Progressive movement (moving forward) 32% or more
Total movement of 40 mil and more
Morphology: 4% or more of normal sperm forms
Liquefaction: up to 60 minutes (after collection the ejaculate is not liquid, has a gel
consistency, liquefies up to several tens of minutes)
Viscosity: After liquefaction, we evaluate the viscosity by aspiration into a 5 ml pipette, from
which the sperm should drip freely. Normal sperm creates simple drops
Presence of other cellular elements: up to 1 mil / ml (leukocytes, erythrocytes, epithelial
cells, etc.
88
Nomenclature:
•
•
•
•
•
•
•
•
•
Normozoospermia: parameters in the norm
Oligozoospermia: decreased concentration
Astenosoospermia: decreased movement
Teratozoospermia: decreased morphology
Azoospermia: absence of sperm
Aspermia: absolute absence of sperm
Cryptozoospermia: sperm found only after centrifugation of the sample
Pyospermia: increased number of leukocytes
Hematospermia: presence of blood in the sample
Possibility of further examination:
We treat male fertility disorders in cooperation with a urologist, sexologist, geneticist,
endocrinologist.
Testicular dysgenesis syndrome
In recent decades, since the 1940s in the economically developed countries, deterioration of semen
analysis parameters (reduction of concentration and movement of about 1% per year) and increase
in the incidence of testicular cancer and hypospadias have been observed. Damage to testicular
development in the embryonic period by endocrine disruptors - cigarette smoke products,
environmental pollutants is considered to be the cause.….
89
12. Pediatric gynecology
examination, pubertal
development, vaginal smear test
Pediatric gynecology examination
Specific approach considering the age of the girl and the presence of the parent(s)
•
•
•
•
•
Medical history (mainly from parents, but it is appropriate to ask the girl as well to estabilish
a contact and gain a trust)
Family history – hereditary diseases, blood clotting disorders, congenital disorders of the
genital
Personal medical history – the course of pregnancy and childbirth, psychomotor
development...
Gynecological history (menarche, regularity of the cycle, absence or omission of menses,
after the age of 15 coitarche, number of sexual partners, methods of contraception...,
question about discharges, urination, stool...)
Aspection – in addition to the overall evaluation with focus on secondary sexual signs
according to Tanner (breasts, pubic hair), height and weight
90
•
•
•
•
•
Palpation, percussion, gynecological examination (rectoabdominal - index finger, little finger
by the little girls)
Vaginal examination – for virgo vaginoscopy
Taking of samples for cultivation, functional cytology
Imagining methods ( ultrasound abdominal, rectal, CT, MR)
Others according to the finding (genetics, endocrinology, surgery, urology and nephrology,
dermatology, psychiatry...)
Vaginal smear test in pediatric gynecology = functional
cytology (FC) = hormonal cyto-diagnostics
•
•
Previously the only method to evaluate the dynamic changes of steroids in the female body
Today used only in pediatric gynecology and endocrinology
91
Vaginal epithelium in different periods:
•
Newborn – the epithelium of the vagina is the same as that of the mother.
o With the FC the secretion of maternal hormones can be monitored
•
Childhood – atrophic type (basal and parabasal cells)
92
•
•
•
Puberty – basal and parabasal cells are replaced by intermediate and superficial cells
Reproductive age – cyclical changes
• Follicular phase – number of superficial cells increases (maturation is caused by
estrogens)
• Luteal phase – rolling up and folding of the cells
Pregnancy – significant folding of the cells (over 50 cells so–called pregnancy plate) and the
rolling up
o Significant extension of the intermediate layer, typical shape of cells – shuttle
93
•
Klimakterium a senium - gradual loss of mature cells, their replacement with basal and
parabasal (atrophy)
FC evaluation
Effect of estrogen:
•
•
•
The maturation index (MI) is the ratio between parabasal intermediate and superficial cells
The caryopyknotic index (KI) is the ratio of the number of cells with pyknotic nucleus
(superficial cells) to intermediate cells regardless of the color of the cytoplasm
The eosinophilic index (EI) is the ratio of eosinophilic cells to cyanophilic cells regardless of
the appearance of the nucleus
94
Effect of progesteron
•
Folded index shows the ratio of the number of cells with smooth edges to the number of
cells with folded edges, regardless of the shape and staining of the cells
95
13. Gynecologic oncology ultrasound, clinical staging, breast
cancer imaging
•
•
•
Diagnosis of tumors, staging, planning of operations, navigation of invasive procedures,
diagnosis of postoperative complications, monitoring of the effect of therapy – restaging,
dispensarization
ultrasound is the basic method in gynecology
ultrasound, CT, chest X-ray, MMG – part of each staging; PET/MR, MR – for selected
Ultrasound
•
•
•
•
•
•
Transvaginal (trans-rectal) + abdominal
Tumor detection, diff. dg. of ovarian tumors, local spread and growth into parametria,
distant metastases, ascites, peritoneum carcinoma, omental cake, lymphadenopathy, renal
dilation
commonly available, without preparation, risks, contraindications
Low price, excellent distinctiveness
Dynamic examination, sono-palpation – evaluation of soreness, mobility of tissues, Doppler
exam – pathological blood flow of onco-suspicious findings
the need for an expert ultra-sonographer
Fig. 1 Endometrial carcinoma (clear cell), pathological blood flow - color score 3-4.
