1. The structure of obstetrical hospital. Specificity of each unit and service.
The structure of an obstetrical hospital can vary depending on the size and type
of hospital. However, in general, it includes the following units and services:
Labor and delivery unit: This unit is responsible for the management of labor and
delivery. It typically includes delivery rooms, operating rooms for caesarean
sections, and recovery rooms. Medical personnel such as obstetricians, nurses,
and anesthesiologists work in this unit.
Antenatal care unit: This unit provides care for pregnant women before labor
and delivery. It includes services such as prenatal visits, ultrasounds, and
prenatal testing. Obstetricians, midwives, and
nurses work in this unit.
Neonatal unit: This unit provides care for newborns who require specialized
medical attention, such as premature babies or those with medical conditions.
It typically includes neonatal intensive care units (NICUs) with specialized
medical equipment and staffed by neonatologists, nurses, and
respiratory therapists.
Postpartum unit: This unit provides care for women and newborns after
delivery. It includes services such as breastfeeding support, postpartum checkups, and newborn care education. Obstetricians, midwives, and nurses work in
this unit.
Obstetric emergency unit: This unit provides emergency care for pregnant
women experiencing complications such as preterm labor, bleeding, or
preeclampsia. It typically includes operating rooms and staffed by obstetricians,
anesthesiologists, and nurses.
In addition to these units, an obstetrical hospital may also have services such
as a fertility clinic, genetic counseling, and social work services. The hospital
may also offer educational classes for expectant parents, such as childbirth
education and parenting classes.
2. Antenatal care, pre-conceptional counseling and care.
Antenatal care, also known as prenatal care, is the medical care provided to
pregnant women during their pregnancy to monitor the health of both the
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mother and the developing fetus. It involves a
series of regular checkups and tests that are designed to identify and address any
potential health problems that may arise during pregnancy. Antenatal care aims
to promote a healthy pregnancy, reduce the risk of complications, and ensure
the safe delivery of the baby.
Pre-conceptional counseling and care refer to the medical care and advice given
to women before they become pregnant to ensure that they are healthy and
prepared for pregnancy. This includes counseling on nutrition, exercise, and
lifestyle changes that may be necessary to optimize health and fertility. Preconceptional care also involves identifying and addressing any underlying
medical
conditions that may pose a risk during pregnancy, such as diabetes, high blood
pressure, or thyroid disease.
Antenatal and pre-conceptional care typically involve a team of healthcare
professionals, including obstetricians, midwives, and nurses. The care provided
may include:
Regular checkups and tests to monitor the health of the mother and fetus,
including ultrasound scans, blood tests, and urine tests.
Counseling on nutrition, exercise, and lifestyle changes.
Screening for medical conditions that may pose a risk during pregnancy, such as
diabetes, high blood pressure, and thyroid disease.
Education on childbirth preparation, breastfeeding, and newborn care.
Support for mental health issues that may arise during pregnancy, such as anxiety
or depression. Referral to specialists, such as a genetic counselor, if needed.
Antenatal and pre-conceptional care are critical components of ensuring a
healthy pregnancy and delivery. Pregnant women are encouraged to seek early
and regular medical care to optimize the health outcomes for both themselves
and their babie
3. Safe motherhood. Epidemiology of obstetrics:
maternal morbidity and mortality, perinatal
morbidity and mortality.
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Safe motherhood is a global public health initiative that aims to reduce maternal
and perinatal mortality and morbidity. Maternal morbidity refers to the health
complications that occur during pregnancy, childbirth, or in the postpartum
period, while maternal mortality refers to the death of a
woman during pregnancy or within 42 days of delivery. Perinatal morbidity and
mortality refer to the health complications and death of the fetus or newborn
during the pregnancy, childbirth, or within the first week of life.
The epidemiology of obstetrics focuses on the incidence, distribution, and
determinants of maternal and perinatal morbidity and mortality. According to
the World Health Organization (WHO), approximately 830 women die from
preventable causes related to pregnancy and childbirth every day, with the
majority of these deaths occurring in low-income countries. The leading causes
of maternal mortality include severe bleeding, infections, high blood pressure
during pregnancy, and unsafe abortions.
Perinatal morbidity and mortality also remain significant public health issues.
Factors that contribute to perinatal morbidity and mortality include maternal
age, low socioeconomic status, poor maternal nutrition, inadequate prenatal
care, and complications during pregnancy and childbirth.
Prevention and management of maternal and perinatal morbidity and mortality
require a
comprehensive approach that includes access to quality antenatal care, skilled
attendance at birth, emergency obstetric care, and postpartum care.
Implementation of evidence-based interventions such as proper nutrition,
prevention and treatment of infections, and timely management of
complications can reduce maternal and perinatal morbidity and mortality.
4. Audit in obstetrics. Medico- legal aspects of obstetries practice.
Audit in obstetrics is the process of reviewing and evaluating the quality of care
provided to pregnant women and their newborns, with the aim of identifying
areas for improvement and implementing changes to improve outcomes. This
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includes the assessment of the clinical practice, decision-making, and care
provided during pregnancy, labor, delivery, and postpartum periods.
The process of audit involves the following steps:
Defining standards of care: This involves developing guidelines and protocols for
the care of pregnant women and their newborns, based on best available
evidence.
Measuring practice against standards: This involves collecting data on the care
provided and comparing it with the established standards of care.
Identifying areas of improvement: This involves analyzing the data collected to
identify areas of care that need improvement.
Implementing changes: This involves making changes to the care provided,
based on the findings of the audit, and evaluating the impact of these changes.
Medico-legal aspects of obstetric practice refer to the legal implications of
obstetric care. These include issues related to malpractice, negligence, informed
consent, and confidentiality.
Obstetricians must ensure that they provide care in accordance with
established standards of care and adhere to legal and ethical principles. They
should also maintain accurate and complete medical records and ensure that
patient confidentiality is protected.
In addition, obstetricians must ensure that patients are fully informed about the
risks and benefits of any interventions or treatments and obtain their informed
consent before proceeding. Failure to obtain informed consent or providing
substandard care can result in legal action being taken against the obstetrician.
As such, it is important for obstetricians to have a thorough understanding of the
legal and ethical issues related to obstetric practice.
It is important to discuss with a healthcare provider the most appropriate
method of contraception for individual needs and circumstances.
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5. Medical termination of pregnancy in different trimesters, procedures.
Medical termination of pregnancy (MTP) is the use of medications to end a
pregnancy. It can be done in different trimesters using different procedures:
First trimester (up to 12 weeks): MTP can be done using medications such as
mifepristone and
misoprostol, which are taken orally or vaginally. These medications work by
blocking the hormone progesterone, which is needed for the pregnancy to
continue. This causes the lining of the uterus to break down and the cervix to
soften and open, leading to the expulsion of the embryo/fetus.
Second trimester (13-24 weeks): MTP in the second trimester is more complex
and usually requires hospitalization. It can be done using medications such as
mifepristone and misoprostol, but at higher doses and for a longer duration.
Another option is to have a surgical abortion, which involves dilation and
curettage (D&C) or dilation and evacuation (D&E) procedures.
Third trimester (after 24 weeks): MTP in the third trimester is not allowed
except in cases of severe fetal abnormalities or if the mother's life is at risk. In
these cases, labor induction or caesarean
section may be done to end the pregnancy.
It's important to note that MTP should only be performed by a trained
healthcare provider in a safe and legal setting. Counseling before and after the
procedure is also crucial to ensure the woman's physical and emotional wellbeing.
6. Anatomy and physiology of female reproductive system.
The female reproductive system consists of internal and external structures. The
internal structures include the ovaries, fallopian tubes, uterus, cervix, and vagina.
The external structures include the mons pubis, labia majora and minora, clitoris,
and Bartholin's glands.
The ovaries are the female gonads responsible for producing eggs and
hormones, such as estrogen and progesterone. Each ovary is located on either
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side of the uterus and is connected to the uterus by the fallopian tubes.
The fallopian tubes, also known as oviducts, are a pair of tubes that transport
eggs from the ovaries to the uterus. Fertilization typically occurs in the fallopian
tubes.
The uterus is a muscular organ that houses and nourishes a developing fetus
during pregnancy. The lower part of the uterus is called the cervix, which is the
opening to the vagina.
The vagina is a muscular canal that connects the cervix to the external genitalia. It
serves as the birth canal during childbirth and also functions in sexual intercourse
and menstruation.
The external structures of the female reproductive system include the mons
pubis, which is the fatty tissue that covers the pubic bone; the labia majora and
minora, which protect the clitoris and vaginal opening; the clitoris, which is a
highly sensitive organ involved in sexual arousal; and the Bartholin's glands,
which secrete lubricating fluid during sexual activity.
Overall, the female reproductive system is a complex and intricately regulated
system responsible for the production of female gametes, hormones, and the
nourishment and protection of a developing fetus during pregnancy.
7. Endocrinology in relation to reproduction.
Endocrinology plays a critical role in female reproduction, as it regulates the
menstrual cycle,
ovulation, and pregnancy. The female reproductive system is under the control
of the hypothalamic- pituitary-gonadal (HPG) axis, which regulates the
production of hormones that control the menstrual cycle and ovulation.
The hypothalamus produces gonadotropin-releasing hormone (GnRH), which
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stimulates the pituitary gland to release follicle-stimulating hormone (FSH) and
luteinizing hormone (LH). FSH and LH then act on the ovaries to stimulate the
development and maturation of follicles, which contain eggs. As the follicles
mature, they produce estrogen, which triggers the thickening of the uterine
lining and prepares it for potential implantation.
Once a follicle reaches maturity, it releases an egg during ovulation. If the egg is
fertilized by sperm, it implants in the uterine lining and pregnancy begins. The
fertilized egg then produces human
chorionic gonadotropin (hCG), which signals to the ovaries to continue producing
estrogen and progesterone, which maintain the uterine lining and support the
developing fetus.
If the egg is not fertilized, it disintegrates and the corpus luteum, which is the
remaining structure of the mature follicle, stops producing estrogen and
progesterone. This leads to the shedding of the uterine lining during
menstruation, which starts a new menstrual cycle.
Other hormones that play a role in female reproduction include prolactin, which
stimulates milk production after childbirth, and oxytocin, which triggers uterine
contractions during labor and delivery.
8. The placenta and the membranes: development, structure, function.
The placenta and the membranes play a crucial role in fetal development and
pregnancy. The
development of the placenta and membranes begins at fertilization, when the
fertilized egg implants into the uterine lining.
The placenta is an organ that develops in the uterus during pregnancy
and is responsible for providing oxygen, nutrients, and waste elimination
for the developing fetus. It also produces
hormones that are essential for maintaining the pregnancy, such as human
chorionic gonadotropin (hCG), estrogen, and progesterone.
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The structure of the placenta consists of a fetal side and a maternal side,
separated by a layer of tissue called the placental membrane. The fetal side is
covered in small, branching structures called chorionic villi, which allow for
exchange of gases, nutrients, and waste products between the fetal and
maternal blood supplies. The maternal side is composed of blood vessels and
tissues that supply oxygen and nutrients to the developing fetus.
The membranes refer to the sac that surrounds the developing fetus and
contains the amniotic fluid. The amniotic sac is composed of two layers: the
chorion and the amnion. The chorion forms the outer layer of the sac and
contains the chorionic villi that develop into the placenta. The amnion is the
innermost layer of the sac and contains the amniotic fluid, which acts as a
cushion and protects the developing fetus.
Overall, the placenta and membranes are essential for fetal development and
play a crucial role in maintaining a healthy pregnancy.
9. Physiological changes during pregnancy: genital and extragenital.
During pregnancy, the female body undergoes significant physiological changes to
accommodate the developing fetus and prepare for childbirth. These changes can
be divided into genital and
extragenital
changes. Genital
Changes:
Uterus: The uterus increases in size as the fetus grows, and its weight increases
from about 70 grams to about 1 kilogram at term. The uterus also undergoes
rhythmic contractions throughout pregnancy to prepare for labor.
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Cervix: The cervix softens, lengthens, and thins out (effaces) in preparation for
childbirth. This process is known as cervical ripening.
Vagina: Increased blood flow to the vagina can cause it to become swollen, and
hormonal changes can cause the vagina to produce more mucus.
Ovaries: Ovulation ceases during pregnancy, and the ovaries stop producing
estrogen and progesterone.
Extragenital Changes:
Cardiovascular system: Blood volume increases by about 50% during pregnancy,
and the heart rate and cardiac output increase to accommodate the increased
demand. Blood pressure may also decrease slightly in the first and second
trimesters.
Respiratory system: The respiratory rate increases, and oxygen consumption
also increases to support the fetus.
Renal system: The kidneys increase in size and produce more urine, and the
glomerular filtration rate increases.
Gastrointestinal system: Hormonal changes can cause constipation and
heartburn, and the growing uterus can push the stomach and intestines upward,
causing discomfort and indigestion.
Musculoskeletal system: The center of gravity shifts forward as the uterus
grows, which can cause back pain and changes in posture. Hormonal changes
also loosen the ligaments in the pelvic area in preparation for childbirth.
Overall, these changes are essential for a healthy pregnancy and successful
childbirth, but they can also cause discomfort and complications, which require
proper management and monitoring by healthcare professionals.
10. Application of different diagnostic methods in obstetrics (physical
examination, auscultation, palpation, laboratory, ultrasonography).
Different diagnostic methods are used in obstetrics to evaluate the health of
both the mother and the fetus during pregnancy. Here are some of the
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commonly used diagnostic methods:
Physical examination: This involves a general assessment of the mother's health
and physical condition. The obstetrician checks the mother's weight, blood
pressure, and heart rate, and also performs a pelvic exam to check the size and
position of the uterus and to evaluate the cervix.
Auscultation: This involves listening to the fetal heartbeat using a fetal doppler
or a fetoscope. It is usually done during routine prenatal visits and is a noninvasive way to monitor the fetal heart rate. Palpation: This involves feeling the
mother's abdomen to assess the size and position of the fetus. The obstetrician
can also determine the presentation (e.g. head-down or breech) of the fetus
through palpation.
Laboratory tests: These include blood and urine tests to monitor the mother's
health and to detect any conditions that may affect the pregnancy, such as
gestational diabetes or preeclampsia.
Ultrasonography: This is a non-invasive imaging technique that uses highfrequency sound waves to create images of the fetus and the mother's
reproductive organs. It is used to monitor fetal growth, evaluate the placenta and
amniotic fluid, and to detect any abnormalities or complications during
pregnancy.
Other diagnostic methods that may be used in obstetrics include fetal
monitoring (to assess the fetal heart rate and detect any signs of distress),
amniocentesis (to test for chromosomal abnormalities or other genetic
conditions), and magnetic resonance imaging (MRI) (to evaluate fetal and
maternal health in more detail). The specific diagnostic methods used will
depend on the individual patient and the specific concerns or conditions that
are being monitored or evaluated.
11. Methods of obstetrical examination.
Obstetrical examination involves a series of physical and medical assessments to
monitor the health of the mother and fetus during pregnancy. Some of the
methods of obstetrical examination include:
Physical examination: This involves assessing the general health of the mother,
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including blood pressure, weight, and any symptoms or complaints she may have.
Obstetrical history: This involves obtaining information about the mother's past
obstetrical and medical history, including previous pregnancies, deliveries,
miscarriages, and medical conditions.
Pelvic examination: This involves examining the size and shape of the pelvis to
assess the likelihood of a vaginal delivery. The cervix and vaginal walls are also
examined for any abnormalities.
Ultrasonography: This is a non-invasive imaging technique that uses sound
waves to produce images of the fetus and uterus. It is used to assess fetal
growth, development, and well-being.
Fetal monitoring: This involves monitoring the fetal heart rate using a fetal
Doppler or electronic fetal monitor. It is used to assess fetal well-being during
pregnancy and labor.
Laboratory tests: These include blood tests, urine tests, and other diagnostic
tests that are used to screen for medical conditions that may affect pregnancy,
such as gestational diabetes, preeclampsia, and infections.
Non-stress test: This is a test that is used to assess fetal well-being during
pregnancy. It involves monitoring the fetal heart rate in response to fetal
movement.
Biophysical profile: This is a combination of fetal monitoring and
ultrasonography that is used to assess fetal well-being in high-risk pregnancies.
Amniocentesis: This is a diagnostic test that involves withdrawing a small amount
of amniotic fluid from the uterus using a needle. The fluid is then analyzed for
genetic abnormalities or other medical conditions.
Chorionic villus sampling (CVS): This is a diagnostic test that involves taking a
small sample of the placenta to test for genetic abnormalities or other medical
conditions.
12. Diagnosis of pregnancy in 1*. 200 and 3" trimesters.
Diagnosis of pregnancy in the first trimester is usually based on the presence of
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clinical signs and symptoms, as well as laboratory tests. The most common signs
of pregnancy in the first trimester
include a missed period, nausea and vomiting, breast tenderness, and fatigue.
Pregnancy tests that detect the presence of human chorionic gonadotropin (hCG)
in urine or blood are also reliable
indicators of pregnancy.
In the second trimester, pregnancy can be diagnosed by a combination of
clinical examination, such as abdominal palpation and ultrasound imaging. Fetal
movements can also be felt by the mother during this trimester, which is
another sign of a viable pregnancy.
In the third trimester, diagnosis of pregnancy is typically confirmed by the
presence of a fetus on ultrasound imaging, as well as fetal movements and a
growing uterus. The mother may also
experience more physical symptoms such as back pain, shortness of breath, and
difficulty sleeping.
13. Differential diagnosis of pregnancy.
Differential diagnosis of pregnancy involves the identification of
conditions that have similar symptoms to pregnancy. Some of the
conditions that may present with symptoms similar to pregnancy include:
Pseudocyesis: This is also known as false pregnancy. It is a condition where a
woman experiences symptoms of pregnancy, but she is not actually pregnant.
Ectopic pregnancy: This is a condition where the fertilized egg implants itself
outside the uterus, usually in the fallopian tube. It can cause symptoms similar to
pregnancy, but it is a life-threatening condition that requires immediate medical
attention.
Hydatidiform mole: This is a type of gestational trophoblastic disease that occurs
when the cells that are supposed to form the placenta develop into abnormal
cells. It can cause symptoms similar to pregnancy, but it requires immediate
medical attention.
Ovarian cyst: This is a fluid-filled sac that develops on the ovaries. It can cause
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abdominal discomfort, bloating, and irregular menstrual periods, which may be
mistaken for pregnancy.
Fibroids: These are non-cancerous growths that develop in the uterus. They can
cause abdominal pain, heavy menstrual bleeding, and a feeling of fullness in the
abdomen, which may be mistaken for pregnancy.
Urinary tract infection: This is a bacterial infection that affects the urinary system.
It can cause
symptoms such as frequent urination, painful urination, and lower abdominal
pain, which may be mistaken for pregnancy.
Menopause: This is a natural process that occurs when a woman stops ovulating
and menstruating. It can cause symptoms such as hot flashes, mood swings, and
irregular menstrual periods, which may be mistaken for pregnancy.