96
Fig. 2 Granulosa cell ovarian cancer - adult type.
97
CT
•
•
•
•
•
•
•
•
Abdomen + small pelvis; chest
Good availability, short waiting time
Scan large volume in a short time
Contrast administration – iv/po, frequent allergic reactions, lower tissue resolution than MRI
Significant radiation load
Deficiencies in the evaluation of growth into parametria and diff. dg. ovarian tumors due to
the smaller tissue resolution
Good assessment of lymphadenopathy and dissemination, used mainly in staging of
advanced diseases, monitoring of response to treatment, planning of radiotherapy
KI: pregnancy, relative – renal failure, children
Fig. 3 Voluminous ovarian tumor – histologically malignant transformation of the teratoma. Ileus.
98
MR
•
•
•
•
•
High tissue contrast, no ionizing radiation
Higher price, lower availability, longer waiting time
Noise and length of examination – less tolerated
Cervical tumors, endometrial ca (e.g. before fertility-sparing therapy), non-onco indications –
endometriosis, adenomyosis, fibroids
KI: pacemaker, cochlear implant, ferromagnetic implant
Fig. 4 Tumorous infiltration of the uterus
99
PET/CT, PET/MR
•
•
•
•
•
Combination of functional and morphological imaging – allows you search for viaible tumor
tissue (accumulation of radiopharmaceuticals), and in addition, unlike PET itself, specify its
localization
Complementary method at ambiguous conclusion of previous, staging, evaluation of
response to treatment, detection of tumor origo, confusion in tumor duplicates
High price, poorer availability, long waiting time
Application of radiopharmaceuticals (fluorodeoxyglucose marked with fluorine 18F
radioisotope) + contrast agents
CAVE: false positive results – physiological changes in fertile women, reactive changes after
surgery, RT, CHT – sufficient time interval should be observed
Fig. 5 and 6 Accumulation of radiopharmaceuticals in lymph nodes
100
Mammography
•
•
•
•
•
•
Screening – tumor search up to 2 cm in asymptomatic women
from 45 years each 2 years (each 1 year in risk groups – HRT, BRCA),
Diagnosis of breast cancer
Cranio-kaudal and medio-lateral oblique projection, soft radiation
Evaluation in classification BI-RADS 0-6 and Tabar I-V (degree of density of breast tissue)
KI: pregnancy, breast-feeding
Fig. 7 and 8 Breast cancer in craniokaudal and mediolateral oblique projection
101
Breast ultrasound
•
•
•
•
Mamma + axilla (detection of lymphadenopathy)
In oncogynecology auxiliary method, in younger women, in pregnancy and lactation
Cysts, fibro-adenomas, unclear MMG findings, abscesses
Biopsy navigation, pre-operation focus
Fig. 9 Sonographic focus of breast tumor before surgery.
•
CEUS – contrast ultrasound – iv administration of contrast agent increases the intensity of
the Doppler signal (microbubbles in CA increase the intensity of reflected waves)
o dg foci of the breast, as well as liver meta
o Higher sensitivity and specificity
o Evaluation of not only the location of the KL accumulation, but also the saturation
rate
102
Fig. 10, 11, 12 Breast ultrasound: simple display, Doppler display, use of contrast agent.
103
SPECT/CT
•
•
•
•
hybrid method – SPECT and low-dose CT in one device – combination of functional and
anatomical display
Detection of sentinel nodules in breast cancer
Administration of the 99mTc radiopharmaceutical near the tumor, followed by a series of
images.
The descending lymphatic drainage pathways and deposition of the radiopharmaceutical in
the sentinel node are displayed, the location of the sentinel node on the skin for surgical
intervention is marked
Fig. 13 Capturing sentinel nodules before planned surgery for breast cancer.
•
•
Scintigrafie – planární zobrazení gamakamerou; SPECT – analogie CT, přístroj
s gamakamerami, které se otáčí kolem vyšetřovaného -> funkční struktura)
Scinti skeletu – využití při stagingu, pokud nebylo provedeno jiné celotělové vyšetření
Fig. 14 Bone scintigraphy
104
X-ray
•
•
Chest – part of staging examinations (if there was no chest CT), diff dg dyspnea – fluid-thorax
(malignant, often in ovarian cancer), pneumothorax,
X-ray of the abdomen standing – postoperative complications (ileus)
Fig. 15 Fluid thorax bilaterally – malignant effusion in ovarian cancer
105
14. Pelvic ultrasound in
gynecology
•
•
•
•
•
•
Sonography is the most used imaging method in gynecology, a non-invasive and safe
Uses high frequency sound waves (waves with frequencies 16 kHz – 1 GHz, in Gynaecology
2.5 to 7.5 MHz)
Practical use of obstetrics and gynecology since the late 1950s
Doppler ultrasound – show the flow in blood vessels
We use a colourless inert gel - reduces the formation of air layer, improves visibility
International Society for Ultrasound in Obstetrics and Gynecology – ISUOG
The physical principle of ultrasound
•
•
•
•
Conversion of kinetic or mechanical energy, due to crystal deformation, into electrical energy
using the piezoelectric effect
Different tissue has different echogenity (density and elasticity), the waves propagate and
reflects differently
The Doppler effect - the change in frequency of a wave in relation to an observer who is
moving relative to the wave source.
Higher frequencies of ultrasound have shorter wavelengths and are absorbed more easily.
Therefore, higher frequencies are not as penetrating - high frequencies are used for the
superficial body structures and low frequencies are used for those that are deeper.
106
Ultrasound probes used in gynecology:
•
•
•
•
•
Transabdominal convex
Transabdominal 3D
Transvaginal 3D
Linear
Transvaginal
In Gynecology, we most often use B-mode and 2D imaging.
Examination options:
Transabdominal examination:
•
5 to 5 MHz, we show the abdominal cavity and a lesser (true) pelvis over the abdominal wall,
the advantage is a filled urinary bladder
107
•
we can observe
o Vagina (worse)
o Uterus
o Ovaries (worse)
o Urinary bladder
o Intestine, kidneys, liver, spleen, pancreas, lymph nodes, free fluid (ascites,
hemoperitoneum),...
Transvaginal examination:
•
0 to 7.5 MHz, imaging of lesser pelvic organs
108
•
we can observe:
o Vagina
o Cervix
o Uterus – endometrium, myometrium
o Ovaries
o Fallopian tubes – a normal fallopian tube is almost always invisible on ultrasound.
o Urinary bladder
o Recto-uterine pouch (Pouch of Douglas)
Recording of a physiological ultrasound finding
•
•
what we are looking at and evaluating as often as possible
uterus in AVF / RVF (ante / retroversion / flexion) of normal size (measured in the
longitudinal x transverse axis), endometrium 6 mm high (depending on the phase of the
menstrual cycle / pathology of the uterine cavity), sharply demarcated from the
myometrium (tumours), myometrium without pathology, ovaries bilaterally normal
structure and echogenicity, pouch of Douglas without free fluid
The most common pathologies diagnosable by
ultrasound:
•
•
•
•
•
•
Myometrium – myoma (fibroids), adenomyosis, congenital malformation
Cervix – tumours, polyps
Endometrium – non-viable pregnancy, retained products of conception, endometrial polyps,
fibroids, position of IUD, tumours, congenital malformations
Fallopian tube – ectopic pregnancy, hydrosalpinx, adnexal masses
Ovaries – cysts, tumours
Pouch of Douglas – free fluid (blood, …)
109
Frequent ultrasound findings
Endometrial polyps
110
Ovarian cyst
111
Ovarian cancer
112
Cervical cancer
Ascites, carcinomatosis
Pictures – resources:
•
•
•
•
http://krishnaivf.com/various-types-ultrasound-transducers/
https://cs.wikipedia.org/wiki/Sonar
https://www.slideshare.net/tailaamber/transvaginal-ultrasound
Ultrasound images taken of Gynecology and Obstetrics Clinic, University Hospital Brno
113
15. Ultrasound scans in pregnancy,
dopplerometry
In modern obstetrics, ultrasound is one of the elementary diagnostic methods approving monitoring
of the pregnancy and enabling to detect pathological conditions.
At the beginning of pregnancy (positive pregnancy test) we use ultrasound to verify whether the
pregnancy is in the uterus, if it develops in the right way (present embryonic structures, action of the
fetal heart), length of pregnancy etc.
Intrauterine pregnancy, gestational sac
•
DB, DP a DC (decidua basalis, capsularis, parietalis)
source: Doporučená ultrazvuková vyšetření v těhotenství,M.,Lubušský, L., Krofta a spol
114
Heterotopic pregnancy
•
left - intrauterine pregnancy, right - ectopic pregnancy
source: https://www.ultrasound-images.com/early-pregnancy/
Bichorionic biamnial pregnancy
•
(2xAD, 2xCD)
source: Doporučená ultrazvuková vyšetření v těhotenství,M.,Lubušský, L., Krofta a spol
115
Monochorionic biamnial pregnancy
•
(2xAD, 1xCD)
source: Doporučená ultrazvuková vyšetření v těhotenství,M.,Lubušský, L., Krofta a spol
We determine the date of pregnancy according to the crown-rump length (CRL). CRL measured in
the first trimester allows the calculation of the estimated date of birth according to the ultrasound
examination.