14. Signs and symptoms of pregnancy in chronological order.
Here are some common signs and symptoms of pregnancy in chronological order:
Missed period: This is often the first sign of pregnancy, occurring around 4 weeks
after the last menstrual period.
Nausea and vomiting: Often called morning sickness, this can occur any time of
the day and usually starts around 6 weeks of pregnancy.
Fatigue: Feelings of exhaustion are common in early pregnancy due to increased
levels of progesterone.
Breast changes: The breasts may become sore, swollen, or tender around 6-8
weeks of pregnancy. Frequent urination: As the uterus expands, it can put
pressure on the bladder, causing frequent trips to the bathroom, usually around
6-8 weeks of pregnancy.
Food cravings and aversions: Changes in hormones can lead to specific food
cravings or aversions, often beginning around 8-10 weeks of pregnancy.
Mood swings: Hormonal changes during pregnancy can cause mood swings,
ranging from happiness to sadness or irritability, often starting in the first
trimester.
Braxton Hicks contractions: These "practice" contractions can start as early as
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the second trimester. Fetal movement: Around 16-25 weeks of pregnancy, the
fetus may start moving and kicking, which can be felt by the mother.
Shortness of breath: As the uterus expands, it can put pressure on the
diaphragm, causing shortness of breath, typically in the third trimester.
It's important to note that not all women experience every symptom, and some
may experience none at all. Additionally, some symptoms may occur at different
times or in a different order than listed above.
15. Normal duration of pregnancy: time limits for early and late abortions,
preterm. term and post-term labor. Estimation of expected delivery date.
The normal duration of pregnancy is around 40 weeks or 280 days, calculated
from the first day of the last menstrual period. This is divided into three
trimesters, each lasting approximately 12-14 weeks.
Early abortion refers to the termination of pregnancy before 12 weeks of
gestation. Late abortion refers to the termination of pregnancy between 12 and
24 weeks of gestation. Preterm labor is defined as the onset of labor before 37
weeks of gestation. Term labor is defined as labor that occurs between 37 and
42 weeks of gestation. Post-term labor refers to labor that occurs after 42
weeks of gestation.
The expected delivery date can be estimated using several methods, including
the last menstrual period, ultrasound measurement of the fetal crown-rump
length, and measurement of the fundal height. The most commonly used
method is the last menstrual period, with the expected delivery date calculated
by adding 280 days to the first day of the last menstrual period. Ultrasound
measurements and fundal height measurements can also be used to estimate
the gestational age and expected delivery date.
16. Fetus-in-utero: attitude, lie, presentation, position.
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Fetus-in-utero refers to the position of the fetus within the uterus during
pregnancy. There are several terms used to describe the position of the fetus:
Attitude: This refers to the position of the fetal head and limbs in relation to the
fetal body. The normal attitude is the fetal head flexed forward onto the chest,
with the arms crossed over the chest and the legs flexed at the hip and knee
joints.
Lie: This refers to the orientation of the fetus in relation to the mother's
longitudinal axis. The two possible lies are longitudinal lie (fetal spine is parallel
to the mother's spine) and transverse lie (fetal spine is perpendicular to the
mother's spine).
Presentation: This refers to the fetal body part that is closest to the birth canal.
There are three main types of presentation: cephalic (head-first), breech (bottomfirst), and shoulder (transverse)
presentation.
Position: This refers to the specific location of the fetal presenting part in relation
to the mother's pelvis. There are four positions for each presentation: occiput
anterior (OA), occiput posterior (OP), sacrum anterior (SA), and sacrum posterior
(SP).
It is important to determine the attitude, lie, presentation, and position of the
fetus during pregnancy to ensure a safe and successful delivery. This can be
done through obstetrical examination, including ultrasound imaging.
17. Fetal length, weight at different ages, nutrition, circulation and its changes
at birth.
Fetal growth and development occur throughout the pregnancy, and the fetus
undergoes many changes in size, weight, and circulation.
During the first trimester, the fetus is approximately 3 inches long and weighs
about 1 ounce. By the end of the second trimester, the fetus is around 14 inches
long and weighs around 2 pounds. In the third trimester, the fetus continues to
grow and gain weight rapidly, with an average length of around 20 inches and a
weight of around 7-8 pounds at term.
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Nutrition is essential for fetal growth and development, and the fetus
receives all its nutrition through the placenta. The mother's diet and
nutritional status can affect fetal growth, and it is essential for pregnant
women to maintain a healthy diet and receive proper prenatal care.
The fetal circulation is unique in that it is adapted to the low oxygen
environment of the uterus. The fetus receives oxygen and nutrients from the
placenta through the umbilical vein, which carries oxygenated blood to the liver
and then to the heart. The oxygenated blood is then distributed to the body
through the aorta. Deoxygenated blood is carried back to the placenta through
the umbilical arteries.
At birth, the fetal circulation undergoes significant changes. The umbilical cord
is clamped and cut, and the lungs take over the role of oxygenation. Blood flow
to the lungs increases, and the foramen ovale and ductus arteriosus, which allow
blood to bypass the lungs in utero, close. These changes result in the
establishment of the adult circulatory system.
18. Fetal skull from obstetrical perspective: structure, sutures,
fontanelles. diameters, adaptation to the birth canal.
The fetal skull is an important aspect to consider in obstetrics as it determines
the ability of the fetus to pass through the birth canal during delivery. Here are
some key points regarding the fetal skull:
Structure: The fetal skull is made up of several bones that are not yet fused
together. This allows for some flexibility and molding of the skull during delivery.
Sutures: The areas where the fetal skull bones meet are called sutures. These
sutures are made up of fibrous tissue and allow for some movement of the skull
bones during delivery.
Fontanelles: The areas where several skull bones meet and form a "soft spot" are
called fontanelles. The anterior fontanelle is the larger of the two and is often
used to assess the position of the fetal head during delivery.
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Diameters: There are several diameters of the fetal skull that are important to
consider during delivery. The biparietal diameter (BPD) is the distance between
the two parietal bones and is the
most commonly used measurement to estimate fetal head size. The
occipitofrontal diameter (OFD) is the distance between the occipital and frontal
bones, and the suboccipitobregmatic diameter (SOD)
is the distance between the occipital bone and the bregma (an anatomical
landmark on the skull).
Adaptation to the birth canal: The fetal skull is designed to adapt to the shape of
the birth canal
during delivery. This is accomplished through a combination of molding (changes
in the shape of the skull bones) and descent (movement of the fetal head
through the birth canal). The position of the fetus (i.e. occiput anterior, occiput
posterior) can also affect how the skull adapts to the birth canal.
19. Female pelvis from obstetrical perspective: bony
structure, inlet, cavity. outlet, diameters, axis, joints,
external diameters.
The female pelvis is a bony structure that supports the weight of the upper body
and protects the pelvic organs. It is divided into two parts: the greater pelvis and
the lesser pelvis.
The greater pelvis is located above the pelvic brim (or inlet) and is wider than
the lesser pelvis, which is located below the pelvic brim. The pelvic brim is an
imaginary line that separates the two parts of the pelvis.
The pelvic cavity, which is located in the lesser pelvis, is where the fetal head
passes during delivery. It has an inlet, a cavity, and an outlet. The inlet is the
upper opening of the pelvic cavity and is defined by the pelvic brim. The cavity
is the space between the inlet and the outlet, and the outlet is the lower
opening of the pelvic cavity.
The diameters of the pelvic inlet are important in determining whether a fetus
can pass through the pelvis during delivery. The main diameters are the
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anteroposterior diameter (from the sacral promontory to the pubic symphysis),
the transverse diameter (the widest part of the pelvic inlet), and the oblique
diameters (from one iliopectineal eminence to the opposite sacroiliac joint).
The pelvic joints are important for allowing the pelvis to expand during delivery.
The sacroiliac joints connect the sacrum to the ilium, while the pubic symphysis
connects the two pubic bones.
The external diameters of the pelvis are also important in determining whether a
fetus can pass through the pelvis during delivery. The main external diameters
are the interspinous diameter (the distance between the two ischial spines), the
intertuberous diameter (the distance between the two ischial tuberosities), and
the bispinous diameter (the distance between the two anterior superior
iliac spines).
Overall, the shape and size of the female pelvis play a crucial role in the
successful delivery of a fetus.
20. Diagnosis of prelabour and labour. Definitions of normal and abnormal
labour.
Prelabour is the time period before the onset of true labour. It is characterized
by contractions that do not result in cervical dilation. The diagnosis of prelabour
is based on the absence of cervical changes and the presence of irregular
contractions.
Labour is defined as the process by which the fetus is expelled from the uterus.
The diagnosis of
labour is based on the presence of regular, painful contractions that result in
cervical dilation and effacement. The onset of labour is typically diagnosed when
the woman's contractions become regular and increase in intensity, leading to
progressive cervical dilation and effacement.
Normal labour is defined as labour that progresses spontaneously, without
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complications, and results in the safe delivery of a healthy baby. Abnormal
labour is defined as labour that is prolonged, obstructed, or associated with
complications that may put the mother or baby at risk.
Prolonged labour is defined as labour that lasts longer than 18-24 hours in
primigravidas or longer than 12-14 hours in multigravidas. Obstructed labour is
defined as labour in which the fetus cannot pass through the birth canal due to
a mechanical obstruction, such as cephalopelvic disproportion or malposition of
the fetus.
Other factors that may be considered abnormal in labour include failure of
cervical dilation, failure of descent of the fetal head, abnormal fetal heart rate
patterns, and maternal exhaustion or distress.
These factors may require medical intervention to ensure a safe delivery for both
the mother and the baby.
21. Causes of onset of labour.
The onset of labor is a complex process that is not fully understood, but there are
several factors that are believed to contribute to it. These include:
Hormonal changes: As the pregnancy progresses, the levels of certain
hormones, such as oxytocin and prostaglandins, increase in the mother's body.
These hormones play a role in stimulating uterine contractions and preparing
the cervix for delivery.
Fetal factors: As the fetus grows and develops, it puts increasing pressure on the
uterus and cervix. This pressure can also help to stimulate contractions and
initiate labor.
Maternal factors: Maternal factors, such as physical activity, stress, and
dehydration, can also play a role in initiating labor. For example, physical activity
can help to stimulate contractions by increasing blood flow to the uterus.
Placental factors: Towards the end of pregnancy, the placenta may begin to
deteriorate, which can trigger the release of hormones that stimulate labor.
Genetic factors: There is some evidence to suggest that genetic factors may play
19 | P a g e
a role in the onset of labor. For example, certain genes have been linked to an
increased risk of preterm labor.
22. Contractile system of myometrium.
The contractile system of the myometrium is composed of smooth muscle cells
that are arranged in multiple layers with various orientations. During pregnancy,
the uterus undergoes significant changes in structure and function in
preparation for labor and delivery. Hormones such as estrogen and
progesterone play a critical role in these changes by modulating the contractile
properties of the myometrium.
The myometrium contains specialized cells known as pacemaker cells that
generate spontaneous electrical impulses, which propagate through gap junctions
to neighboring smooth muscle cells.
These electrical impulses trigger the release of calcium ions from intracellular
stores, which activate the contractile machinery of the smooth muscle cells and
lead to contraction of the myometrium.
During labor, the myometrium undergoes a series of coordinated contractions
that gradually increase in frequency, duration, and intensity. These contractions
are stimulated by a variety of factors,
including hormonal changes, mechanical stretch of the uterus, and neural signals
from the fetus. The coordinated contractions of the myometrium are essential for
the expulsion of the fetus and
placenta during delivery.
23. Stages of labour. Normal duration
of labour. Labor is typically divided
into three stages:
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First stage of labor: This stage starts with the onset of regular uterine
contractions and ends with complete cervical dilation at 10 centimeters. The
first stage is further divided into a latent phase and an active phase. The latent
phase can last for several hours or even days, during which the cervix
gradually thins and begins to dilate. The active phase typically lasts for several
hours and is characterized by more rapid cervical dilation and stronger
contractions.
Second stage of labor: This stage begins once the cervix is fully dilated and ends
with the delivery of the baby. During this stage, the mother is encouraged to
push with each contraction to help move the baby down the birth canal and out
of the body.
Third stage of labor: This stage begins after the baby is delivered and ends with
the delivery of the placenta. During this stage, the uterus continues to contract
to help detach the placenta from the uterine wall and push it out of the body.
The normal duration of labor varies widely, but for first-time mothers, the first
stage of labor typically lasts around 12-14 hours, while subsequent labors may
be shorter. The second stage of labor usually lasts between 20 minutes to 2
hours, and the third stage usually lasts around 5-30 minutes. However, these
durations can be affected by factors such as the mother's age, the size and
position of the baby, and the use of medical interventions. It's important to note
that every woman's labor
experience is unique and there is no "right" or "wrong" way for labor to progress
as long as both the mother and baby are healthy.
24. Mechanism of labour for occipito-anterior position.
The mechanism of labor for occipito-anterior position refers to the movements
that the fetal head undergoes as it descends through the birth canal during a
normal vaginal delivery. Here are the steps of the mechanism of labor for
occipito-anterior position:
Engagement: The widest diameter of the fetal head (the biparietal diameter)
passes through the maternal pelvic inlet, and the head becomes fixed in the
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pelvic cavity.
Descent: The head moves further down the birth canal as a result of uterine
contractions and maternal pushing efforts.
Flexion: As the head descends, it encounters resistance from the soft tissues of
the pelvic floor. To negotiate this resistance, the fetal head flexes forward, so
that the chin comes into contact with the fetal chest.
Internal rotation: Once the fetal head reaches the pelvic floor, it rotates 45-90
degrees so that the occiput (back of the head) faces the maternal symphysis
pubis. This is known as "internal rotation." Extension: After internal rotation, the
fetal head begins to extend, so that the chin is lifted up towards the pubic bone.
Restitution: Once the head is delivered, it will rotate back to its original position,
aligning itself with the shoulders.
External rotation: After restitution, the shoulders descend into the pelvis in a
transverse position. Once the shoulders reach the pelvic outlet, they rotate 90
degrees to align with the anteroposterior diameter of the outlet.
Expulsion: The rest of the body follows the shoulders, and the baby is born.
The normal duration of labor varies, but is generally considered to be around 1218 hours for first- time mothers and 6-8 hours for subsequent deliveries.
However, labor can be longer or shorter than these time frames and still be
considered normal as long as progress is being made and the mother and baby
are tolerating labor well.
25. Mechanism of labour for occipito-posterior position.
Occipito-posterior position is a fetal position during childbirth where the baby's
head is facing towards the mother's abdomen rather than her spine. This
position is also called the posterior
position, and it occurs in about 10-20% of births. It is associated with prolonged
labor, more difficult vaginal delivery, and increased rates of cesarean section. The
mechanism of labor for the occipito- posterior position is different from that of
the occipito-anterior position, and it is generally more difficult.
During the first stage of labor, the fetus may rotate to the occipito-posterior
position due to various factors such as a small maternal pelvis, weak
22 | P a g e
contractions, or fetal anomalies. In this position, the
fetal head enters the maternal pelvis with the occiput facing towards the
mother's sacrum instead of towards the pubic bone.
As the fetus descends into the birth canal, the occipito-posterior position causes
the head to extend and rotate further back towards the mother's spine. This
can lead to pressure on the mother's sacrum and tailbone, causing more intense
back pain and longer pushing phases. The fetus may also have difficulty
navigating the curves of the birth canal, leading to slower progress and
increased
likelihood of assisted delivery.
During the second stage of labor, the fetal head typically rotates to a more
favorable position, such as occipito-anterior, before delivery. However, in some
cases, the fetus may remain in the occipito- posterior position, making delivery
more difficult. In these cases, the healthcare provider may need to use special
techniques such as forceps or vacuum extraction to assist with delivery.
26. First stage of labour: physiology, clinical course and management.
The first stage of labor is the period of time between the onset of true labor
contractions and the full dilation of the cervix. It is divided into two phases: the
latent phase and the active phase.
During the latent phase, the cervix begins to efface (thin out) and dilate (open
up) slowly. Contractions become more frequent and regular, but are typically
mild and irregular. This phase can last for several hours or even days.
During the active phase, the cervix continues to dilate more rapidly, typically
at a rate of 1 cm per hour. Contractions become stronger, longer, and closer
together, typically every 3-5 minutes. This phase can last for several hours, but
typically lasts between 3-8 hours for first-time mothers.
Management during the first stage of labor includes frequent monitoring of fetal
23 | P a g e
heart rate, maternal vital signs, and uterine contractions. Pain relief options such
as epidurals, nitrous oxide, and non- pharmacologic methods like breathing
techniques and position changes may be offered to the mother. In some cases,
oxytocin (Pitocin) may be used to augment or induce labor if progress is slow or
if there are concerns for fetal or maternal well-being.
If progress is slow or there are concerns for the safety of the mother or baby,
a cesarean delivery may be recommended.
Immediate postpartum period: This period lasts from delivery to 2 hours after
birth. During this time, the mother is monitored closely for signs of hemorrhage,
uterine atony, and other complications.
Early puerperium: This period lasts from 2 hours to 24 hours after birth. The
mother is monitored for vital signs, uterine involution, and lactation. She is also
assessed for any signs of infection or other complications.
Late puerperium: This period lasts from 24 hours to 6 weeks after birth. The
mother is monitored for continued uterine involution, lactation, and the
resumption of menstruation. She is also assessed for any signs of postpartum
depression or other emotional disturbances.
Management during the puerperium includes monitoring for complications, such
as hemorrhage, infection, or thromboembolism, as well as providing education
and support for breastfeeding and
infant care. Mothers are also encouraged to practice good self-care, including
getting adequate rest, eating a healthy diet, and engaging in light exercise.
27. Lactation: physiology, stimulation ailments.
Lactation is the process of producing and secreting milk from the mammary
glands of the breasts. It is essential for providing nutrition to newborn infants
and promoting their growth and development. The physiology of lactation is
complex and involves the interaction of hormones, nerves, and breast tissue.
24 | P a g e
During pregnancy, hormonal changes stimulate the development of the breast
tissue and prepare it for lactation. The hormone prolactin, produced by the
pituitary gland, stimulates milk production in the mammary glands, while the
hormone oxytocin, also produced by the pituitary gland, causes the let-down
reflex, which is the release of milk from the mammary glands.
After delivery, the baby's suckling stimulates the release of prolactin, which
maintains milk production, and oxytocin, which causes the milk to be released
from the mammary glands. Frequent and effective breastfeeding is important
for maintaining milk production and ensuring that the baby is well-nourished.
Several factors can affect lactation, including stress, fatigue, hormonal
imbalances, and certain
medications. In some cases, lactation may be difficult or even impossible, and
formula feeding may be necessary.
Stimulation ailments, such as mastitis and engorgement, can also affect lactation.