CRL – crown rump lenght
source: http://pccwellness.org/pcc-salud-family-health-center/14-programs-and-services/primarycare/pregnancy-services/
116
As a part of regular follow-up, all pregnant women should undergo three subsequent screening
ultrasound examinations (for more details read the practical question INVASIVE AND NON-INVASIVE
METHODS OF PRENATAL DIAGNOSIS).
Ultrasound examination until 14th week of pregnancy
•
•
•
•
•
•
number of fetuses
vitality of a fetus
fetal biometry (CRL)
determination of chorionicity and amnionicity in a case of multiple pregnancy
screening for structural defects
screening of UZ markers of chromosomal aberrations
Ultrasound examination between 20-23th week of pregnancy
•
•
•
•
•
•
vitality of the fetus
biometry measurement (BPD - biparietal head diameter, HC - head circumference, AC abdominal circumference, FL - femur length) and calculation of the estimated fetal weight
localization of a placenta
amount of the amniotic fluid
screening of structural defects of a fetus
screening of UZ markers of chromosomal aberrations
Ultrasound examination between 30-32th week of pregnancy
•
•
•
•
•
•
•
vitality of a fetus
position of the fetus
Biometry (BPD, HC, AC, FL parameters are measured and the estimated weight of the fetus is
calculated
localization of the placenta
amount of the amniotic fluid
screening of structural defects
Dopplerometry to assess placental function in the case of suspected placental insufficiency
Placenta praevia and its types - placenta attaches inside the low uterine segment, near or over the
cervical opening.
Vaginal bleeding may occur during pregnancy. In the case of massive bleeding, immediate
termination of pregnancy is inevitable. Otherwise, pregnancy is terminated by the elective cesarean
section around the 38th week of the pregnancy due to the risk of bleeding and placental abruption in
the case of spontaneous labor onset. The surgical procedure is associated with a higher risk of
excessive blood loss due to the possible abnormal placental invasion.
117
sources: https://editorial.glowm.com/?p=glowm.cml/ultrasoundAtlasImage&image=611
a https://www.medicinus.net/placenta-previa/?lang=en
In the case of twin pregnancy (which is associated with more frequent pathologies) ultrasound
examinations should be performed more often than in single-pregnancy. Ultrasound should exclude
the signs of complications specific to the monochorial twins (twin-to-twin transfusion syndrome,
selective intrauterine growth restriction etc.) and the risk of the possible premature birth
(measurement of the length of the cervix – UZ cervicometry.
Cervical incompetency With funneling of the internal cervical os
118
Estimating of the fetal weight – measurement of the specific parameters (BPD, HC, AC, FL).
BPD – biparietal diameter, HC – head circumference
source: https://www.ultrasound-images.com/early-pregnancy/
AC – abdominal circumference, Ž – stomach, DDŽ – inferior vena cava
source: https://www.ultrasound-images.com/early-pregnancy/
FL – femur length, E – epiphysis
source: https://www.ultrasound-images.com/early-pregnancy/
119
The ultrasound can be helpful in the diagnosis of emergency conditions. An example is the
determination of the presenting parts of the fetus during the second stage of the labor before the
vaginal extraction (vacuum extraction, forceps) and increasing the safety of these procedures.
Another example is monitoring the heart rate of the second twin after vaginal birth of the first twin
or excluding placental abruption in the case of peripartal bleeding of the mother.
Synciput presentation – orbits
source: https://www.ultrasound-images.com/early-pregnancy/
x
Occiput (vertex) presentation – occiput and spine
source: https://www.ultrasound-images.com/early-pregnancy/
120
Placental abruption
sources: https://medsphere.wordpress.com/2017/04/09/abruptio-placentae/
a https://cz.pinterest.com/pin/167266573645976766/
Dopplerometry in obstetrics
Doppler ultrasonography is a diagnostic method based on the Doppler effect Which describes the
change in frequency of a wave in relation to an observer who is moving relative to the wave source.
Ultrasound uses acoustic waves with a frequency above 20 kHz
source: https://www.researchgate.net/figure/Doppler-principle-The-Doppler-shift-Df-can-becalculated-as-Df2uf0-C-in-which-u-is_fig5_51708943
121
A - systolic blood flow, B – end-diastolic velocity, PI - pulsatility index (A - B/V)
source: https://www.ultrasound-images.com/early-pregnancy/
Dopplerometry has become a routine examination in prenatal diagnosis. It allows to assess the
hemodynamics in uteroplacental and fetal circulation.