Mastitis is an inflammation of the breast tissue that can cause pain, swelling, and
fever. Engorgement is the overfilling of the mammary glands with milk, which
can cause discomfort and difficulty
breastfeeding. Treatment for both conditions includes rest, warm compresses,
and antibiotics for mastitis. Gentle massage, warm compresses, and frequent
breastfeeding can help relieve
engorgement.
28. Second stage of labour: physiology, clinical course and management,
The second stage of labor is the stage of active pushing and delivery of the baby.
It begins when the cervix is fully dilated and ends with the delivery of the baby.
Physiology:
During this stage, the uterus contracts to push the baby down the birth canal,
while the mother actively pushes to help deliver the baby. The contractions
become stronger and closer together, and the mother experiences an urge to
push as the baby moves lower in the birth canal. The pelvic floor muscles also
play a significant role in the second stage of labor. The pelvic floor muscles need
to relax to allow the baby to pass through the birth canal, and the mother needs
25 | P a g e
to use these muscles to push effectively.
Clinical course and management:
The second stage of labor can last anywhere from a few minutes to a few hours,
depending on the position and size of the baby and the mother's pushing effort.
During this stage, the mother is
encouraged to push with each contraction and rest in between contractions to
conserve energy. The healthcare provider will monitor the baby's heart rate and
the mother's vital signs and may guide the mother through different positions to
help facilitate delivery.
If progress is slow, the healthcare provider may assist with forceps or a vacuum
extraction to help deliver the baby. In some cases, the healthcare provider may
recommend a cesarean section if there are concerns about the safety of the baby
or mother.
After the baby is delivered, the healthcare provider will clamp and cut the
umbilical cord and may administer medication to help the uterus contract and
reduce bleeding. The baby will be assessed for breathing and overall health, and
the mother will continue to have her vital signs monitored.
29. Third stage of labour: physiology, clinical course and management.
The third stage of labor is the delivery of the placenta and membranes after the
baby is born. During the third stage, the uterus continues to contract, causing the
placenta to separate from the uterine wall and be expelled through the vagina.
Physiology: During the third stage, the contraction of the uterus prevents
bleeding and causes the separation of the placenta from the uterine wall. The
contractions help to decrease the size of the uterus, which helps expel the
placenta and membranes.
Clinical course: The third stage of labor typically lasts about 5-30 minutes, with
an average of 10-15 minutes. The signs that indicate the onset of the third stage
of labor are a change in the shape of the uterus, a lengthening of the umbilical
26 | P a g e
cord, and a gush of blood. The healthcare provider may use controlled cord
traction, gentle pulling on the umbilical cord to assist in the delivery of the
placenta.
Management: Active management of the third stage of labor involves giving a
uterotonic agent such as oxytocin, which helps the uterus to contract and expel
the placenta more quickly, reducing the risk of postpartum hemorrhage.
Controlled cord traction is performed to help deliver the placenta. The
healthcare provider will also check the placenta and membranes to ensure that
they are complete
and no fragments are left inside the uterus. If fragments are left, it can increase
the risk of infection and bleeding.
30. Mother and fetal monitoring in labour. Apgar score. Immediate post partum
neonatal care.
Mother and fetal monitoring during labor is essential to identify any potential
problems and
intervene promptly. There are several ways to monitor both the mother and fetus
during labor, including:
Maternal vital signs: Blood pressure, heart rate, and respiratory rate should be
monitored at regular intervals during labor.
Fetal heart rate monitoring: This can be done through intermittent auscultation or
continuous
electronic fetal monitoring (EFM). Intermittent auscultation involves listening to
the fetal heart rate with a stethoscope or handheld Doppler device at specific
intervals, while EFM uses a device that is strapped to the mother's abdomen to
continuously monitor the fetal heart rate.
Uterine contractions: The frequency, duration, and strength of uterine
contractions can be monitored using a tocodynamometer, which measures
changes in the abdominal girth.
Cervical dilation: The progress of cervical dilation can be assessed by performing
vaginal examinations.
The Apgar score is a standardized method of evaluating the physical condition of
27 | P a g e
a newborn
immediately after delivery. The score is based on five parameters: heart rate,
respiratory effort, muscle tone, reflex irritability, and skin color. Each parameter
is scored from 0 to 2, and the scores are added up to give a total score ranging
from 0 to 10. A score of 7 or higher is considered normal, while a score of 3 or
lower indicates that the newborn requires immediate medical attention.
Immediate postpartum neonatal care includes a thorough physical examination
of the newborn to assess for any abnormalities or signs of distress. The
newborn's vital signs, including temperature, heart rate, and respiratory rate, are
also monitored. The newborn may receive preventive measures such as eye
prophylaxis and vitamin K administration. The mother and newborn are typically
kept together to promote bonding and initiate breastfeeding, unless there are
medical reasons for
separation.
31. The puerperium: physiology, clinical course and management.
The puerperium is the period following childbirth during which the mother's
body returns to its pre- pregnancy state. It usually lasts for 6 weeks but can be
shorter or longer depending on individual
circumstances. During this time, the uterus undergoes involution, which is the
process of returning to its pre-pregnancy size and location.
Physiologically, the puerperium is characterized by changes in hormone levels,
particularly a
decrease in estrogen and progesterone levels. The breasts produce milk for
lactation, and there is a gradual decrease in the amount of lochia, which is the
vaginal discharge consisting of blood, mucus, and tissue debris.
Clinically, the puerperium is characterized by the following stages:
Immediate postpartum period: This period lasts from delivery to 2 hours after
birth. During this time, the mother is monitored closely for signs of hemorrhage,
28 | P a g e
uterine atony, and other complications.
Early puerperium: This period lasts from 2 hours to 24 hours after birth. The
mother is monitored for vital signs, uterine involution, and lactation. She is also
assessed for any signs of infection or other complications.
Late puerperium: This period lasts from 24 hours to 6 weeks after birth. The
mother is monitored for continued uterine involution, lactation, and the
resumption of menstruation. She is also assessed for any signs of postpartum
depression or other emotional disturbances.
Management during the puerperium includes monitoring for complications, such
as hemorrhage, infection, or thromboembolism, as well as providing education
and support for breastfeeding and
infant care. Mothers are also encouraged to practice good self-care, including
getting adequate rest, eating a healthy diet, and engaging in light exercise.
32. Lactation: physiology, stimulation ailments.
Lactation is the process of producing and secreting milk from the mammary
glands of the breasts. It is essential for providing nutrition to newborn infants
and promoting their growth and development. The physiology of lactation is
complex and involves the interaction of hormones, nerves, and breast tissue.
During pregnancy, hormonal changes stimulate the development of the breast
tissue and prepare it for lactation. The hormone prolactin, produced by the
pituitary gland, stimulates milk production in the mammary glands, while the
hormone oxytocin, also produced by the pituitary gland, causes the let-down
reflex, which is the release of milk from the mammary glands.
After delivery, the baby's suckling stimulates the release of prolactin, which
maintains milk production, and oxytocin, which causes the milk to be released
from the mammary glands. Frequent and effective breastfeeding is important
for maintaining milk production and ensuring that the baby is well-nourished.
Several factors can affect lactation, including stress, fatigue, hormonal
imbalances, and certain
29 | P a g e
medications. In some cases, lactation may be difficult or even impossible, and
formula feeding may be necessary.
Stimulation ailments, such as mastitis and engorgement, can also affect lactation.
Mastitis is an inflammation of the breast tissue that can cause pain, swelling, and
fever. Engorgement is the overfilling of the mammary glands with milk, which
can cause discomfort and difficulty
breastfeeding. Treatment for both conditions includes rest, warm compresses,
and antibiotics for mastitis. Gentle massage, warm compresses, and frequent
breastfeeding can help relieve
engorgement.
30 | P a g e
31 | P a g e
33. Breech presentation: etiology, varieties, diagnosis and prognosis for delivery.
ETIOLOGY:1. Prematurity: It is the most common cause of breech presentation.
Factors preventing spontaneous version: (a) Breech with extended legs, (b) Twins,
(c) Oligohydramnios, (d) Congenital malformation of the uterus such as septate or
bicornuate uterus, (e) Short cord, relative or absolute, (f) Intrauterine death of
the fetus.
2. Favorable adaptation: (a) Hydrocephalus- big head can be well accommodated
in the wide fundus, (b) Placenta previa, (c) Contracted pelvis, (d) Cornu-fundal
attachment of the placenta-minimizes the space of the fundus where the smaller
head can be placed comfortably.
3. Undue mobility of the fetus: (a) Hydramnios, (b) Multiparae with lax abdominal
wall.
Fetal abnormality: Trisomies 13, 18, 21, anencephaly and myotonic dystrophy due
to alteration of fetal muscular tone and mobility.
Recurrent breech: On occasion, the breech presentation recurs in successive
pregnancies. When it recurs in three or more consecutive pregnancies, it is called
habitual or recurrent breech. The probable causes are congenital malformation of
the uterus, septate or bicornuate, and repeated cornu-fundal attachment of the
placenta.
VARIETIES
There are two varieties of breech presentation.
• Complete
• Incomplete
Complete (Flexed breech): The normal attitude of full flexion is maintained.
Thighs are flexed at hips and legs at knees. The presenting part consists of two
buttocks, external genitalia and two feet. It is commonly present in multi-parae
(10%).
Incomplete: This is due to varying degrees of extension of thighs or legs at the
podalic pole.
Three varieties are possible:
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• Breech with extended legs (Frank breech): In this condition, thighs are flexed on
the trunk and legs are extended at the knee joints
(Fig. 26.10). The presenting part consists of the two buttocks and external
genitalia only. It is commonly present in primigravidae, about
70%. The increased prevalence in primigravida is due to a tight abdominal wall,
good uterine tone and early engagement of breech.
Footling presentation (25%): Both thighs and legs are partially extended bringing
the legs to present at brim.
Knee presentation: Thighs are extended but the knees are flexed, bringing the
knees down to present at the brim. The latter two varieties are not common.
Clinical varieties: In an attempt to find out the dangers inherent to breech, breech
presentation is clinically classified as:
Uncomplicated It is defined as one where there is no other associated obstetric
complications apart from the breech, prematurity being excluded.
Complicated--When the presentation is associated with conditions which
adversely influence the prognosis such as prematurity, twins, contracted pelvis,
placenta previa, etc. It is called complicated breech. Extended legs, extended
arms, cord prolapse or difficulty encountered during breech delivery should not
be called complicated breech but are called complicated or abnormal breech
delivery.
DIAGNOSIS OF BREECH PRESENTATION
Clinical.
Sonography
ULTRASONOGRAPHY is most informative. (1) It confirms the clinical diagnosisespecially in primigravidae with engaged frank breech or with tense abdominal
wall and irritable uterus. (2) It can detect fetal congenital abnormality and also
congenital anomalies of the uterus. (3) Type of breech (complete or incomplete.
(4) It measures biparietal diameter, gestational age and estimated weight of the
fetus. (5) It also localizes the placenta. (6) Assessment of liquor volume (important
for ECV).
(7) Attitude of the head - flexion or hyperextension (important for decision
making at the time of delivery). CT and MRI can be used to assess the pelvic
capacity in addition to all the above-mentioned information.
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34. Mechanism of breech delivery
MECHANISM OF LABOR IN BREECH
PRESENTATION
SACROANTERIOR POSITION: In the mechanism of breech delivery, the principal
movements occur at three places-buttocks, shoulders and the head. The first two
successive parts to be born are bigger but more compressible while the head
because of nonmolding due to rapid descent, presents difficulties. Each of the
three components undergo cardinal movements as those of normal mechanism
Buttocks
• The diameter of engagement of the buttock is one of the oblique diameters of
the inlet. The engaging diameter is bitrochanteric (10 cm or 4*) with the sacrum
directed toward the iliopubic eminence. When the diameter passes through the
pelvic brim, the breech is engaged.
* Descent of the buttocks occurs undthe anterior Duttock touches the pelvIc
floor.
interna rotation of the anterior buttock occurs throuch 178th of a circle blacing it
behind the symbhysis
pubis.
* Further descent with lateral flexion of the trunk occurs until the anterior hip
hinges under the symphysis pubis which is released first followed by the posterior
hip.
* Delivery of the trunk and the lower limbs follow.
* Restitution occurs so that the buttocks occupy the original position as during
engagement in oblique diameter.
Shoulders:
* Bisacromial diameter (12 cm or 4 3/4") engages in the same oblique diameter as
that occupied by the buttocks at the brim soon after the delivery of the breech.
34 | P a g e
* Descent occurs with internal rotation of the shoulders bringing the shoulders to
lie in the anteroposterior diameter of the pelvic outlet. 'The trunk simultaneously
rotates externally through 1/8th of a circle.
* Delivery of the posterior shoulder followed by the anterior one is completed by
anterior flexion of the delivered trunk.
* Restitution and external rotation: Untwisting of the trunk occurs putting the
anterior shoulder toward the right thigh in LSA and left thigh in RSA. External
rotation of the shoulders occurs to the same direction because of internal
rotation of the occiput through 1/8th of a circle anteriorly. The fetal trunk is now
positioned as dorsoanterior
Head:
* Engagement occurs either through the opposite oblique diameter as that
occupied by the buttocks or through the transverse diameter. The engaging
diameter of the head is suboccipitofrontal (10 cm).
* Descent with increasing flexion occurs.
* Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a
circle placing the occiput behind the symphysis pubis.
* Further descent occurs until the subocciput hinges under the symphysis pubis.
* Head is born by flexion-chin, mouth, nose, forehead, vertex and occiput
appearing successively. The expulsion of the head from the pelvic cavity depends
entirely upon the bearing-down efforts and not at all on uterine contractions.
Sacronosterior position: In sacroposterior position, the mechanism is not
substantially modified. The head has To rotate 3/8th of circle to bring the occiput
behind the symphysis pubis.
35. Antenatal management of breech presentation. Place of external cephalic
version in modern obstetrics.
Antenatal management in breech presentation consists of:
􏰀 Identificationofthecomplicatingfactorsrelatedwithbreechpresentation.
􏰀 Externalcephalicversion,ifnotcontraindicated.
35 | P a g e
􏰀 Formulation of the line of management, if the version fails or is contraindicated.
Identification of complicating factor: It can be detected by clinical examination,
supplemented by sonography. Sonography is particularly useful to detect
congenital malformations of the fetus, the precise location of the placental site
and congenital anomalies of the uterus.
External Cephalic Version (ECV): There are protagonists and antagonists to
external version. As such, in an institution or to an individual where the perinatal
mortality in vaginal breech delivery is appreciably high, there is enough
justification for its use. The success rate of version is about 65%.
Cardiotocography (CTG) should ideally be done before and after the procedure.
Time of version: ECV has been considered from 36 weeks onward. While version
in the early weeks is easy but chance of reversion is more. Late version may be
difficult because of increasing size of the fetus and diminishing volume of liquor
amnii. However, the use of uterine relaxant (tocolysis) has made the version at
later weeks less difficult. It minimizes chance of reversion and should fetal
complications develop, it can be effectively tackled by cesarean section.
Hypertonus or irritable uterus can be overcome with the use of tocolytic drugs.
36. Management of vaginal breech delivery.
FIRST STAGE: The management protocol is similar to that mentioned in normal
labor. The following are the important considerations. Spontaneous onset of labor
increases the chance of successful vaginal delivery.
􏰀 Vaginalexaminationisindicated—
(a)attheonsetoflaborforpelvicassessment,(b)soonafter rupture of the membranes
to exclude cord prolapse.
􏰀 An intravenous line is sited with Ringer’s solution, oral intake is avoided, blood
is sent for group and cross matching (considering the chance of CS).
􏰀 Adequate analgesia is given, epidural is preferred.
􏰀 Fetal status and progress of labor are monitored.
􏰀 Oxytocin in fusion may be used for augmentation of labor.
36 | P a g e
Indications of Cesarean Section (CS): (a) Cases seen for the first time in labor with
presence of complications; (b) Arrest in the progress of labor; (c) Nonreassuring
FHR pattern (Fetal distress); (d) Cord presentation or prolapse.
SECOND STAGE: There are three methods of vaginal breech delivery:
􏰀 Spontaneous(10%):Expulsion of the fetus occurs with very little assistance. This
is not preferred.
􏰀 Assisted breech:The delivery of the fetus is by assistance from the beginning to
the end.This method should be employed in all cases (see below).
􏰀 Breech extraction(partial or total):When part or the entire body of the fetus is
extracted by the obstetrician. It is rarely done these days as it produces trauma to
the fetus and the mother. Indications are: (a) Delivery of the second twin after IPV
(see p. 242, 665), (b) Cord prolapse, (c) Extended legs arrested at the cavity or at
the outlet.
37. Assisted breech delivery and extraction of breech.
Steps:
􏰀The patient is brought to the table when the anterior buttock and fetal an
usarevisible. She is placed in lithotomy position when the posterior buttock
distends the perineum.
􏰀To avoid aortocaval compression, the woman is tilted laterally (15°) using a
wedge under the back.
􏰀Antisepticc leaning is done, bladder is emptied with an “in and out” catheter.
􏰀 Pudendal block is done along with perineal infiltration if not epidural has been
used earlier.
􏰀 Episiotomy: It should be made in all cases of primigravidae and selected
multiparae. Its
advantages are—(a) to straighten the birth canal which especially facilitates the
delivery of breech with extended legs where lateral flexion is inadequate; (b) to
facilitate intravaginal manipulation and for forceps delivery, (c) to minimize
compression of the aftercoming head. The best time for episiotomy is when the
perineum is distended and thinned by the breech as it is “climbing” the
perineum.
37 | P a g e
􏰀 The patient is encouraged to bear down as the expulsive forces from above
ensure flexion of the fetal head and safe descent. The “no touch to the fetus”
policy is adopted until the buttocks are delivered along with the legs in flexed
breech and the trunk slips up to the umbilicus.
􏰀 Soon after the trunk up to the umbilicus is born. The following are to be done:
(a) The extended legs (in frank breech) are to
be decomposed by pressure on the knees (popliteal fossa) in a manner of
abduction and flexion of the thighs
(b) The umbilical cord is to be pulled down and to be mobilized to one side of
the sacral bay to minimize compression. There may be transient abnormality in
cord pulsation at this stage which has got no prognostic significance. An attempt
of hasty delivery for this reason alone should be avoided.
(c) If the back remains posteriorly, rotate the trunk to bring the back anteriorly
(sacro anterior).
(d) The baby is wrapped with a sterile towel to prevent slipping when held by
the hands and to facilitate manipulation, if required.
􏰀 Delivery of the arms: The arms are delivered one after the other only when
one axilla is visible, by simply hooking down each elbow with a finger. It is
immaterial as to which arm is to be delivered first.
􏰀 Delivery of the aftercoming head:
(a) Burns-Marshall method (Fig. 26.17): The baby is allowed to hang by its own
weight. The assistant is asked to give suprapubic pressure with the flat of
hand in a downward and backward direction, the pressure is to be exerted
more toward the sinciput. When the nape of the neck is visible under the
pubic arch, the baby is grasped by the ankles with a finger in between the
two. When the mouth is cleared off the vulva, there should be no hurry.
Mucus of the mouth and pharynx is cleared by mucus sucker. The trunk is
depressed to deliver rest of the head.
(b) Forceps delivery: Forceps can be used as a routine. The head must be in the
cavity. The advantages are—(a) delivery can be controlled by giving pull directly
on the head and the force is not transmitted through the neck, (b) flexion is
better maintained and (c) mucus can be sucked out from the mouth more
effectively. The head should be brought as low down as possible by allowing the
baby to hang by its own weight aided by suprapubic pressure. When the occiput
lies against the back of the symphysis pubis, an assistant raises the legs of the
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child as much to facilitate introduction of the blades from below. Too much
elevation of the trunk may cause extension of the head. The head should be
delivered slowly (over 1 minute) to reduce compression-decompression forces as
that may cause intracranial bleeding.
(c) Malar flexion and shoulder traction (modified Mauriceau-Smellie-Veit
technique): The technique is named after the three great obstetricians who
described the use of the grip independently. The baby is placed on the supinated
left forearm (preferred) with the limbs hanging on either sides. The assistant
gives suprapubic pressure during the period to maintain flexion. Thereafter, the
fetus is carried in upward and forward direction toward the mother’s abdomen
releasing the face, brow and lastly, the trunk is depressed to release the occiput
and vertex.
38. Face presentation: etiology, varieties, mechanism of labour, diagnosis and
prognosis for delivery.
Etiology: The cause of extreme extension of the head is not clear in all the cases.
The following are the factors which are often associated.
Maternal: (1) Multiparity with pendulous abdomen, (2) Lateral obliquity of the
uterus especially, if it is directed to the side toward which the occiput lies, (3)
Contracted pelvis is associated in about 40% cases. Flat pelvis favors face
presentation, (4) Pelvic tumors.
Fetal: (1) Congenital malformations (15%)—(a) The most common one is
anencephaly. The almost nonexistent neck with absence of the cranium makes it
easy to feel the facial structure even with semi- extended head, (b) Congenital
goiter prevalent in endemic areas, (c) Dolichocephalic head with long
anteroposterior diameter, (d) Congenital bronchocele. (2) Twist of the cord
several turns round the neck. (3) Increased tone of the extensor group of neck
muscles.
Mechanism :
MENTOANTERIOR 60–80% (LMA OR RMA)
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The principal movements are like those of corresponding occipitoanterior
position. The exceptions are increasing extension instead of flexion and delivery
by flexion instead of extension of the head.
Engagement: The diameter of engagement is the oblique diameter—right in LMA,
left in RMA, with the mentum related to one iliopubic eminence and the glabella
to the opposite sacroiliac joint. The engaging diameter of the head is
submentobregmatic 9.5 cm (3 3/4") in fully extended head or submentovertical
11.5 cm (4 1/2") in partially extended head. Engagement is delayed because of
long distance between the mentum and biparietal plane (7 cm). Descent with
increasing extension occurs till the chin touches the pelvic floor.
Internal rotation—Internal rotation of the chin occurs through 1/8th of a circle
anteriorly, placing the mentum behind the symphysis pubis. Further descent
occurs till the submentum hinges under the pubic arch.
Delivery of the head—The head is born by flexion delivering the chin, face, brow,
vertex and lastly the occiput. The diameter distending the vulval outlet is
submentovertical—11.5 cm (4 1/2"). Restitution occurs through 1/8th of a circle
opposite to the direction of internal rotation. External rotation occurs further
1/8th of circle to the same side of restitution so that ultimately the face looks
directly to the left thigh in LMA and right thigh in RMA. This follows delivery of
the anterior shoulder followed by the posterior shoulder and the rest of the trunk
by lateral flexion.
MENTOPOSTERIOR (20–25%) (RMP OR LMP):
The cardinal movements in the mechanism of mento- posterior positions are like
those of occipitoposterior position. The salient differentiating features are—(1) In
the mentoposterior position, anterior rotation of the mentum occurs in only 20–
30% cases.
(2) In the rest (70–80%), incomplete anterior rotation, non rotation or short
posterior rotation of the mentum occurs. Arrest occurs in all these positions with
average size pelvis and fetalhead. Unlike persistent occipitoposterior, where
occasional face-to-pubis delivery occurs, there is no possibility of spontaneous
delivery in persistent mentoposterior. This is because the relatively short neck
cannot clear off the total length of the sacrum (12 cm). As such the thorax is
thrust in, resulting bregmaticosternal diameter (18 cm or 7") to occupy the pelvis.
As a result, the labor becomes inevitably obstructed.
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Diagnosis
VAGINAL EXAMINATION
The diagnostic features are palpating the mouth with hard alveolar margins,
nose, malar eminences, supraorbital ridges and the mentum (Fig. 26.26). In
early labor, because of high head and sausage shaped bag of membranes, the
parts are not clearly defined. In late labor, the parts are often obscured due to
edema. It is often confused with breech presentation. The distinguishing
features are—(1) the mouth and the malar eminences are not in a line; but in
breech, the anus and the ischial tuberosities are in one line, (2) sucking effect of
mouth, (3) hard alveolar margins and (4) absence of meconium staining on the
examination fingers. The mentum and the mouth should be clearly identified to
exclude brow presentation and to identify the position. The examination should
be conducted gently, as there is chance of injury to the eyes. Assessment of the
pelvis should be done as a routine.
SONOGRAPHY/RADIOGRAPHY: This should be done to confirm the diagnosis, to
exclude bony congenital malformation of the fetus and to note the size of the
baby.
39. Brow presentation: etiology. varieties, mechanism of labour, diagnosis and
prognosis for delivery.
CAUSES: The causes of persistent brow are more or less the same as those of face
presentation. The position is commonly unstable and converts to either vertex or
face presentation.
DIAGNOSIS: Antenatal diagnosis is rarely made. The findings are more or less like
those of face presentation. The cephalic prominence and the groove between it
and the back are less prominent. The head feels very big and is nonengaged.
Vaginal examination: The position is to be confirmed on vaginal examination by
palpating supraorbital ridges and anterior fontanel. If the anterior fontanel is on
mother’s left, with the sagittal suture in transverse pelvic diameter, it is left
41 | P a g e
frontum transverse position. In late labor, the landmarks may be obscured by
caput formation.
Sonography is confirmatory and also helps in excluding bony congenital
malformation of the fetus.
MECHANISM OF LABOR: Diameter of engagement is through the oblique diameter
with the brow anterior or posterior. As the engaging diameter of the head is
mentovertical (14 cm), there is no mechanism of labor in an average size baby
with normal pelvis. However, if the baby is small and the pelvis is roomy with
good uterine contractions, delivery can occur in mentoanterior brow position. The
brow descends until it touches the pelvic floor. Internal rotation and descent
occur till the root of the nose hinges under the symphysis pubis. The brow and
the vertex are delivered by flexion followed by extension to deliver the face. The
mechanism is more or less the same as face-to-pubis delivery. Usual restitution
and external rotation occur. There is no mechanism in posterior brow position.
TRIAL OF LABOR: Brow presentation when transitory, trial of labor may be
permissible. Correction of brow with felexion to occiput presentation or complete
extension to a face presentation occurs. In such a situation, though rare, trial of
labor may be possible.
COURSE AND PROGNOSIS: In case of persistent brow presentation, there is a
chance of obstructed labor. It is an important cause of rupture of uterus in
multiparae. On occasion (10%), there may be spontaneous conversion of brow
into face or vertex presentation.
MANAGEMENT
During pregnancy: If the presentation is diagnosed during pregnancy and there is
no other contraindications for vaginal delivery, nothing is to be done. Contracted
pelvis and congenital malformation of the fetus are to be excluded. Spontaneous
correction into face is likely to occur.
Elective cesarean section: Cases with persistent brow presentation are delivered
by elective cesarean section.
During labor: (1) In uncomplicated cases, if spontaneous correction to either
vertex or face fails to occur early in labor, cesarean section is the best method of
treatment.
(2) Manual Correction to face with full dilatation of cervix is seldom practiced
nowadays.
(3) Craniotomy—If the labor becomes obstructed and the baby is dead,
craniotomy is done. Rupture
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of the uterus should be excluded.
40. Transverse and oblique lies: etiology, varieties, mechanism of labour,
diagnosis and prognosis for delivery.
ETIOLOGY: The causes are—(1) Multiparity— lax and pendulous abdomen,
imperfect uterine tone and extreme uterine obliquity are the responsible
factors. (2) Prematurity—center of the gravity lies almost in the middle of the
body. (3) Twins—it is more common for the second baby than the first one to be
in transverse position. (4) Hydramnios. (5) Contracted pelvis. (6) Placenta
previa. (7) Pelvic tumors. (8) Congenital malformation of the uterus—arcuate or
subseptate and (9) Intrauterine death.
ABDOMINAL EXAMINATION
Inspection: The uterus looks broader and often asymmetrical, not maintaining the
pyriform shape.
Palpation:
􏰀 The fundal height is less than the period of amenorrhea.
􏰀 Fundalgrip—Fetalpole(breechorhead) is not palpable.
􏰀 Lateralgrip—(a)Soft,broadandirregular breech is felt to one side of the midline
and smooth, hard and globular head is felt on the other side. The head is usually
placed at a lower level on one iliac fossa. (b) The back is felt anteriorly across the
long axis in dorsoanterior or the irregular small parts are felt anteriorly in dorsoposterior.
􏰀 Pelvicgrip—Thelowerpoleoftheuterus is found empty. This, however, is evident
only during pregnancy but during labor, it may be occupied by the shoulder.
Auscultation: FHS is heard easily much below the umbilicus in dorsoanterior
position. FHS is, however, located at a higher level and often indistinct in
dorsoposterior position.
Ultrasonography or radiography confirms the diagnosis.
VAGINAL EXAMINATION
During pregnancy, the presenting part is so
high that it cannot be identified properly but one can feel some soft parts.
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Management:
ANTENATAL: External cephalic version should be done in all cases beyond 35
weeks provided there is no contraindication as mentioned in breech presentation
(see p. 440). If the lie fails to stabilize even at 36th week, the case is to be
managed as outlined in unstable lie.
If version fails or is contraindicated:
􏰀
Thepatientistobeadmittedat37thweek,becauseriskofearlyruptureofthemembrane
sand cord prolapse is very much there. Elective cesarean section is the preferred
method of delivery.
􏰀
Vaginaldeliverymaybeallowedinadeadorcongenitallymalformed(smallsize)fetus.Th
e labor may be allowed to continue under supervision till full dilatation of the
cervix, when the baby can be delivered by internal version.
LATE LABOR:
􏰀 Baby alive—There is hardly any scope of external version in late labor because
of invariable rupture of the membranes and drainage of liquor. If the baby is
mature and the fetal condition is good, it is preferable to do cesarean section in
all cases.
Internal version—In a singleton fetus, the risk of internal version is high. Not only
it might inflict injury to the uterus (rupture uterus) but also the fetal mortality is
increased to the extent of about 50%. In modern obstetric practice, internal
version is not recommended except in the case of second twin.
􏰀 Babydead—
Cesareansectioneveninsuchcases,ismuchsaferinthehandsofthosewhoare not
conversant with destructive operations. Internal version should not be done.
41. Vomiting in pregnancy
The vomiting is related to the pregnant state and depending upon the severity, it
is classified as: (i) Simple vomiting of pregnancy or milder type (ii) Hyperemesis
gravidarum or severe type.
SIMPLE VOMITING (Syn: morning sickness, emesis gravidarum): The patient
complains of nausea and occasional sickness on rising in the morning. Slight
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vomiting is so common in early pregnancy (about 50%) that it is considered as a
symptom of pregnancy. It may, however, occur at other times of the day. The
vomitus is small and clear or bile stained. It does not produce any impairment of
health or restrict the normal activities of the women. The feature disappears with
or without treatment by 12–14th week of pregnancy. High level of serum human
chorionic gonadotropin, estrogen and altered immunological states are
considered responsible for initiation of the manifestation, which is probably
aggravated by the neurogenic factor.
Management: Assurance is important. Taking of dry toast or biscuit and
avoidance of fatty and spicy foods are enough to relieve the symptoms in
majority. Supplementation with vitamin B1 100 mg daily is helpful. If the simple
measures fail, antiemetic drugs — trifluoperazine (Espazine) 1 mg twice daily is
quite effective. Promethazine and ondansetron can be used. Patient is advised to
take plenty of fluids (2.5 L in 24 hours) and fruit juice.
HYPEREMESIS GRAVIDARUM
DEFINITION: It is a severe type of vomiting of pregnancy which has got deleterious
effect on the health of mother and/or incapacitates her in day-to-day activities.
The adverse effects of severe vomiting are—dehydration, metabolic acidosis
(from starvation) or alkalosis (from loss of hydrochloric acid), electrolyte
imbalance (hypokalemia) and weight loss.
DIAGNOSIS: The pregnancy is to be confirmed first. Thereafter, all the associated
causes of vomiting (enumerated before) are to be excluded. Ultrasonography is
useful not only to confirm the pregnancy but also to exclude other, obstetric
(hydatidiform mole, multiple pregnancy), gynecological, surgical or medical
causes of vomiting
MANAGEMENT
The principles in the management are:
􏰀 Maintenance of hydration
􏰀 To control vomiting
􏰀 To correct the fluids and electrolytes imbalance
􏰀 To correct metabolic disturbances (acidosis or alkalosis)
􏰀 To prevent the serious complications of severe vomiting
􏰀 Care of pregnancy.
Hospitalization: Whenever a patient is diagnosed as a case of hyperemesis
gravidarum, she is admitted. Surprisingly, with the same diet and drugs used at
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home, the patient improves rapidly. The relatives may be too sympathetic or too
indifferent.
Drugs :
1) Antiemetic Drugs - Promethazine 25mg
Metoclopramide
2)Hydrocortisone 100 mg IV drip
3) Nutritional supplementation
42. Hypertensive disorders
43. Preeclampsia
DEFINITION: Preeclampsia is a multisystem disorder of unknown etiology
characterized by development of hypertension to the extent of 140/90 mm Hg or
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more with proteinuria after the 20th week in a previously normotensive and
nonproteinuric woman.
SYMPTOMS: Preeclampsia is principally a syndrome of signs and when symptoms
appear, it is usually late.
Mild symptoms: Slight swelling over the ankles which persists on rising from the
bed in the morning or tightness of the ring on the finger is the early manifestation
of edema due to preeclampsia. Gradually, the swelling may extend to the face,
abdominal wall, vulva and even the whole body
Alarming symptoms: The following are the ominous symptoms, which may be
evident either singly or in combination. These are usually associated with acute
onset of the syndrome. (1) Headache — either located over the occipital or
frontal region, (2) Disturbed sleep, (3) Diminished urinary output— Urinary output
of less than 400 mL in 24 hours is very ominous, (4) Epigastric pain—acute pain in
the epigastric region associated with vomiting, at times coffee color, is due to
47 | P a g e
hemorrhagic gastritis or due to subcapsular hemorrhage in the liver, (5) Eye
symptoms—there may be blurring, scotomata, dimness of vision or at times
complete blindness. Vision is usually regained within 4–6 weeks following
delivery. The eye symptoms are due to spasm of retinal vessels (retinal
infarction), occipital lobe damage (vasogenic edema) or retinal detachment.
Reattachment of the retina occurs following subsidence of edema and
normalization of blood pressure after delivery.
HOSPITAL MANAGEMENT
Rest: Admission in hospital and rest is helpful for continued evaluation and
treatment of the patient. While in bed patient should be in left-lateral position as
much as possible, to lessen the effects of vena caval compression. Rest — (1)
increases renal blood flow → diuresis, (2) increases uterine blood flow →
improves placental perfusion, and (3) reduces the blood pressure. However
completed bed rest is not essential.
Diet: The diet should contain adequate amount of daily protein (about 100 g).
Usual salt intake is permitted. Fluids need not be restricted. Total calorie
approximate 1,600 cal/day.
Diuretics: The diuretics should not be used injudiciously, as they cause harm to
the baby by diminishing placental perfusion and by electrolyte imbalance. The
compelling reasons for its use are—(1) Cardiac failure, (2) Pulmonary edema, (3)
Along with selective antihypertensive drug therapy (diazoxide group) where blood
pressure reduction is associated with fluid retention, (4) Massive edema, not
relieved by rest and producing discomfort to the patient. The most potent diuretic
commonly used is furosemide (Lasix) 40 mg, given orally after breakfast for 5 days
in a week.
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44. Spontancous abortion: definition, classification, common causes, mechanism
and stages, misscd abortion, septic abortion, management.
DEFINITION: Abortion is the expulsion or extraction from its mother of an embryo
or fetus weighing 500 g or less when it is not capable of independent survival.
The etiology of miscarriage is often complex and obscure. The following factors
(embryonic or parental) are important: 􏰀 Genetic 􏰀 Endocrine and metabolic 􏰀
Anatomic 􏰀 Infection
􏰀 Immunological 􏰀 Thrombophilias 􏰀 Environmental
􏰀 Others 􏰀 Unexplained
MECHANISM OF MISCARRIAGE: In the early weeks, death of the ovum occurs first,
followed by its expulsion. In the later weeks, maternal environmental factors are
involved leading to expulsion of the fetus which may have signs of life but is too
small to survive.
􏰀 Before 8 weeks: The ovum, surrounded by the villi with the decidual coverings,
is expelled out intact. Sometimes, the external os fails to dilate so that the entire
mass is accommodated in the dilated cervical canal and is called cervical
miscarriage.
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􏰀 Between 8 weeks and 14 weeks: Expulsion of the fetus commonly occurs leaving
behind the placenta and the membranes. A part of it may be partially separated
with brisk hemorrhage or remains totally attached to the uterine wall.
􏰀 Beyond 14th week: The process of expulsion is similar to that of a “mini labor”.
The fetus is expelled first followed by expulsion of the placenta after a varying
interval.
COMMON CAUSES OF MISCARRIAGE:
First trimester: (1) Genetic factors (50%). (2) Endocrine disorders (LPD, thyroid
abnormalities, diabetes). (3) Immunological disorders (autoimmune and
alloimmune). (4) Infection. (5) Unexplained.
Second trimester: (1) Anatomic abnormalities—(a) Cervical incompetence
(congenital or acquired). (b) Müllerian fusion defects (bicornuate uterus, septate
uterus). (c) Uterine synechiae. (d) Uterine fibroid. (2) Maternal medical illness. (3)
Unexplained.
MISSED MISCARRIAGE
DEFINITION: When the fetus is dead and retained inside the uterus for a variable
period, it is called missed miscarriage or early fetal demise.
SEPTIC ABORTION
DEFINITION: Any abortion associated with clinical evidences of infection of the
uterus and its contents is called septic abortion. Although clinical criteria vary,
abortion is usually considered septic when there are: (1) rise of temperature of at
least 100.4°F (38°C) for 24 hours or more, (2) offensive or purulent vaginal
discharge and (3) other evidences of pelvic infection such as lower abdominal
pain and tenderness.