We use Doppler methods
1. to examine chromosomal aneuploidy (also see prenatal diagnosis) (Ist trimester - tricuspid
regurgitation, abnormal flow in the venous duct)
2. as part of preeclampsia screening in the Ist trimester (uterine arteries)
3. diagnosis of fetal anemia: MCA-PSV Measurement of maximum flow rate in the middle
cerebral artery (due to the blood rheology)
4. diagnosis of the specific pathologies of the monochorial twin pregnancy
5. diagnosis of the fetal distress in the fetal growth restriction due to placental insufficiency
(IUGR ): a. umbilicalis, a. cerebri media, ductus venosus, a. uterina
Different flow rates in the midde cerebral artery (ACM-PSV)
122
Changes in fetal hemodynamics due to fetal distress, IUGR
Arteriální oběh plodu se od novorozeneckého liší ve dvou ohledech:
The arterial circulation of the fetus differs from the newborn in two aspects: Oxygenated blood from
the placenta returns to the fetus through the umbilical veins to the liver. In the liver, part of the
venous blood flows into the portal system, partly continues to the venous duct to the right heart.
Blood from the right heart flows through the foramen ovale to the left heart and then into the aorta,
50% of the blood from the aorta flows along the umbilical arteries back to the placenta.
Scheme of the fetal circulation and changes in hemodynamics due to the
distress of the fetus
source:
http://www.jiaecho.org/viewimage.asp?img=JIndianAcadEchocardiogrCardiovascImaging_2018_2_3
_155_247028_f5.jpg
The first reaction to the reduced supply of nutrients from the placenta is a decrease in the metabolic
needs of the fetus leading to a decreation in growth followed by an centralization of the circulation
(increase in cerebral flow). If this compensatory mechanism is not sufficient, an increase in systemic
arterial pressure and abnormal flow in the umbilical arteries occurs (zero to reverse flow) than into
123
the venous duct and umbilical vein All these compensatory mechanisms are reflected in PI -pulsatility
index.
CPR – PI arteria cerebri media / PI a. umbilicalis
The fetus reacts to the development of hypoxia by redistributing blood flow with a preferential
supply of central organs - the heart, brain, and adrenal glands. Increasing flow through the brain
arteries is called the “brain - sparing” effect. To describe this condition we use cerebroplacental index
(CPR), comparing the pulsatility in the cerebral artery and umbilical artery.
doppler - umbilical artery
Normal umbilical artery doppler (1,2), Absent diastolic flow (3, 4), Reverse end-diastolic flow (5)
124
doppler – venous duct
Normal A-Wave (1), absent (2) and reverse A-wave
Dopplerometry in uterine arteries – high resistance (diastolic notch) in uterine arteries is associated
with a high risk of developing IUGR and the development of preeclampsia.
Normal wave, 24th week of pregnancy
source: https://slideplayer.cz/slide/4875284/
125
Pathological placentation
source: https://slideplayer.cz/slide/4875284/
Changes in doplerometry due to the development of intrauterine distress of the fetus precede
changes in CTG in days to weeks.
The doplerometric parameters helps us to determine the severity of the placental insufficiency and
thus the ideal timing of termination of pregnancy before the onset of serious complications
126
16. Cervical and vaginal cytology,
HPV testing and vaccination
Cervical cytology (Pap smear):
•
•
•
•
main screening method for the secondary prevention of cervcial cancer
once a year, since age of 15
sample of cells is taken from exocervix/ endocervix usually by spatula/brush – after
application on slide glass is sample fixated by alcohol
another option is LBC – liquid based cytology – more sensitive and more accurate method,
higher price
127
•
the basis is a description of the criteria for malignancy
o morphological changes:
▪ cell nucleus – the most important for diagnostics
▪ enlargement of nucleus, change of shape and size (anizonucleosis),
irregular nucleus
▪ change of dyeability (hyperchromasia) – darker nucleus
▪ appearance abnormalitis, chromatin distribution, different dyeability
▪ changes of nucleolus – enlargement, multiplicity, irregular shape
▪ cytoplasm – in not an important diagnostic feature
▪ cell dimensions – different dimensions of cells (anizocytosis)
o Bethesda classification:
▪ evaluation of cervical cytology by pathologist: the following criteria are
evaluated:
▪ Interpretation of cell pathologies
▪ Evaluation of squamous cells:
▪ Typical squamous cells
▪ NILM (negative for intraepithelial lesions or
malignity)
▪ Atypical squamous cells
▪ ASC-US (atypical squamous cells of undetermined
significance)
▪ ASC-H (atypical squamous cells cannot exclude HG
SIL)
▪ LG SIL (low grade squamous intraepithelial lesion)
▪ HG SIL (high grade squamous intraepithelial lesion)
128
▪
▪
▪ Squamous cell carcinoma
Evaluation of glandular cells
▪ Typical glandular cells
▪ NILM (negative for intraepithelial lesions or
malignity)
▪ Atcypical glandular cells
▪ AGC-NOS (atypical glandular cells not
otherwise specified)
▪ AGC-NEO (atypical glandular cells favour
neoplastic)
▪ AIS (endocervical adenocarcinoma in situ)
▪ Adenocarcinoma (endocervical,
endometrial, extrauterinne, not otherwise
specified
▪ Evaluation of sample quality (satisfying X satisfying
but without endocervical cells X unsatisfying)
▪ Evaluation of presence of microoragnisms (yeast,
trichomonas, acinomycetes, heprpetic infection,
chlamydia, signs of bacterial vaginosis)
▪ Evaluation of endometrial cells presence in women
over 40 years of age
▪ Evaluation of other malignancy elements presence
(metastasis)
▪ Description of other findings (atrophy, reactive
changes in inflammation/after radiation/ IUD)
Conclusion and recommendation by examining cytopathologist (next check interval, bioptic verification etc.)