GENERAL MANAGEMENT:
􏰀 Hospitalization is essential for all cases of septic abortion. The patient is kept in
isolation.
􏰀 To take high vaginal or cervical swab for culture, drug sensitivity test and Gram
stain.
􏰀 Vaginal examination is done to note the state of the abortion process and
extension of the
infection.
50 | P a g e
􏰀Overall assessment of the case and the patient is leveled in accordance with the
clinical grading.
􏰀 Investigation protocols as outlined before are done.
􏰀 Principles of management are: (a) To control sepsis. (b) To remove the source of
infection.
(c) To give supportive therapy to bring back the normal homeostatic and cellular
metabolism. (d) To assess the response of treatment.
45. Recurrent miscarriage: definition, etiology, investigation, management.
RECURRENT MISCARRIAGE
DEFINITION: Recurrent miscarriage is defined as a sequence of three or more
consecutive spontaneous abortion before 20 weeks. Some, however, consider
two or more as a standard. It may be primary or secondary (having previous
viable birth). A woman procuring three consecutive induced abortions is not a
habitual aborter.
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INVESTIGATIONS FOR RECURRENT MISCARRIAGE
A thorough medical, surgical and obstetric history with meticulous clinical
examination should be carried out to find out the possible cause or causes as
mentioned previously. Careful history taking should include—(i) The nature of
previous abortion process. (ii) Histology of the placenta or karyotyping of the
conceptus, if available. (iii) Any chronic illness.
Diagnostic tests: (1) Blood-glucose (fasting and postprandial), VDRL, thyroid
function test, ABO and Rh grouping (husband and wife), toxoplasma antibodies
IgG and IgM. (2) Autoimmune screening—lupus anticoagulant and anticardiolipin
antibodies (3) Serum LH on D2/D3 of the cycle. (4) Ultrasonography—to detect
congenital malformation of uterus, polycystic ovaries and uterine fibroid. (5)
Hysterosalpingography in the secretory phase to detect—cervical incompetence,
uterine synechiae and uterine malformation. (6) This is supported by
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hysteroscopy and/or laparoscopy. (7) Karyotyping (husband and wife). (8)
Endocervical swab to detect chlamydia, mycoplasma and bacterial vaginosis.
46. Antepartum haemorrage: etiological classification.
DEFINITION: It is defined as bleeding from or into the genital tract after the 28th
week of pregnancy but before the birth of the baby (the first and second stage of
labor are thus included). The 28th week is taken arbitrarily as the lower limit of
fetal viability. The incidence is about 3% amongst hospital deliveries.
47. Placenta praevia: definition, etiology, types, differential diagnosis,
management at different stages of pregnancy prog1nosis for delivery.
PLACENTA PREVIA
DEFINITION: When the placenta is implanted partially or completely over the
lower uterine segment (over and adjacent to the internal os) it is called placenta
previa.
Etiology:
􏰀 Dropping down theory: The fertilized ovum drops down and is implanted in the
lower segment. Poor decidual reaction in the upper uterine segment may be the
cause. Failure of zona pellucida to disappear in time can be a hypothetical
possibility. This explains the formation of central placenta previa.
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􏰀 Persistence of chorionic activity in the decidua capsularis and its subsequent
development into capsular placenta which comes in contact with decidua vera of
the lower segment can explain the formation of lesser degrees of placenta previa.
􏰀 Defective decidua, results in spreading of the chorionic villi over a wide area in
the uterine wall to get nourishment. During this process, not only the placenta
becomes membranous but encroaches onto the lower segment. Such a placenta
previa may invade the underlying decidua or myometrium to cause placenta
accreta, increta or percreta.
DIFFERENTIAL DIAGNOSIS
Placenta previa is at times confused with other causes of bleeding occurring in
later months of pregnancy. The most common one from which it has to be
differentiated is bleeding from premature separation of a normally situated
placenta (abruptio placentae).
The local cervical lesions (polyps, carcinoma) can easily be differentiated by a
speculum examination. However, both the conditions can co-exist.
Management:
AT HOME: (1) The patient is immediately put to bed. (2) To assess the blood
loss—(a) inspection of the clothing soaked with blood (b) to note the pulse, blood
pressure and degree of anemia (3) Quick but gentle abdominal examination to
mark the height of the uterus, to auscultate the fetal heart sound and to note any
tenderness on the uterus (4) Vaginal examination must not be done. Only
inspection is done to see whether the bleeding is present or absent and to put a
sterile vulval pad.
TRANSFER TO HOSPITAL: Arrangement is made to shift the patient to an equipped
hospital having facilities of blood transfusion, emergency cesarean section and
neonatal intensive care unit (NICU). ‘Flying Squad ’service is ideal for transfer of
such type of patients. An intravenous Ringer’s solution drip should be started and
is kept running during transport. Patient should be accompanied by two or three
persons fit for donation of blood, if necessary.
ADMISSION TO HOSPITAL: All cases of APH, even if the bleeding is slight or absent
by the time the patient reaches the hospital, should be admitted. The reasons are:
(1) All the cases of APH should be regarded as due to placenta previa unless
proved otherwise. (2) The bleeding may recur sooner or later and none can
predict when it recurs and how much she will bleed.
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48. Abruptio placentae: definition, etiology, types, differential diagnosisS,
management at different stages of pregnancy prognosis for delivery.
ABRUPTIO PLACENTAE
(Syn: Accidental Hemorrhage. Premature Separation of Placenta)
DEFINITION: It is one form of antepartum hemorrhage where the bleeding occurs
due to premature separation of normally situated placenta.
Types: 1) Revealed : Following separation of the placenta, the blood insinuates
downwards between the membranes and the decidua. Ultimately, the blood
comes out of the cervical canal to be visible externally. This is the most common
type.
2) Concealed : The blood collects behind the separated placenta or collected in
between the membranes and decidua. The collected blood is prevented from
coming out of the cervix by the presenting part which presses on the lower
segment.
3) Mixed : In this type, some part of the blood collects inside (concealed) and a
part is expelled out (revealed). Usually one variety predominates over the other.
This is quite common.
DIFFERENTIAL DIAGNOSIS: (a) Revealed type: There may be occasional diagnostic
difficulty with placenta previa. The differentiating points have been given
previously in tabulated form (Table 19.1). Confusion with the indeterminate
causes of APH is difficult to eliminate (b) Mixed or concealed type: This variety is
often confused with — (i) rupture uterus (ii) rectus sheath hematoma (iii)
appendicular or intestinal perforation (iv) twisted ovarian tumor (v) volvulus (vi)
acute hydramnios (vii) tonic uterine contraction.
MANAGEMENT OF ABRUPTIO PLACENTAE
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􏰀 Early detection and effective therapy of preeclampsia and other hypertensive
disorders of pregnancy.
􏰀 Needle puncture during amniocentesis should be under ultrasound guidance.
􏰀 Avoidance of trauma—specially forceful external cephalic version under
anesthesia.
􏰀 To avoid sudden decompression of the uterus— in acute or chronic hydramnios,
amniocentesis is
preferable to artificial rupture of the membranes.
􏰀 To avoid supine hypotension the patient is advised to lie in the left lateral
position in the later months of pregnancy.
􏰀 Routine administration of folic acid from the early pregnancy — of doubtful
value.
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49. Postpartum haemoIrage: ctiological classification.
♦ Atonic ♦ Traumatic ♦ Retained tissues ♦ Blood coagulopathy (Thrombin)
♦ Atonic uterus (80%): Atonicity of the uterus is the commonest cause of
postpartum hemorrhage. With the separation of the placenta, the uterine
sinuses, which are torn, cannot be compressed effectively due to imperfect
contraction and retraction of the uterine musculature and bleeding continues.
The following are the conditions, which often interfere with the retraction of the
uterus as a whole and of the placental site in particular.
— Grand multipara—Inadequate retraction and frequent adherent placenta
contribute to it. Associated anemia may also probably play a role.
— Overdistension of the uterus as in multiple pregnancy, hydramnios and big
baby (>4 kg). Imperfect retraction and a large placental site are responsible for
excessive bleeding.
— Malnutritionandanemia(<9.0g/dL)—
Evenslightamountofbloodlossmaydevelopclinical manifestations of postpartum
hemorrhage.
— Antepartum hemorrhage (Both placenta previa and abruption): The causes of
excessive bleeding are mentioned in Chapter 19 p. 282.
—
Prolongedlabor(>12hours):Poorretraction,infection(amnionitis),dehydrationareim
portant factors (Tone).
—
Anesthesia:Depthofanesthesiaandtheanestheticagents(ether,halothane)maycaus
eatonicity.
— Initiation or augmentation of delivery by oxytocin:Post delivery uterine
atonicity is likely unless
the oxytocin is continued for at least one hour following delivery.
— Malformation of the uterus: Implantation of the placenta in the uterine septum
of a septate uterus or in the cornual region of a bicornuate uterus may cause
excessive bleeding.
— Uterine fibroid causes imperfect retraction mechanically.
— Mismanaged third stage of labor:This includes—(a)Too rapid delivery of the
baby preventing the uterine wall to adapt to the diminishing contents, (b)
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Premature attempt to deliver the placenta before it is separated, (c) Kneading and
fiddling the uterus, (d) Pulling the cord. All these produce irregular uterine
contractions leading to partial separation of placenta and hemorrhage, (e)
Manual separation of the placenta increases blood loss during cesarean delivery.
— Placenta:Morbidly adherent(accreta,percreta),partially or completely
separated and/orretained (constriction ring uterus) cause PPH.
— Precipitate labor:In rapid delivery,separation of the placenta occurs following
the birth of the baby. Bleeding continues before the onset of uterine retraction.
Bleeding may be due to genital tract trauma also (see p. 420).
— Other causes of atonic hemorrhage are: t Obesity (BMI > 35) t Previous PPH t
Age (>40 yrs) t Drugs: Use of tocolytic drugs (ritodrine), MgSO4, Nifedipine.
— Traumatic(20%):Trauma to the genital tract usually occurs following operative
delivery;even after spontaneous delivery. Blood loss from the episiotomy wound
is often underestimated. Similarly, blood loss in cesarean section amounting to
800–1000 mL is most often ignored. Trauma involves usually the cervix, vagina,
perineum (episiotomy wound and lacerations), paraurethral region and rarely,
rupture of the uterus occurs. The bleeding is usually revealed but can rarely be
concealed (vulvovaginal or broad ligament hematoma).
Retained tissues: Bits of placenta, blood clots cause PPH due to imperfect uterine
retraction.
Combination of atonic and traumatic causes.
Thrombin: Blood coagulation disorders, acquired or congenital, are less common
causes of postpartum hemorrhage. The blood coagulopathy may be due to
diminished procoagulants (washout phenomenon) or increased fibrinolytic
activity. The firmly retracted uterus can usually prevent bleeding. The conditions
where such disorders may occur are abruptio placentae, jaundice in pregnancy,
thrombocytopenic purpura, severe preeclampsia, HELLP syndrome or in IUD.
Specific therapy following coagulation screen including recombinant activated
factor VII (rF VIIa) may be given.
50. Atonic postpartum haemorrage: etiology, diagnosis and management.
Etiology - Above question
Diagnosis : In atonic hemorrhage, the uterus is found flabby and becomes hard on
massaging. However, both the atonic and traumatic cause may coexist. Even
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following massive blood loss from the injured area, a state of low general
condition can make the uterus atonic.
The effect of blood loss depends on—(a) Predelivery hemoglobin level, (b) degree
of pregnancy induced hypervolemia and (c) speed at which blood loss occurs.
Alteration of pulse, blood pressure and pulse pressure appears only after class 2
hemorrhage (20–25% loss of blood volume). On occasion, blood loss is so rapid
and
brisk
that
death may occur within a few minutes.
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51. Retaincd and morbid adherent placenta as causes of postpartum
haemorrhages, their types, diagnosis and management.
DEFINITION: The placenta is said to be retained when it is not expelled out even
30 minutes after the birth of the baby (WHO 15 minutes).
CAUSES: There are three phases involved in the normal expulsion of placenta: (1)
Separation through the spongy layer of the decidua, (2) Descent into the lower
segment and vagina, (3) Finally its expulsion to outside.
Interference in any of these physiological processes, results in its retention.
— Placenta completely separated but retained is due to poor voluntary expulsive
efforts.
—
Simpleadherentplacentaisduetouterineatonicityincasesofgrandmultipara,overdist
ension
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of uterus, prolonged labor and uterine malformation or due to bigger placental
surface area. The commonest cause of retention of non-separated placenta is
atonic uterus.
— Morbid adherent placenta—partial or rarely, complete.
—
Placentaincarceratedfollowingpartialorcompleteseparationduetoconstrictionring(
hour- glass contraction), premature attempts to deliver the placenta before it is
separated.
DIAGNOSIS: The diagnosis of retained placenta is made by an arbitrary time (15
minutes) spent following delivery of the baby. Features of placental separation
are assessed. The hour- glass contraction or the nature of adherent placenta
(simple or morbid) can only be diagnosed during manual removal.
Management
PERIOD OF WATCHFUL EXPECTANCY
—
Duringtheperiodofarbitrarytimelimitofhalfanhour,thepatientistobewatchedcarefu
llyfor evidence of any bleeding, revealed or concealed and to note the signs of
separation of placenta.
— The bladder should be emptied using a rubber catheter.
— Any bleeding during the period should be managed as outlined in third stage
bleeding.
RETAINED PLACENTA: t Separated t Unseparated t Complicated
Placenta is separated and retained—To express the placenta out by controlled
cord traction.
Unseparated retained placenta (apparently uncomplicated): Manual removal of
placenta is to be done under general anesthesia as described earlier.
PLACENTA ACCRETA
(Syn: Morbid adherent placenta)
Placenta accreta is an extremely rare form in which the placenta is directly
anchored to the myometrium partially or completely without any intervening
decidua.
The diagnosis is made only during attempted manual removal when the plane of
cleavage between the placenta and the uterine wall cannot be made out.
Ultrasound imaging, color Doppler and MRI have all been valuable in the
diagnosis of placenta accreta, increta and percreta during pregnancy.
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MANAGEMENT: t Multidisciplinary team approach in management is to be done.
In partial placenta accreta (focal) → Remove the placental tissue as much as
possible. Effective uterine contraction and hemostasis are achieved by oxytocic
and if necessary by intrauterine plugging. In cases following cesarean delivery
bleeding areas are oversewed. If the uterus fails to contract, an early decision of
hysterectomy may have to be taken and this is preferable in multiparous women.
t In total placenta accreta, hysterectomy is indicated in parous women, while in
patients desiring to have a child, conservative attitude may be taken. This consists
of incising the uterus above the placental attachment and clamping and cutting
the umbilical cord as close to its base as possible and leaving behind the placenta,
which is expected to be autolyzed in due course of time. Appropriate antibiotics
should be given. Any attempt of placental separation risks massive hemorrhage
and ends in hysterectomy in 100% of cases. Uterine artery embolization or
therapy with methotrexate has been done for conservation of the uterus.
t In a rare case, placenta accreta may invade the bladder. In that case, try to avoid
placental removal. It may need hysterectomy and partial cystectomy.
52. Manual removal of placentae: indications, prerequisites, procedure.
Step–I: The operation is done under general anesthesia. In extreme urgency
where anesthetist is not available, the operation may have to be done under deep
sedation with 10 mg diazepam given intravenously. The patient is placed in
lithotomy position. With all aseptic measures, the bladder is catheterized.
Step–II: One hand is introduced into the uterus after smearing with the antiseptic
solution in cone shaped manner following the cord, which is made taut by the
other hand (Fig. 28.1). While introducing the hand, the labia are separated by the
fingers of the other hand. The fingers of the uterine hand should locate the
margin of the placenta.
Step–III: Counter pressure on the uterine fundus is applied by the other hand
placed over the abdomen. The abdominal hand should steady the fundus and
guide the movements of the fingers inside the uterine cavity until the placenta is
completely separated.
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Step–IV: As soon as the placental margin is reached, the fingers are insinuated
between the placenta and the uterine wall with the back of the hand in contact
with the uterine wall. The placenta is gradually separated with a sideways slicing
movement of the fingers, until whole of the placenta is separated.
Step–V: When the placenta is completely separated, it is extracted by traction of
the cord by the other hand. The uterine hand is still inside the uterus for
exploration of the cavity to be sure that nothing is left behind.
Step–VI: Intravenous methergine 0.2 mg is given and the uterine hand is gradually
removed while massaging the uterus by the external hand to make it hard. After
the completion of manual removal, inspection of the cervicovaginal canal is to be
made to exclude any injury. Introduction of the hand into the uterus in a cone
shaped manner following the taut umbilical cord. The placenta is separated by (A)
keeping the back of the hand in contact with the uterine wall with slicing
movements of the hand
Step–VII: The placenta and membranes are inspected for completeness and be
sure that the uterus remains hard and contracted.
Difficulties: (1) Hour-glass contraction leading to difficulty in introducing the hand,
(2) Morbid adherent placenta which may cause difficulty in getting to the plane of
cleavage of placental separation. In such a case placenta is removed gently in
fragments using an ovum forceps.
Complications: (1) Hemorrhage due to incomplete removal, (2) Shock, (3) Injury to
the uterus, (4) Infection, (5) Inversion (rare), (6) Subinvolution, (7)
Thrombophlebitis, (8) Embolism. In such cases placenta is removed in fragments
using an ovum forceps or a flushing curette.
53. Contracted pelvis in obstetrics: parent pelvic types and their obstetrie
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outcomes.
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54. Contracted pclvis in obstetrics: etiology, types of contacted pelvis and their
obstetric outcomes, diagnosis, mechanism of labour. prognosis for vaginal
delivery.
ETIOLOGY OF CONTRACTED PELVIS: Gross degree of contracted pelvis is
nowadays a rarity. Severe malnutrition, rickets, osteomalacia and bone
tuberculosis affecting grossly the pelvic architecture are now rarely met in clinical
practice. Instead, minor variation in size and/or shape of the pelvis is commonly
found which is often overlooked until complication arises.
Common causes of contracted pelvis are:
(1) Nutritional and environmental defects — 􏰀 Minor variation: Common 􏰀 Major:
Rachitic and osteomalacic — rare
(2) Diseases or injuries affecting the bones of the pelvis — fracture, tumors,
tubercular arthritis; spine — kyphosis, scoliosis, spondylolisthesis, coccygeal
deformity; lower limbs — poliomyelitis, hip joint disease.
(3) Development defects — Naegele’s pelvis, Robert’s pelvis; high or low
assimilation pelvis.
FLAT PELVIS (Figs 24.5A to C)
In the flat pelvis, the head finds difficulty in negotiating the brim and once it
passes through the brim, there is no difficulty in the cavity or outlet. The head
negotiates the brim by the following mechanism:
􏰀 The head engages with the sagittal suture in the transverse diameter.
􏰀 Head remains deflexed and engagement is delayed.
􏰀 If the anteroposterior diameter is too short, the occiput is mobilized to the
same side to occupy the sacral bay. The biparietal diameter is thus placed in the
sacrocotyloid diameter (9.5 cm or 8.5 cm) and the narrow bitemporal diameter is
placed in the narrow conjugate. If lateral mobilization is not possible, there is a
chance of extension of the head leading to brow or face presentation.
􏰀 Engagementoccursbyexaggeratedparietalpresentationsothatthesupersubparietaldiameter (8.5 cm), instead of the biparietal diameter (9.5 cm), passes
through the pelvic brim.
􏰀 Molding may be extreme and often there is an indentation or even a fracture of
one parietal bone. However, the caput that forms is not big.
􏰀 Once the head negotiates the brim, there is no difficulty in the cavity and outlet
and normal mechanism follows.
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GENERALLY CONTRACTED PELVIS: In this type of pelvis the shape remains
unaltered, but all the diameters in the different planes—inlet, cavity and outlet—
are shortened. There is difficulty from the beginning to the end.
55. Cephalopelvie disproportion: definition, diagnosis, trial labour.
DEFINITION: Disproportion, in relation to the pelvis, is a state where the normal
proportion between the size of fetus to the size of the pelvis is disturbed. The
disparity in the relation between the head and the pelvis is called cephalopelvic
disproportion.
DIAGNOSIS OF CEPHALOPELVIC DISPROPORTION (CPD) AT THE BRIM
The presence and degree of cephalopelvic disproportion at the brim can be
ascertained by the following:
􏰀 Clinical — (a) Abdominal method; (b) Abdominovaginal (Muller-Munro Kerr)
􏰀 Imaging pelvimetry (see above)
􏰀 Cephalometry — (a) Ultrasound; (b) Magnetic Resonance Imaging; (c) X-ray
Abdominovaginal method (Muller-Munro Kerr): This bimanual method is superior
to the abdominal method as the pelvic assessment can be done simultaneously.
Muller introduced the method by placing the vaginal finger tips at the level of
ischial spines to note the descent of the head. Munro Kerr added placement of
the thumb over the symphysis pubis to note the degree of overlapping.
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TRIAL LABOR
Definition: It is the conduction of spontaneous labor in a moderate degree of
cephalopelvic disproportion, in an institution under supervision with watchful
expectancy, hoping for a vaginal delivery. Every arrangement should be made
available for operative delivery, either vaginal or abdominal, if the condition so
arises.
Aims: A trial labor aims at avoiding an unnecessary cesarean section and at
delivering a healthy baby.
The phrase “trial” was used originally to test for pelvic adequacy but subsequently
its use has been extended to test numerous factors other than the pelvic capacity.
For example, the trial is conducted to test the integrity of the scar in a woman
with prior cesarean delivery when she goes into labor.
56. Cesarean section: its place and trends in modern obstetries, indications,
contraindications, types and complications.
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DEFINITION: It is an operative procedure whereby the fetuses after the end of
28th weeks are delivered through an incision on the abdominal and uterine walls.
TYPES OF OPERATIONS: 􏰀 Lower segment 􏰀 Classical or upper segment
Lower segment cesarean section (LSCS): In this operation, the extraction of the
baby is done through an incision made in the lower segment through a
transperitoneal approach. It is the only method practiced in present day
obstetrics and unless specified, cesarean section means lower segment operation.
The operation done through an extraperitoneal approach to the lower segment in
infected cases is obsolete.
Classical: In this operation, the baby is extracted through an incision made in the
upper segment of the uterus. Its indications in present day obstetrics are very
much limited and the operation is only done under forced circumstances such as:
􏰀
Lowersegmentapproachisdifficult:(1)Denseadhesionsduetopreviousabdominalope
ration (2) severe contracted pelvis (osteomalacic or rachitic) with pendulous
abdomen.
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􏰀 Lower segment approach is risky: (1) Big fibroid on the lower segment—blood
loss is more and contemplating myomectomy may end in hysterectomy (2)
carcinoma cervix—to prevent dissemination of the growth and postoperative
sepsis (3) repair of high VVF (4) complete anterior placenta previa with engorged
vessels in the lower segment—risk of hemorrhage.
􏰀 Perimortem cesarean section: It is done to have alive baby(rare). Perimortem
section is an extreme emergency procedure. Classical section is done in a woman
who has suffered a cardiac arrest. The infant may survive if delivery is done within
10 minutes of maternal death.
57. Operative vaginal delivery. Obstetric forceps: varieties, indications,
prerequisites, low forceps operation, dangers and complications.
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Operative vaginal delivery refers to any delivery process which is assisted by
vaginal operations. Delivery by forceps, ventouse and destructive operations are
generally included.
FORCEPS
Obstetric forceps is a pair of instruments, especially designed to assist extraction
of the fetal head and thereby accomplishing delivery of the fetus.
VARIETIES OF OBSTETRIC FORCEPS: Ever since either Peter I or Peter II of the
Chamberlen family invented the forceps around AD 1600, more than 700 varieties
were invented or modified. Most of them are of historical interest only. But only
three varieties are commonly used in present day obstetric practice (Figs 37.7A to
D). These are:
􏰀 Long-curved forceps with or without axis-traction device
􏰀 Short-curved forceps
􏰀 Kielland’s forceps
The basic construction of these forceps is the same in that each consists of two
halves (blades) articulated by a lock.
Low forceps operation
STEPS: The operation consists of the following steps:
􏰀 Identification of the blades and their application
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􏰀 Locking of the blades
􏰀 Traction
􏰀 Removal of the blades
58. Operative vaginal delivery. Ventouse: indications, prerequisites, procedure,
dangers and complications.
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Ventouse is an instrumental device designed to assist delivery by creating a
vacuum between it and the fetal scalp. The pulling force is dragging the cranium
while in forceps, the pulling force is directly transmitted to the base of the skull.
Procedure :
Step I: Application of the cup: The largest possible cup is to be selected. The cup is
introduced after retraction of the perineum with two fingers of the other hand.
The cup is placed against the fetal head nearer the occiput (flexion point) with the
“knob” of the cup pointing towards the occiput.
Traction over this flexion point either by ventouse or forceps facilitates flexion
and presents the smaller diameter to the pelvis
The pressure is gradually raised at the rate of 0.1 kg/cm2 per minute until the
effective vacuum of 0.8 kg/cm2 is achieved in about 10 minutes time. The scalp is
sucked into the cup and an artificial caput succedaneum (chignon) is produced.
The chignon usually disappears within few hours.
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Step II: Traction
􏰀 Traction must be at right angle to the cup
􏰀 Traction should be synchronous with the uterine contractions
􏰀 Traction is released in between uterine contractions
􏰀 Traction should be made using one hand along the axis of the birth canal. The
fingers of the other hand are to be placed against the cup to note the correct
angle of traction, rotation and advancement of the head
􏰀 Operative vaginal delivery(forceps ventouse) should be abandoned, where
there is nodescent of the presenting part with each pull or when delivery is not
imminent after three pulls with correctly applied instruments by an experienced
operator. On no account, traction should exceed 30 minutes.
COMPLICATIONS:
Neonate: (1) Superficial scalp abrasion (2) sloughing of the scalp and (3) cephalhematoma—due to rupture of emissary veins beneath the periosteum. Usually it
resolves by one or two weeks (4) subaponeurotic (subgaleal) hemorrhage (not
limited by suture line as it is not subperiosteal) (5) intracranial hemorrhage (rare)
(6) retinal hemorrhage (no long-term effect) and (7) jaundice.
Maternal: The injuries are uncommon but may be due to inclusion of the soft
tissues such as the cervix or vaginal wall inside the cup. However, failure rate is
high. The sequential use of ventouse and forceps increases the risk of trauma
both to the mother and the neonate. Outlet forceps may be used following failure
of ventouse.
59. Destructive operations: types indications and procedures.
The destructive operations are designed to diminish the bulk of the fetus so as to
facilitate easy delivery through the birth canal. In modern obstetric practice,
virtually there is hardly any place for destructive operations.
Some commonly performed operations are discussed here. There are four types
of operations:
􏰀 Craniotomy 􏰀 Evisceration 􏰀 Decapitation 􏰀 Cleidotomy
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CRANIOTOMY
DEFINITION: It is an operation to make a perforation on the fetal head, to
evacuate the contents followed by extraction of the fetus.
INDICATIONS:
􏰀
Cephalicpresentationproducingobstructedlaborwithdeadfetus:Thisisthemostcom
mon indication of craniotomy in the referral hospitals of the developing countries.
􏰀
Hydrocephaluseveninalivingfetus:Thisisapplicablebothfortheforecomingandtheaft
er- coming head (see p. 470).
􏰀 Interlocking head of twins.
PROCEDURES: Preliminaries: The preliminary preparations are the same as
mentioned in p. 642. The operation is to be done under general anesthesia.
Actual steps
Step I: The two fingers (index and middle) are introduced into the vagina and the
finger tips are to be placed on proposed site of perforation. However, when the
suture line cannot be defined because of big caput, the perforation should be
done through the dependent part.
Sites of perforation: Vertex: On the parietal bone either side of the sagittal suture.
Suture is avoided to prevent collapse of the bone thereby preventing escape of
the brain matter. Face:Through the orbit or hard palate. Brow: Through the
frontal bone.
Step II: The Oldham’s perforator with the blades closed is introduced under the
palmar aspect of the fingers protecting the anterior vaginal wall and the adjacent
bladder (as shown in Figs 37.20A and B) until the tip reaches the proposed site of
perforation.
Step III: By rotating movements the skull is perforated. During this step, an
assistant is asked to steady the head per abdomen in a manner of first pelvic grip.
After the skull is perforated, the instrument is thrust up to the shoulders and the
handles are approximated so as to allow separation of the sharp blades for about
2.5 cm.
Alternative to Oldham’s perforator, similar procedure could be performed using a
sharp-pointed Mayo’s scissors.
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Step IV: With the fingers brain matter is evacuated. The idea is to make the skull
collapse as much as possible. Step V: When the skull is found sufficiently
compressed, the extraction of the fetus is achieved either by using a cranioclast or
by two giant volsella. Giant volsella are used to hold the incised skull and scalp
margins.
Step VI: The traction is now exerted in the same direction as like that mentioned
in forceps operation.
Step VII: After the delivery of the placenta, the uterovaginal canal must be
explored as a routine for evidence
of rupture uterus or any tear.
DECAPITATION
DEFINITION: It is a destructive operation whereby the fetal head is severed from
the trunk and the delivery is completed with the extraction of the trunk and that
of the decapitated head per vaginum.
INDICATION: (1) Neglected shoulder presentation with dead fetus where neck is
easily accessible. (2) Interlocking head of twins.
PROCEDURES: Preliminaries — The preliminaries to be followed are the same as
outlined earlier. The operation is done under general anesthesia.
Actual Steps
Step I: If the fetal hand is not prolapsed, bring down a hand. A roller gauze is tied
on the fetal wrist and an assistant is asked to give traction towards the side away
from the fetal head to make the neck more accessible and fixed.
Step II: Two fingers of the left hand (middle and index) are introduced with the
palmar surface downwards and the finger tips are to be placed on the superior
surface of the neck—the proposed site of decapitation.
Step III: The decapitation hook with knife is to be introduced flushed under the
guidance of the fingers placed into the vagina, the knob pointing towards the fetal
head. The hook is pushed above the neck and rotated to 90° so as to place the
knife firmly against the neck. The internal fingers, in the meantime, are placed on
the under surface of the neck to guard the tip of the hook.
Step IV: By upward and downward movements of the hook with knife, the
vertebral column is severed (evident by sudden loss of resistance). The rest of the
soft tissue left behind may be severed by the same instrument or by embryotomy
scissors. While removing the decapitation hook—it is to be pushed up; rotated to
75 | P a g e
90° and then to take out under the guidance of the internal fingers. The
decapitated head is pushed up and the trunk is delivered by traction on the
prolapsed arm.
Step V: Delivery of the decapitated head—Any of the following methods may be
usually effective:
􏰀 By hooking the index finger into the mouth 􏰀 By holding the severed neck with
giant vulsellum (Fig. 42.33)
and delivery of the head as that of aftercoming head in breech 􏰀 Using forceps.
Step VI: Routine exploration of the uterovaginal canal to exclude rupture of the
uterus or any other injury.
EVISCERATION
The operation consists of removal of thoracic and abdominal contents piecemeal
through an opening on the thoracic or abdominal cavity at the most accessible
site. The object is to diminish the bulk of the fetus which facilitates its extraction.
If difficulty arises, the spine may have to be divided (spondylectomy) with
embryotomy scissors.
The indications are: (1) Neglected shoulder presentation with dead fetus; the
neck is not easily accessible and (2) fetal malformations, such as fetal ascites or
hugely distended bladder or monsters.
CLEIDOTOMY
The operation consists of reduction in the bulk of the shoulder girdle by division
of one or both the clavicles.
The operation is done only in dead fetus (anencephaly excluded) with shoulder
dystocia. The clavicles are divided by the embryotomy scissors or long straight
scissors introduced under the guidance of left two fingers placed inside the
vagina.
60. Abnormal uterine action: definition, classification, etiology.
Any deviation of the normal pattern of uterine contractions (as mentioned in
page 138) affecting the course of labor is designated as disordered or abnormal
uterine action.
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ETIOLOGY: As the physiology of normal uterine contraction is not fully
understood, the cause of its disordered action remains obscure. However, the
following clinical conditions are often associated: (1) Prevalent in first birth,
especially with elderly women; (2) Prolonged pregnancy; (3) Overdistension of the
uterus (twins and fibroids); (4) Emotional factor (anxiety, stress); (5)
Constitutional factor (obesity); (6) Contracted pelvis and malpresentation; (7)
Injudicious administration of sedatives, analgesics and oxytocics; (8) Premature
attempt at vaginal delivery (induction of labor or ARM) or attempted instrumental
vaginal
delivery under light anesthesia.
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61. Uterine inertia: clinical features. prognosis for mother, child and delivery.
management.
Uterine inertia is the common type of abnormal uterine contraction but is
comparatively less serious. It may complicate any stage of labor. It may be
present from the beginning of labor or may develop subsequently after a variable
period of effective contractions.
EFFECTS ON THE MOTHER AND FETUS: Maternal exhaustion and/or fetal distress
are unusual and appear late.
MANAGEMENT: Case is reassessed to exclude cephalopelvic disproportion or
malpresentation. Place of cesarean section: (1) Presence of contracted pelvis (2)
Malpresentation (3) Evidences of
fetal or maternal distress.
Vaginal delivery — (A) General measures: (1) To keep up the morale of the
patient. Maternal stress, pain and anxiety appear to inhibit uterine contractions
through release of endogenous catecholamines. (2) Posture of the woman is
changed. Supine position is avoided. (3) To empty the bladder, catheterization is
made. (4) To maintain hydration by infusion of Ringer’s solution. (5) Adequate
pain relief.
(B) Active measures: Acceleration of uterine contraction can be brought about by
low rupture of the membranes followed by oxytocin drip. The drip rate is
gradually increased until effective contractions are set up. The drip is to be
continued till 1 hour after delivery.
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62. Inco-ordinate uterine action: varieties, clinical features, prognosiS for mothe
child and delivery, management.
63. Injures to the birth canal: vulval, perineal, vaginal, cervical, their etiology,
diagnosis and management.
Maternal injuries following childbirth process are quite common and contribute
significantly to maternal morbidity and even to death.
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VULVA
Lacerations of the vulval skin posteriorly and the paraurethral tear on the inner
aspect of the labia minora are the common sites. Paraurethral tear may be
associated with brisk hemorrhage and should be repaired by interrupted catgut
sutures, preferably after introduction of a rubber catheter into the bladder to
prevent injury of the urethra.
PERINEUM
While minor injury is quite common especially during first birth, gross injury (third
and fourth degree) is invariably a result of mismanaged second stage of labor.
Overall risk is 1% of all vaginal deliveries.
CAUSES: Perineal injury (mainly the third and fourth degree) results from (i) over
stretching and/ or (ii) rapid stretching of the perineum especially when the
perineum is inelastic
VAGINAL
Isolated vaginal tears or lacerations without involvement of the perineum or
cervix are not uncommon. These are usually seen following instrumental or
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manipulative delivery. In such cases, the tears are extensive and often associated
with brisk hemorrhage.
TREATMENT: Tears associated with brisk hemorrhage require exploration under
general anesthesia with a good light. The tears are repaired by interrupted or
continuous sutures using chromic catgut No. “0”. In case of extensive lacerations,
in addition to sutures, hemostasis may be achieved by intravaginal plugging by
roller gauze, soaked with glycerin and acriflavine. The plug should be removed
after 24 hours. Selective arterial embolization may also be done if bleeding
persists.
CERVIX
Minor degree of cervical tear is invariable during first delivery and requires no
treatment. Extensive cervical tear is rare. It is the commonest cause of traumatic
postpartum hemorrhage. Left lateral tear is the commonest.
DIAGNOSIS: Excessive vaginal bleeding immediately following delivery in presence
of a hard and contracted uterus—raises the suspicion of a traumatic bleeding.
Exploration of the uterovaginal canal under good light not only confirms the
diagnosis but also helps to know the extent of the tear.
TREATMENT:
Only deep cervical tear associated with bleeding should be repaired soon after
delivery of the placenta. Repair should be done under general anesthesia, in
lithotomy position with a good light.
64. Rupture of the uterus: etiology, pathology, diagnosis, prophylaxis, treatment.
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DEFINITION: Disruption in the continuity of the all uterine layers (endometrium,
myometrium and serosa) any time beyond 28 weeks of pregnancy is called
rupture of the uterus.
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PATHOLOGY
TYPES: Pathologically, it is customary to distinguish between complete and
incomplete rupture depending on whether the peritoneal coat is involved or not.
So far from the treatment point of view, it matters little. In incomplete rupture,
the peritoneum remains intact.
Incomplete rupture usually results from rupture of the lower segment scar or
extension of a cervical tear into the lower segment with formation of a broad
ligament hematoma. Complete rupture usually occurs following disruption of the
scar in upper segment. It may also be due to spontaneous rupture of both
obstructive and nonobstructive type.
FETUS AND PLACENTA: In incomplete rupture, both the fetus and placenta remain
inside the uterine cavity or part of the fetus may occupy in between the layers of
broad ligament. In complete rupture, the fetus with or without the placenta
usually escapes out of the uterus. The uterus remains contracted. Blood loss is not
much unless major vessels are affected.
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PROPHYLAXIS: The following guidelines are helpful to prevent or to detect at the
earliest the tragic occurrence of rupture uterus:
􏰀 The at-risk mothers, likely to rupture, should have mandatory hospital delivery.
These are— (a) Contracted pelvis.
(b) Previous history of cesarean section,
hysterotomy or myomectomy. (c) Uncorrected transverse lie. (d) Grand
multiparity. (e) Known case of hydrocephalus.
􏰀 General anesthesia should not be used to give undue force in external version.