Limits of current screening:
•
•
•
Low patient participation (~50 %)
Age limit (better since age of 25)
High specificity, but low sensitivity (false negative result 15–40 %)
129
HPV testing
•
•
•
•
•
•
Replenishment of pre-bioptic methods, indicated in abnormal cytology findings and in
subsequent follow-up of patients with confirmed precancerous after conisation (at the
earliest in 6-12 months)
Based on molecular biological methods (DNA hybridization a PCR)
The most common HR variants are tested including selective genotyping (specific type of HR
HPV)
significant in women over 30 years of age
sample taken by brush from endocervix into a special liquid medium
low risk HPV testing has no clinical significance
HPV vaccination
•
•
•
•
Primary prevention of cervix cancer (only some types HR HPV! – i.e, protection is not
completa, on the other hand there si cross-imunity with other HR HPV)
Health insurance pays vaccine for 13 years old girls and boys – the principle is to undergo
vaccination before starting sexual life
Elderly individuals may also be vaccinated, Czech Gynecological and Obstetrical Society
recommends vaccinating patients diagnosed with precancerous lesion (before even after
conisation)
Currently three types of vaccines:
o Cervarix – bivalent (high risk HPV 16, 18)
o Gardasil (Silgard) – quadrivalent (high risk HPV 16, 18 and low risk 6, 11 – reduces
risk of genital warts)
o Gardasil 9 – nonavalent (high risk HPV 16, 18, 31, 33, 45, 52, 58 and low risk HPV 6,
11) – can protect against 90 % HPV infection associated cancer!
130
17. Colposcopy
•
•
•
•
Colposcope – binocular magnification system with a strong light source, allows direct
scanning
we detect basic changes in the vulva, vagina and cervix, infection and sources of bleeding
under colposcopy control, we can perform a biopsy of suspect foci
We perform colposcopy after fixing the cervix in the specula and cleaning the mucus
131
Native colposcopy – only mucus wiping (tampon soaked in saline)
Advanced colposcopy – highlighting of pathological changes
•
•
•
Application of 3-5% acetic acid → pathological changes of the epithelium are highlighted
(whitening)
Application of Lugol´s solution → helps to demark the lesion precisely
o epithelium with glycogen iodine-positive = mahogany brown color
▪ mature squamous epithelium
o complete iodine-negativity = yellow color
▪ suspected HG lesion
o area with iodine-negative districts
▪ immature metaplasia, CIN, atrophy
o spotted look
▪ immature metaplasia, LG lesion
color filter (green) → highlighting of pathological vessels
132
Normal findings
•
O (original epithelium) – smooth, pink, there are no remains of cylindrical epithelium
•
E (ektropium) – visualized cylindrical epithelium of the cervix, which reached the exocervix
from the endocervix (single–row, mucosus, „grape–like structure and red coloring“)
o
Juvenile ectopy:
133
•
TZ (transformation zone) – area between the original and cylindrical epithelium (various
stages of metaplasia maturation in it)
o Ectropium with incipient metaplasia (arrow shows squamous–colonary junction):
o
Ectropium with metaplasia:
o
Highlighting of iodine–negative immature metaplasia using Lugol´s solution
134
•
Topography of the transformation zone
o
o
o
Type I – fully visualizable placed on ecto-cervix only
Type II – fully visualizable, but part also placed in the endo-cervix
Type III – the endocervical part can´t be visualized or TZ is completely embedded
135
Abnormal findings
•
BE (white epithelium) – after application of acetic acid the areas with a higher density of
nuclei turn white – the more pronounced the whitening is, the faster the change is
noticeable and the longer it lasts, the more severe the lesion is (HG)
•
P (the spotting – fine/coarse) – capillaries appearing as dots – the coarser and farther apart,
the more severe (HG)
•
M (mosaic – fine/coarse) – new vessel formation is displayed as a flat horizontal field pattern
– the coaster, larger and irregular the fields, the more severe (HG)
136
•
V (atypical vessels) – newly formed vessels of bizarre shapes, (typewritten lines, corkscrews,
root system, sprouts of climbing plants, open hairpins, tuberous roots, centipedes, cut pieces
of thread or spaghetti)
137
18. Small gynecological surgeries
and instruments - excision, biopsy,
endometrial ablation,
hysteroscopy
•
•
•
•
•
One day surgery (ODS, Day surgery, Ambulatory surgery) - surgical procedures not requiring
an overnight hospital care, hospitalization (hospital stay) is not longer than 24 hours
Includes 50% of all surgery
The services provided can be generally called procedures - operative time is mostly in
minutes (usually around ten minutes)
Reduced risk of hospital-acquired (nosocomial) infection, faster convalescence, shortening
the times of temporary work incapacity
Procedures are usually performed under short term general anaesthesia
Introitus, vagina
•
Extirpation of Bartholin's cyst – recurrent abscesses
•
•
•
A vulvar biopsy - especially a part of diagnostics (for example lichen, VIN...)
Elimination of genital warts (condyloma acuminata) - coagulation, loop ablation, laser
Small (minor) plastic and aesthetic surgery - labiaplasty
Cervix
•
•
•
A cervical biopsy - diagnostics, especially on an outpatient basis
Ablation of cervical polyps
Conization of the cervix (cold knife cone, CKC)
o used to treat or diagnose cervical dysplasia
o the excision of a cone-shaped portion of the cervix to remove a cervical lesion and
the entire transformation zone. Conization can be done in most cases with an
electrosurgical instrument typically referred to as a LEEP (Loop Electrosurgical
Excision Procedure), LLETZ (Large Loop Excision of Transformation Zone) or NETZ
(Needle Excision of The Transformation Zone)
138
Uterus
•
Dilatation and Curettage (D&C)
o The most common indication for this procedure is abnormal uterine bleeding
o The first step in this procedure is place the speculum in the vagina to see the cervix
(1), then a tenaculum is placed to steady the cervix (2), use the blunt-tipped probe
for carefully measures the length of the uterus (3) dilate the cervix with Hegar or
similar dilators - a series of progressively larger metal rods (4) remove tissue
separately from the uterus and cervix with a curette - spoon-shaped instruments
with a sharp edge (5)
139
•
•
•
May be performed in early pregnancy to remove pregnancy tissue - in the case of nonviable pregnancy, such as a missed or incomplete miscarriage, an undesired pregnancy, or in
case of postpartum haemorrhage, retained product of conception, tissue from the uterine
cavity only
Suction curettage - method using a suction to remove pregnancy tissue from the uterine
cavity, gentler than using a curette,
Hysteroscopy
o principle of hysteroscopy - imaging of the uterine cavity (1). Diagnostic and surgical
hysteroscopes (2), optics 2-4 mm, outer diameter 3-9 mm. To fill the uterine cavity
are used distension media (nowadays liquid - mannitol solution with sorbitol
(Purisol), saline solution). We diagnose and solve pathologies of the uterine cavity
(congenital malformations, polyps, fibroids, tumours (4), adhesions, etc.). Normal
Finding (3)
140
Hysteroscopy
Diagnostics
•
•
•
•
infertility, sterility
abnormal uterine bleeding
suspicious finding in the uterine cavity
during ultrasound examination
Surgery
•
•
•
•
biopsy
disruption of adhesions, septal resection
resection of fibroids, polyps, endometrial ablation
removal part of IUD
Ovaries
•
Ovarian cyst aspiration (transvaginal, transabdominal) with the help of vectors, which will
allow us the exact position suitable for aspiration.
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Pictures – resources:
https://www.mayoclinic.org/diseases-conditions/bartholin-cyst/symptoms-causes/syc20369976
https://www.aafp.org/afp/2003/0701/p135.html
https://www.jostrust.org.uk/information/cervical-cancer/treatments/surgery/lletz
https://siteman.wustl.edu/glossary/cdr0000046448/
http://www.abortioninstruments.com
https://www.indiamart.com/proddetail/gynaecological-instruments-1243629612.html
https://www.invitra.com/en/fertility-after-pregnancy-loss/vacuum-or-aspiration-abortionprocedure/
https://mms.mckesson.com/product/630552/Medgyn-Products-022114
https://www.researchgate.net/publication/277412660_UltrasoundGuided_Aspiration_of_Adnexal_Cysts_With_a_Low_Risk_of_Malignancy_Is_It_a_Recomm
endable_Option/figures?lo=1
https://www.fertstert.org/article/S0015-0282(06)03052-4/pdf
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19. Laparoscopic gynecological
surgeries and instruments
•
•
Methods of minimally invasive surgery
Conservative treatment, radical operations, assisted-laparoscopy, open laparoscopy
Gynecology
Indications: congenital anomalies, sterility, infertility, suspicion for endometriosis, chronic pelvic pain
(Allen-Masters syndrom, chronic adnexitis, pelvic venous congestion sy.), acute pelvic pain (ectopic
pregnancy, adnexal torsion, ovarian cyst rupture), foreign body in abdominal cavity (IUD),
laparoscopic control of perforation of the uterus after intrauterine surgery (fausse-route)
Contraindications: physiologic limitations - pulmonary, cardiac/circulatory, diffuse peritonitis with
bowel obstruction (ileus), pregnancy with matching fundal height 20 w. or more, unstable vital signs
(hemoperitoneum)
Operations: myomectomy, laparoscopically assisted vaginal hysterectomy (LAVH), total laparoscopic
hysterectomy (TLH), salpingectomy, ovarectomy, adnexectomy,
appendectomy, adhesiolysis, laparoscopic surgery to treat endometriosis
Oncogynecology
Indication: bioptic verification of oncological process, operative treatment of early stadiums of
precancerous laesions/tumors, radical (staging or paliative) treatment