􏰀 Undue delay in the progress of labor in a multipara with previous uneventful
delivery should be viewed
with concern and the cause should be sought for.
􏰀 Judicious selection of cases with previous history of cesarean sections for
vaginal delivery (VBAC)
􏰀 Judicious selection of cases and careful watch are mandatory during oxytocin
infusion either for induction or augmentation of labor.
􏰀 There is hardly any place of internal podalic version in singleton fetus in present
day obstetrics. It should never be done in obstructed labor as an alternative to
destructive operation or cesarean delivery.
􏰀 Attempted forceps delivery or breech extraction through incompletely dilated
cervix should be avoided.
􏰀 Destructive vaginal operations should be performed by skilled personnel and
exploration of the uterus
should be done as a routine following delivery.
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􏰀 Manual removal in morbid adherent placenta—should be done by a senior
person.
TREATMENT: 􏰀 Resuscitation 􏰀 Laparotomy
Depending upon the state of the clinical condition, either resuscitation is to be
done followed by laparotomy or in acute conditions, resuscitation and laparotomy
are to be done simultaneously.
65. Birth injures to the newborn (head, bones etc.): classification, etiology and
predisposing factors. treatment.
Birth injuries is an impairment of the infant’s body function or structure due to
adverse influences that occurred at birth. Injury commonly occurs during labor or
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delivery. Birth injuries may be severe enough to cause neonatal deaths, still births
or
number of morbidities.
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66. Abnormal puerperium: varictics, clinical features, diagnosis and
management.
Varieties : 1) Puerperal pyrexia 2) Puerperal Sepsis
PUERPERAL PYREXIA
DEFINITION: A rise of temperature reaching 100.4°F (38°C) or more (measured
orally) on two separate occasions at 24 hours apart (excluding first 24 hours)
within first 10 days following delivery is called puerperal pyrexia.
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PUERPERAL SEPSIS
(Syn: Puerperal infection)
DEFINITION: An infection of the genital tract which occurs as a complication of
delivery is termed puerperal sepsis. Puerperal pyrexia is considered to be due to
genital tract infection unless proved otherwise.
commonly due to—(i) endometritis, (ii) endomyometritis, or (iii) endoparametritis
or a combination of all these when it is called pelvic cellulitis.
CLINICAL FEATURES
􏰀 Local infection 􏰀 Uterine infection 􏰀 Spreading infection
LOCAL INFECTION (WOUND INFECTION): (1) There is slight rise of temperature,
generalized malaise or headache, (2) The local wound becomes red and swollen,
(3) Pus may form which leads to disruption of the wound. When severe (acute),
there is high rise of temperature with chills and rigor.
UTERINE INFECTION
Mild—(1) There is rise in temperature (>100.4°F) and pulse rate (>90), (2) Lochial
discharge becomes offensive and copious, (3) The uterus is subinvoluted and
tender.
Severe—(1) The onset is acute with high rise of temperature, often with chills and
rigor, (2) Pulse rate is rapid, out of proportion to temperature, (3) Often there is
breathlessness, coughs, abdominal pain and dysuria, (4) Lochia may be scanty and
odorless, (5) Uterus may be subinvoluted, tender and softer. There may be
associated wound infection (perineum, vagina or the cervix).
SPREADING INFECTION (EXTRAUTERINE SPREAD) is evident by presence of pelvic
tenderness (pelvic peritonitis), tenderness on the fornix (parametritis), bulging
fluctuant mass in the pouch of Douglas (pelvic abscess).
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General care: (i) Isolation of the patient is preferred especially when hemolytic
Streptococcus is obtained on culture, (ii) Adequate fluid and calorie are
maintained by intravenous infusion (IV), (iii) Anemia is corrected by oral iron or if
needed by blood transfusion, (iv) An indwelling catheter is used to relieve any
urine retention due to pelvic abscess. It also helps to record urinary output, (v) A
chart is maintained by recording pulse, respiration, temperature, lochial
discharge, and fluid intake and output.
(vi) Antibiotics: Ideal antibiotic regimen should depend on the culture and
sensitivity report. Pending the report, gentamicin (2 mg/kg IV loading dose,
followed by 1.5 mg/kg IV every 8 hours) and clindamycin (900 mg IV every 8
hours) should be started. Metronidazole 0.5 g IV is given at 8 hours interval to
control the anaerobic group. The treatment is continued until the infection is
controlled for at least 7–10 days.
Surgical treatment: There is little role of major surgery in the treatment of
puerperal sepsis.
􏰀 Perineal wound—The stitches of the perineal wound may have to be removed
to facilitate drainage of pus and relieve pain. The wound is to be cleaned with sitz
bath several times a day and is dressed with an antiseptic ointment or powder.
Retaineduterineproductswithadiameterof3cmorlessmaybedisregardedandleftalon
e.
Otherwise surgical evacuation after antibiotic coverage for 24 hours should be
done to avoid the risk of septicemia. Cases with septic pelvic thrombophlebitis are
treated with IV heparin for 7–10 days.
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Pelvic abscess should be drained by colpotomy under ultrasound guidance.
􏰀
Wounddehiscence:Dehiscenceofepisiotomyorabdominalwoundfollowingcesarean
section is managed by scrubbing the wound twice daily, debridement of all
necrotic tissue and then closing the wound with secondary suture.
Laparotomy has got limited indications. Maintenance of electrolyte balance by
intravenous
fluids along with appropriate antibiotic therapy usually controls the peritonitis.
Hysterectomy is indicated in cases with rupture or perforation, having multiple
abscesses, gangrenous uterus or gas gangrene infection. Ruptured tubo-ovarian
abscess should be removed.
Necrotizing fasciitis is rare but fatal complication of wound infection (abdominal,
perineal, vaginal), involving muscle and fascia.
Treatment includes: Rehydration, wound scrubbing, debridement of all necrotic
tissues, and use of high dose broad-spectrum (IV) antibiotics.
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67. Pregnancy in Rh-negative mothers. Haemolytic disease of fetus and
newborn.
Rh-negative mothers may develop antibodies against Rh-positive fetal blood cells
during pregnancy, which can lead to hemolytic disease of the fetus and newborn
(HDFN). This occurs because the Rh antigen is present on the surface of red blood
cells and is inherited genetically. An Rh-negative mother who carries an Rhpositive fetus is at risk for developing antibodies against the Rh antigen, which
can cross the placenta and attack the fetal red blood cells.
If the mother is Rh-negative and the father is Rh-positive, there is a 50% chance
that the fetus will be Rh-positive. The risk of sensitization to Rh factor increases
with each pregnancy, as the mother's immune system is exposed to more Rhpositive fetal blood cells.
HDFN can cause anemia, jaundice, and in severe cases, brain damage or death in
the fetus or newborn. The severity of HDFN depends on the level of maternal
antibodies, the number of fetal red blood cells destroyed, and the gestational age
at which the disease occurs.
To prevent HDFN, Rh-negative mothers are given Rh immune globulin (RhIg)
during pregnancy and within 72 hours after delivery or any other event that may
have caused mixing of the maternal and fetal blood, such as miscarriage or
abortion. RhIg works by binding to any Rh-positive fetal cells in the mother's
bloodstream before her immune system has a chance to develop an immune
response.
If HDFN is suspected, the fetus can be monitored for signs of anemia using
ultrasound and fetal blood sampling. In severe cases, intrauterine blood
transfusions may be necessary to treat the anemia. After delivery, the newborn
may require phototherapy or exchange transfusions to treat jaundice and prevent
brain damage.
68. Anaemia in pregnancy: possible types, diagnosis, complications. prognosis,
treatment.
Anemia in pregnancy is a common medical condition that occurs when the
number of red blood cells or hemoglobin levels are below normal range. There
are several possible types of anemia in pregnancy, including iron deficiency
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anemia, folate deficiency anemia, and vitamin B12 deficiency anemia.
Iron deficiency anemia is the most common type of anemia in pregnancy. It
occurs when there is insufficient iron available for the body to produce enough
red blood cells. This type of anemia is typically caused by inadequate intake of
iron-rich foods or poor absorption of iron. Folate deficiency anemia and vitamin
B12 deficiency anemia are less common but can also occur during pregnancy.
The diagnosis of anemia in pregnancy is made through a blood test that measures
the levels of hemoglobin and hematocrit. Symptoms of anemia in pregnancy may
include fatigue, weakness, pale skin, shortness of breath, and dizziness.
Untreated anemia in pregnancy can lead to several complications, including
preterm labor, low birth weight, and postpartum hemorrhage. In severe cases,
anemia can also increase the risk of fetal and maternal mortality.
Treatment for anemia in pregnancy typically involves iron supplements or other
nutritional supplements to address the specific type of anemia. In severe cases,
blood transfusions may be necessary. It is also important to identify and treat any
underlying medical conditions that may be contributing to the anemia.
With proper diagnosis and treatment, the prognosis for anemia in pregnancy is
generally good. However, it is important for pregnant women to receive regular
prenatal care and to follow their healthcare provider's recommendations for
nutrition and supplementation to prevent and manage anemia during pregnancy.
69. Heart diseases in pregnancy: prognosis, pregnancy management.
Heart diseases in pregnancy can increase the risk of complications for both the
mother and the fetus. Some common heart diseases that can affect pregnancy
include congenital heart disease, rheumatic heart disease, mitral stenosis, aortic
stenosis, and pulmonary hypertension.
Prognosis for heart diseases in pregnancy depends on the severity of the disease
and the extent of cardiac dysfunction. Women with mild or moderate disease
usually have a good prognosis if managed appropriately. However, those with
severe heart disease may be at risk of heart failure, arrhythmias, and even
maternal mortality.
Pregnancy management for women with heart disease should involve a
multidisciplinary approach, including an obstetrician, a cardiologist, and a
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maternal-fetal medicine specialist. The management plan should be tailored to
the individual woman's specific heart disease and the severity of her symptoms.
Management strategies for heart diseases in pregnancy may include close
monitoring of maternal and fetal health, medication to manage symptoms and
prevent complications, and possible interventions such as cardiac surgery or
catheterization. In some cases, induction of labor or cesarean delivery may be
recommended to reduce the stress on the mother's heart during delivery.
Women with heart diseases in pregnancy require careful monitoring before,
during, and after delivery to ensure the best possible outcome for both the
mother and the baby.
70. Tuberculosis in pregnancy: risk factors, diagnosis, prognosis, management.
Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis
that primarily affects the lungs but can also affect other organs in the body. TB in
pregnancy can be a serious health issue for both the mother and the baby.
Risk factors for TB in pregnancy include living in an area with a high prevalence of
TB, close contact with a person with active TB, immunocompromised status, and
poverty.
Diagnosis of TB in pregnancy can be challenging as the symptoms of TB are similar
to those of pregnancy, such as cough, fever, and weight loss. Diagnostic tests for
TB include chest X-ray, sputum culture, and tuberculin skin test. However, some
diagnostic tests may not be safe for pregnant women, and the timing of testing
may need to be carefully considered.
The prognosis of TB in pregnancy depends on several factors, including the
severity of the infection, the timing of diagnosis, and the effectiveness of
treatment. TB can cause complications during pregnancy, such as preterm labor,
low birth weight, and maternal mortality.
Management of TB in pregnancy involves a multidisciplinary approach with a
team of obstetricians, pulmonologists, and infectious disease specialists. The
treatment of TB in pregnancy is similar to that in non-pregnant patients, but some
anti-TB medications may be contraindicated or require dosage adjustments in
pregnancy. Close monitoring of the mother and the fetus is crucial during the
treatment period.
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71. Diabetes: risk factors, diagnosis, prognosis, management.
Diabetes is a metabolic disorder characterized by high blood glucose levels.
During pregnancy, diabetes can occur in two forms: pre-existing diabetes or
gestational diabetes.
Risk factors for pre-existing diabetes in pregnancy include having type 1 or type 2
diabetes before pregnancy, a family history of diabetes, obesity, and being over
35 years old. Risk factors for gestational diabetes include being overweight or
obese, having a family history of diabetes, and being over 25 years old. Diagnosis
of pre-existing diabetes in pregnancy is usually made before pregnancy or during
the first trimester through blood glucose testing. For gestational diabetes,
screening is typically done between 24 and 28 weeks of pregnancy through a
glucose challenge test, followed by a glucose tolerance test if the initial test is
abnormal.
Complications of diabetes in pregnancy can include preterm labor, preeclampsia,
stillbirth, and delivery complications such as shoulder dystocia. Poorly controlled
diabetes during pregnancy can also lead to health problems for the mother, such
as diabetic retinopathy and nephropathy.
Management of diabetes in pregnancy involves careful monitoring of blood
glucose levels and insulin therapy as needed to maintain normal levels. A healthy
diet and regular exercise are also important components of diabetes
management during pregnancy. Close monitoring of the pregnancy through
frequent ultrasounds and non-stress tests may also be necessary to ensure the
health and well-being of both the mother and baby.
72. 72. Viral hepatitis's: risk factors, diagnosis, prognosis, management.
Viral hepatitis is a group of infectious diseases caused by hepatitis viruses A, B, C,
D, and E. Here are the risk factors, diagnosis, prognosis, and management of viral
hepatitis:
Risk Factors:
•
Exposure to contaminated blood and body fluids
•
Injection drug use
•
Unprotected sex with an infected partner
•
Travel to or residence in an area where hepatitis is prevalent
•
Sharing personal items such as razors or toothbrushes with an
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infected person
•
Healthcare workers who come into contact with infected blood or
body fluids
Diagnosis:
•
Blood tests to detect the presence of viral antibodies and antigens
•
Liver function tests to evaluate the liver's health
•
Imaging tests such as ultrasound, CT scan or MRI to examine the liver
•
Liver biopsy may be done to obtain a sample of liver tissue for further
analysis
Prognosis:
•
The prognosis of viral hepatitis varies depending on the type of virus
and the extent of liver damage.
•
Acute hepatitis may resolve on its own, but chronic hepatitis may
lead to serious complications such as liver cirrhosis, liver failure, and liver cancer.
Management:
•
Treatment options for viral hepatitis depend on the type of virus and
the extent of liver damage.
•
Antiviral medications such as interferon, ribavirin, and direct-acting
antivirals are used to treat hepatitis B and C.
•
Supportive care such as rest, adequate nutrition, and avoiding
alcohol and certain medications that can damage the liver.
•
Vaccines are available to prevent hepatitis A and B.
It is important to seek medical attention if you suspect you have viral hepatitis, as
early diagnosis and treatment can improve outcomes.
73. Syphilis in pregnancy: risk factors, diagnosis, prognosis, management.
Syphilis is a sexually transmitted infection caused by the bacterium Treponema
pallidum. It can be transmitted from an infected mother to her fetus during
pregnancy, leading to congenital syphilis. The following are the risk factors,
diagnosis, prognosis, and management of syphilis in pregnancy:
Risk factors:
•
Being sexually active with a partner who has syphilis
•
Previous history of syphilis or other sexually transmitted infections
•
Unprotected sex
•
Intravenous drug use
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•
Living in an area with a high prevalence of syphilis
Diagnosis:
Syphilis can be diagnosed through blood tests, such as the Venereal Disease
Research Laboratory (VDRL) test or the Rapid Plasma Reagin (RPR) test. If the
results are positive, further testing is needed to confirm the diagnosis, such as the
Treponema pallidum particle agglutination (TPPA) test or the fluorescent
treponemal antibody absorption (FTA-ABS) test.
Prognosis:
If left untreated, syphilis in pregnancy can lead to serious complications, such as
stillbirth, preterm birth, low birth weight, and congenital syphilis. Congenital
syphilis can cause deformities, neurological problems, and developmental delays
in the baby.
Management:
Treatment of syphilis in pregnancy involves antibiotics, such as penicillin. Penicillin
is safe for use in pregnancy and is the only recommended treatment for pregnant
women with syphilis. Treatment should be started as early as possible to prevent
transmission of the infection to the fetus. If the fetus is infected, treatment may
need to be continued after delivery. Regular monitoring of the mother and fetus
is also important to ensure that the infection is treated effectively and to detect
any complications.
74. Urinary tract infection in pregnancy (pyelonephritis, asymptomatic
bacteriuria): risk factors. diagnosis, prognosis, management.
Urinary tract infections (UTIs) are common during pregnancy, especially in the
second and third trimesters. Two common types of UTIs during pregnancy are
asymptomatic bacteriuria (ASB) and pyelonephritis.
Risk factors for UTIs in pregnancy include:
•
Previous history of UTIs
•
Diabetes mellitus
•
Kidney problems
•
Urinary tract abnormalities
•
Sexual activity
•
Use of a diaphragm for contraception
Diagnosis of UTIs in pregnancy involves a urine culture to detect the presence of
bacteria in the urine. Pregnant women should be screened for ASB during their
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first prenatal visit, and those who test positive should be treated with antibiotics
to prevent the development of pyelonephritis.
Pyelonephritis is a more serious type of UTI that can cause kidney damage and
preterm labor. Symptoms of pyelonephritis may include fever, chills, flank pain,
nausea, and vomiting. It is typically treated with a course of antibiotics, and
hospitalization may be required for severe cases.
Prognosis for UTIs in pregnancy is generally good with appropriate treatment.
However, if left untreated, UTIs can lead to serious complications for both the
mother and baby.
Preventive measures for UTIs during pregnancy include drinking plenty of water,
practicing good hygiene, and urinating frequently. Pregnant women should also
avoid holding in urine for extended periods and should empty their bladder
completely when urinating.
75.
HIV/AIDS in pregnancy: risk factors, diagnosis, prognosis, management.
HIV (human immunodeficiency virus) is a viral infection that can be transmitted
from mother to child during pregnancy, childbirth, or breastfeeding. It is
important for pregnant women to know their HIV status, as timely interventions
can significantly reduce the risk of mother-to-child transmission.
Risk factors for HIV/AIDS in pregnancy include unprotected sexual activity with an
infected partner, sharing needles or syringes, and being from a high-prevalence
region.
Diagnosis of HIV in pregnancy involves routine testing, typically at the first
prenatal visit and again in the third trimester for high-risk women. Rapid HIV
testing may also be used during labor and delivery for women who do not know
their HIV status.
The prognosis for HIV-positive mothers and their babies has significantly
improved with the use of antiretroviral therapy (ART) during pregnancy and
delivery, as well as prophylactic medication for the baby. With appropriate
interventions, the risk of mother-to-child transmission can be reduced to less than
1%.
Management of HIV/AIDS in pregnancy involves close monitoring by a healthcare
provider experienced in managing HIV-positive pregnant women. ART is the
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mainstay of treatment, and it is important to adhere to the treatment regimen to
reduce the risk of transmission to the baby. In addition, elective caesarean section
delivery may be recommended to further reduce the risk of transmission.
Breastfeeding may also need to be avoided or limited depending on the mother's
viral load and other factors.