Operations: sentinel lymph node detection, laparoscopic pelvic and paraaortal lymphadenectomy,
radical hysterectomy type A, infracolic omentectomy, appendectomy
Advantages: less blood loss, shorter hospitalisation period and reconvalescence time, fewer
adhesions, fertility preservation, evaluation of laparoscopic findings
Disadvantages: injuries caused by Veress needle insertion (bowl injury, retroperitoneal vessels),
longer operation time in more complicated cases, impossibility to remove safely large findings
(ovarian cysts, tumors), specific anestesiologic risks
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A standard tower for laparoscopic surgery (video-capture unit, light source unit, CO2 insufflation
unit, aqua-purator, coagulation unit)
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Instruments
Verres insertion needle
Classic supra/sub-umbilical access – creation of pneumoperitoneum
Adhesions: use Palmer´s point: Laparoscopic entry by the left upper abdomen
Laparoscopic box
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Trocars 5 mm, 10 mm, 15 mm
Trocar reducer
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Laparoscopic instruments
From left: scissors, grasper DeBakey, bipolar scissors, grasper Dorsey
Suture holder
Dissector
Atraumatic grasper: lower risk of bowl injury
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Monopolar coagulation
Mechanic morcellator (myomas) a electric morcellator (faster)
Uterine manipulator - Koh-colpotomizer for total laparoscopic hysterectomy
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Uterine manipulator RUMI and uterine manipulator HOHL
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20. Abdominal gynecological
surgeries and instruments
•
•
•
the most common approaches: Pfannenstiel incision (transverse suprapubic incision) and
lower midline laparotomy with possible enlargement above the navel, or extension by upper
midline laparotomy (especially in oncogynecology)
Advantages of open surgery: overview in the abdominal cavity, possibility to remove bulky
findings in toto, shorter operation time (against LSK, depends on the experience of the
surgeon)
Disadvantages of open surgery: greater blood loss, prolonged convalescence, higher risk of
inflammation and breakdown of the wound (especially in obese patients), abdominal wall
deformities, hernia, keloid scars
Gynecology
Indications: voluminous findings, obese patients (today with question mark), cardiac/pulmonary
compromise of the patient, severe form of endometriosis
Procedures: hysterectomy, myomectomy, ovarectomy/adnexectomy, hanging operations,
procedures in one - gynecological performance together with surgery/plastic surgery, etc.
Oncogynecology
Indications: staging operations, debulking operations, interval operations, palliative operations
Procedures: radical hysterectomy (A, B, C1, C2, D), paraaortic lymphadenectomy, omentectomy,
appendectomy, peritonectomy, stripping of the diaphragm, resection of parenchymatous organs
affected by metastases (splenectomy, liver resection), resection of the intestines with
anastomosis/stoma, bladder resection, reimplantation of the ureter into the bladder,
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Layers of the abdominal wall (below the linea alba):
1 skin
2 subcutaneous tissue
3 + 4 oblique abdominal muscles
5 transverse abdominal muscle
6 straight abdominal muscle
7 common aponeurosis of abdominal muscles
8 extraperitoneal fat layer
9 peritoneum
Green under the straight muscle: in the middle igamentum umbilicale medianum (chorda urachi), on
the sides arteriae umbilicalis l.dx et l.sin,
Abdominal suture (ideally in anatomical layers)
•
•
•
Parietal peritoneum
o Muscles
o Fascia (aponeurosis) – the most important layer (absorbable suture with a longer
half-life to support the wound)
o Subcutaneous tissue (according to custom, suitable for reducing dead space)
o Skin (intradermal suture, continuation suture, individual sutures ...)
In lower middle laparotomy, the peritoneum, muscles and fascia can be sutured en bloc
drainage of individual layers (intraperitoneally, subfascially, subcutaneously ...)
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Instrumentarium
Tool sute
Scalpel (the first cut)
152
Tweezers
surgical (with ridges) – tissue grip, anatomical (smooth) – tissue shielding to stop bleeding by
monopolar coagulation)
153
Spreaders and hooks, retractors
Scissors (depending on the shape for various uses, can also be used for dissection of adipose tissue)
154
Clamps and forceps (smooth – atraumatic, Kocher forceps with ridges, Allis tissue forceps)
155
Needle holding forceps (length according to the depth in which it is worked)
Needles
156
Towel clamps
157