76. General surgery and acute abdomen during the pregnancy.
Pregnancy itself does not increase the risk of general surgical conditions or acute
abdomen, but pregnancy can affect the presentation, diagnosis, and management
of these conditions. Some common general surgical conditions that can occur
during pregnancy include appendicitis, cholecystitis, pancreatitis, bowel
obstruction, and hernias.
The diagnosis of these conditions in pregnant women can be challenging due to
changes in anatomy and physiology that occur during pregnancy. For example,
the appendix may be located higher in the abdomen due to the upward
displacement of the uterus, making it difficult to diagnose appendicitis based on
typical clinical signs and symptoms. Additionally, the enlarged uterus may
compress the intestines, causing symptoms that can mimic bowel obstruction.
Management of these conditions in pregnant women should be tailored to the
individual patient and the severity of the condition. In general, surgical
intervention should be considered if the condition is life-threatening or if
conservative management fails. Surgery during pregnancy carries a higher risk of
complications, such as preterm labor, fetal distress, and miscarriage, but these
risks must be balanced against the potential risks of delaying or avoiding surgery.
In cases of acute abdomen, the immediate management includes stabilization of
the mother and fetus, and expedited diagnosis to initiate appropriate
management. Surgery may be necessary to manage acute abdomen, but nonsurgical management such as antibiotics may be used for some conditions like
acute cholecystitis.
In summary, general surgical conditions and acute abdomen can occur during
pregnancy and may require surgery or other interventions. Careful diagnosis and
management that considers the unique physiology and anatomy of pregnancy are
important to ensure optimal outcomes for both the mother and fetus.
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77. Multiple pregnancy: diagnosis, prognosis and management.
Multiple pregnancy refers to the presence of more than one fetus in the uterus. It
can result from the fertilization of multiple eggs by multiple sperm (fraternal or
dizygotic twins) or from the division of a single fertilized egg (identical or
monozygotic twins).
Diagnosis of multiple pregnancy is usually made by ultrasound, which can detect
the presence of more than one gestational sac and confirm the number of
fetuses.
Prognosis for multiple pregnancy depends on several factors, including the
number of fetuses, gestational age, and presence of any complications such as
preterm labor or preeclampsia. Multiple pregnancy is associated with a higher risk
of complications such as preterm delivery, low birth weight, and fetal growth
restriction. The risk of these complications increases with the number of fetuses.
Management of multiple pregnancy involves close monitoring for complications
and may require more frequent prenatal visits, ultrasounds, and specialized care.
In some cases, interventions such as cerclage (a stitch to keep the cervix closed),
bed rest, or medications may be recommended to prevent preterm labor or other
complications. In cases where the risk to the mother or fetuses is high, delivery
may be recommended earlier than in a singleton pregnancy. In general, the
management of multiple pregnancy is individualized based on the specific
circumstances of each pregnancy.
78. Post-term pregnancy: diagnosis, prognosis and management.
Post-term pregnancy is defined as a pregnancy that goes beyond 42 completed
weeks of gestation. The diagnosis is made by accurately determining the
gestational age through ultrasound or by calculating the last menstrual period.
The prognosis of post-term pregnancy can be associated with increased risk of
adverse outcomes for both the mother and the baby. The longer the pregnancy
goes beyond the due date, the greater the risk of fetal distress, stillbirth,
meconium aspiration syndrome, and other complications such as shoulder
dystocia, macrosomia, and prolonged labor. For the mother, post-term pregnancy
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can increase the risk of cesarean delivery, perineal trauma, and postpartum
hemorrhage.
The management of post-term pregnancy depends on several factors, including
the overall health of the mother and fetus, the bishop score, and the presence or
absence of fetal distress. Induction of labor is generally recommended after 41
weeks of gestation to reduce the risk of complications. The methods used to
induce labor can vary, but commonly include the use of prostaglandins or
oxytocin. Cesarean delivery may be necessary if there is fetal distress, failed
induction, or other indications for operative delivery. Close monitoring of both
the mother and the baby is crucial during the management of post-term
pregnancy.
79. Diseases of the fetus and newborn: asphyxia neonatorum, respiratory
distress. jaundice. convulsions.
Asphyxia neonatorum is a condition in which the newborn baby is not getting
enough oxygen. It can be caused by a variety of factors such as prolonged labor,
compression of the umbilical cord, or preterm birth. Symptoms include a low
heart rate, pale or blue skin, weak or absent breathing, and low muscle tone.
Treatment may include resuscitation with oxygen, ventilation, and medication to
support the baby's heart rate and blood pressure.
Respiratory distress syndrome (RDS) is a common problem in premature infants
where the lungs have not fully developed. It is caused by a lack of surfactant, a
substance that keeps the air sacs in the lungs open, and leads to difficulty
breathing. Symptoms include rapid breathing, flaring of the nostrils, grunting
sounds, and a bluish tinge to the skin. Treatment may include oxygen therapy,
mechanical ventilation, and medication to stimulate the production of surfactant.
Jaundice is a common condition in newborns where the baby's skin and eyes
appear yellow due to high levels of bilirubin in the blood. It is often harmless but
can be a sign of more serious conditions such as blood type incompatibility or
liver disease. Treatment may include phototherapy, in which the baby is exposed
to special lights that help break down the bilirubin, or exchange transfusion, in
which some of the baby's blood is replaced with donor blood.
Convulsions in newborns can be caused by a variety of factors such as brain
injury, infection, or metabolic disorders. Symptoms include uncontrolled
movements, staring, and changes in breathing and heart rate. Treatment may
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include medication to stop the seizures and treat the underlying cause.
In all cases, early detection and appropriate management are crucial for the best
possible outcome for the baby.
80. 80. Perinatal infections: common sites, causes, mode, prevention,
investigations, treatment.
Perinatal infections are infections that can occur during pregnancy or in the
neonatal period. These infections can have serious consequences for the health of
the mother, the developing fetus, and the newborn. Common perinatal infections
include group B streptococcus (GBS), cytomegalovirus (CMV), toxoplasmosis,
syphilis, rubella, and herpes simplex virus (HSV).
Common sites and causes of perinatal infections:
•
Maternal genital tract: GBS, chlamydia, gonorrhea, HSV, human
papillomavirus (HPV), trichomoniasis
•
Placenta and fetal membranes: CMV, toxoplasmosis, syphilis
•
Amniotic fluid: GBS, E. coli, other bacteria, Candida albicans,
Ureaplasma urealyticum
•
Fetal bloodstream: GBS, syphilis, CMV
•
Neonatal respiratory tract: Group B streptococcus, E. coli,
Haemophilus influenzae, Chlamydia trachomatis, Ureaplasma urealyticum,
respiratory syncytial virus (RSV)
Mode of transmission:
•
Vertical transmission: from mother to fetus or newborn during
pregnancy, delivery, or breastfeeding.
•
Horizontal transmission: from person to person through contact with
infected body fluids or contaminated objects.
Prevention:
•
Routine screening and treatment of maternal infections during
pregnancy
•
Vaccination of the mother before pregnancy to prevent certain
infections (e.g., rubella, hepatitis B)
•
Prevention of exposure to infectious agents through safe sex
practices, good hygiene, and avoiding contact with infected individuals
•
Adequate prenatal care to detect and manage infections promptly
Investigations:
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•
•
•
Treatment:
•
•
•
•
jaundice)
Maternal blood tests (e.g., syphilis, HIV, CMV, rubella, toxoplasmosis)
Amniocentesis (for diagnosis of fetal infections)
Ultrasound (for detection of fetal abnormalities)
Antibiotics for bacterial infections (e.g., GBS, syphilis)
Antivirals for viral infections (e.g., acyclovir for HSV)
Antifungals for fungal infections (e.g., candidiasis)
Supportive care for neonatal complications (e.g., respiratory distress,
81. Anatomy of female reproductive system.
The female reproductive system includes a complex network of organs, glands,
and hormones that work together to produce, transport, and nourish female
reproductive cells and support fetal development during pregnancy.
The main organs of the female reproductive system include:
•
Ovaries: two small, almond-shaped organs that produce and release
eggs (ova) into the fallopian tubes
•
Fallopian tubes: two thin tubes that transport eggs from the ovaries
to the uterus and are the site of fertilization
•
Uterus: a muscular organ that is the site of fetal development during
pregnancy
•
Cervix: the lower part of the uterus that connects to the vagina
•
Vagina: a muscular canal that connects the cervix to the outside of
the body and serves as the birth canal during delivery
•
Vulva: the external genital organs, including the labia, clitoris, and
vaginal opening.
Other important structures and glands in the female reproductive system include
the mammary glands (breasts), which produce milk to nourish newborns, and
various glands that produce and regulate hormones such as estrogen and
progesterone.
82. Physiology of female reproductive system: hypothalamus as the main
neuroendocrine gland; pituitary gland (adenohypophysis).
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The female reproductive system is regulated by a complex interplay of hormones,
neurotransmitters, and other signaling molecules. The hypothalamus and the
pituitary gland, located in the brain, play important roles in this regulation.
The hypothalamus produces gonadotropin-releasing hormone (GnRH), which
stimulates the pituitary gland to release follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) into the bloodstream. These hormones, in turn, act on
the ovaries to regulate the menstrual cycle and ovulation.
FSH stimulates the growth and maturation of ovarian follicles, which contain the
eggs. LH triggers ovulation, the release of a mature egg from the ovary. After
ovulation, the empty follicle transforms into the corpus luteum, which produces
progesterone, a hormone that prepares the uterus for pregnancy.
If fertilization does not occur, the corpus luteum eventually disintegrates, leading
to a drop in progesterone levels, which triggers menstruation. If fertilization does
occur, the fertilized egg implants in the uterus and produces human chorionic
gonadotropin (hCG), a hormone that maintains the corpus luteum and prevents
menstruation.
In addition to the hypothalamus-pituitary-ovarian axis, other hormones such as
estrogen, progesterone, and testosterone also play important roles in the female
reproductive system. Estrogen is responsible for the development of female
secondary sex characteristics and helps regulate the menstrual cycle, while
progesterone prepares the uterus for pregnancy and helps maintain a healthy
pregnancy. Testosterone is produced in small amounts in the ovaries and
contributes to female sexual function and libido.
83. 83. Ovarian steroidogenesis: hormones and their actions.
Ovarian steroidogenesis refers to the process by which the ovaries produce
steroid hormones, primarily estrogens and progesterone. This process is
regulated by the hypothalamic-pituitary-ovarian axis.
The main hormones involved in ovarian steroidogenesis are follicle-stimulating
hormone (FSH) and luteinizing hormone (LH), which are produced by the anterior
pituitary gland. FSH stimulates the growth and maturation of ovarian follicles,
which contain the developing oocytes. LH stimulates the production of
testosterone by the theca cells within the follicles.
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The granulosa cells within the follicle convert testosterone to estradiol, which is
the most potent form of estrogen. The levels of estrogen increase as the follicle
matures, and it reaches its highest levels just prior to ovulation. After ovulation,
the remaining follicle forms the corpus luteum, which secretes progesterone.
Progesterone helps to prepare the uterus for implantation and maintenance of a
fertilized egg.
The levels of estrogen and progesterone are also regulated by feedback
mechanisms between the ovaries, pituitary gland, and hypothalamus. High levels
of estrogen and progesterone inhibit the secretion of FSH and LH, which in turn
decreases the production of estrogen and progesterone. This helps to maintain a
balance between these hormones during the menstrual cycle.
Overall, ovarian steroidogenesis is a complex process that involves the interaction
of multiple hormones and regulatory mechanisms. It is essential for the normal
functioning of the female reproductive system and plays a critical role in the
menstrual cycle, pregnancy, and other aspects of female health.
84. 84. Physiology of menstruation and normal menstrual cycle.
Menstruation is a cyclic process that occurs in women during their reproductive
years, typically from menarche (first menstrual period) to menopause. The
menstrual cycle is regulated by the complex interplay of various hormones,
including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen,
and progesterone.
The menstrual cycle can be divided into three phases: the follicular phase, the
ovulatory phase, and the luteal phase.
1.
Follicular Phase: This phase begins on the first day of menstruation
and lasts for approximately 14 days. During this phase, FSH is secreted by the
pituitary gland, which stimulates the growth and maturation of several ovarian
follicles. The follicles produce estrogen, which causes the lining of the uterus
(endometrium) to thicken in preparation for implantation of a fertilized egg.
2.
Ovulatory Phase: This phase occurs around day 14 of the menstrual
cycle. LH is secreted by the pituitary gland, which triggers the release of a mature
egg (ovulation) from the dominant follicle.
3.
Luteal Phase: This phase begins after ovulation and lasts for
approximately 14 days. The ruptured follicle (now called the corpus luteum)
produces progesterone, which causes the endometrium to become more vascular
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and glandular in preparation for implantation of a fertilized egg. If fertilization
does not occur, the corpus luteum degenerates, and the levels of estrogen and
progesterone decrease, leading to the shedding of the endometrium and the
onset of menstruation.
This menstrual cycle is typically 28 days long, but can vary from woman to
woman. The duration of the menstrual cycle and the amount of bleeding can also
vary.
85. 85. Application of diagnostic methods in gynaecology (general and systemic
examination; abdominal examination; gynaecological examination).
Diagnostic methods play a crucial role in the diagnosis and management of
various gynecological conditions. The following are some of the commonly used
diagnostic methods in gynecology:
1.
General and systemic examination: This includes a thorough
evaluation of the patient's medical history, vital signs, and physical examination of
other body systems to identify any underlying medical conditions that may impact
gynecological health.
2.
Abdominal examination: This involves palpation of the abdomen to
assess the size, shape, and tenderness of the uterus, ovaries, and other pelvic
structures.
3.
Gynecological examination: This is a comprehensive examination of
the female genitalia, including the vulva, vagina, cervix, uterus, and ovaries. It is
performed to detect any abnormality in the structure or function of these organs.
4.
Imaging studies: Imaging studies such as ultrasound, MRI, and CT
scans are used to visualize the internal structures of the female reproductive
system and detect any abnormalities.
5.
Laboratory tests: Laboratory tests such as blood tests, urine tests,
and cervical cytology are used to evaluate the hormonal status, detect infections,
and diagnose gynecological conditions such as cervical cancer.
6.
Biopsy: Biopsy involves the removal of a tissue sample from the
cervix, uterus, or ovaries for further analysis to diagnose conditions such as
cervical dysplasia, endometrial cancer, or ovarian cancer.
7.
Endoscopy: Endoscopy involves the use of a thin, flexible tube with a
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light and camera to visualize the internal structures of the female reproductive
system. It is used to diagnose conditions such as endometriosis, pelvic
inflammatory disease, and fibroids.
Overall, the appropriate use of diagnostic methods is crucial in identifying and
managing gynecological conditions and improving women's health outcomes.
86. 86. Application of diagnostic methods in gynaecology (cytohormonal
evaluation, uterine aspiration cytology and endometrial biopsy. aspiration of
pouch of Douglas, hormonal tests)
In gynecology, various diagnostic methods can be used to evaluate different
aspects of female reproductive health. Here are some examples of diagnostic
methods used in gynecology:
1.
Cytological evaluation: This includes Pap smear, uterine aspiration
cytology, and endometrial biopsy. These methods help to detect abnormal cells in
the cervix, uterus, and endometrium, which may indicate cancer or pre-cancerous
conditions.
2.
Hormonal evaluation: Hormonal tests are used to evaluate the levels
of hormones such as estrogen, progesterone, and follicle-stimulating hormone
(FSH). These tests help to diagnose hormonal imbalances, such as polycystic ovary
syndrome (PCOS) and menopause.
3.
Ultrasonography: This diagnostic method uses high-frequency sound
waves to produce images of the uterus, ovaries, and other pelvic structures. It can
help to detect conditions such as fibroids, ovarian cysts, and endometriosis.
4.
Magnetic resonance imaging (MRI): This imaging technique uses a
strong magnetic field and radio waves to produce detailed images of the body. It
is particularly useful in detecting pelvic masses and evaluating the extent of
endometriosis.
5.
Laparoscopy: This is a surgical diagnostic method that involves
inserting a small camera through a small incision in the abdomen to view the
pelvic structures. It is used to diagnose conditions such as endometriosis, pelvic
inflammatory disease (PID), and ovarian cysts.
6.
Hysteroscopy: This is a diagnostic method that involves inserting a
small camera through the cervix to view the inside of the uterus. It is used to
diagnose conditions such as uterine fibroids, polyps, and adhesions.
7.
Aspiration of pouch of Douglas: This diagnostic method is performed
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by aspirating fluid from the pouch of Douglas, which is located behind the uterus.
It is used to diagnose conditions such as pelvic inflammatory disease (PID) and
endometriosis.
Overall, the choice of diagnostic method depends on the specific condition being
evaluated and the preferences of the healthcare provider and patient.
87. 87. Ultrasonography in gynaecology.
Transvaginal ultrasound is a commonly used diagnostic tool in gynecology. It
involves the insertion of a transducer probe into the vagina to obtain images of
the pelvic organs, including the uterus, ovaries, and cervix.
Ultrasound can be used for a variety of purposes in gynecology, including:
1.
Evaluation of pelvic pain or abnormal vaginal bleeding
2.
Assessment of ovarian cysts or tumors
3.
Monitoring of follicular development during fertility treatments
4.
Confirmation of pregnancy and evaluation of fetal growth and
development
5.
Detection of uterine fibroids or polyps
6.
Identification of the location and cause of an ectopic pregnancy
7.
Guiding procedures such as hysteroscopy, biopsy, or aspiration
Transabdominal ultrasound may also be used to evaluate the pelvic organs, but it
is less commonly used in gynecology compared to transvaginal ultrasound.
88. 88. Radiological investigation in gynaecology.
Radiological investigations are commonly used in gynecology for diagnosis,
treatment planning, and monitoring of various conditions. Some of the common
radiological investigations used in gynecology include:
1.
X-ray: Plain radiographs (X-rays) may be useful in evaluating bony
pelvis anatomy, assessing the position and size of intrauterine contraceptive
devices (IUDs), and detecting calcifications in ovarian teratomas.
2.
Ultrasound: Ultrasound is the most common imaging modality used
in gynecology. It is a safe and non-invasive technique that uses high-frequency
sound waves to generate images of the internal organs. Ultrasound is used to
diagnose and monitor pregnancy, identify and locate pelvic masses, evaluate the
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size and shape of the uterus and ovaries, assess the thickness and vascularity of
the endometrium, and guide certain procedures such as oocyte retrieval for in
vitro fertilization.
3.
Hysterosalpingography: Hysterosalpingography is a type of X-ray that
involves the injection of a contrast medium through the cervix into the uterine
cavity and fallopian tubes. This allows visualization of the shape and contour of
the uterine cavity and fallopian tubes, and may be used to diagnose uterine
abnormalities and tubal blockages.
4.
Magnetic resonance imaging (MRI): MRI uses a magnetic field and
radio waves to produce detailed images of the internal organs. It is useful in
diagnosing certain gynecologic conditions such as uterine fibroids, adenomyosis,
and endometrial cancer. MRI can also be used to guide certain procedures, such
as uterine artery embolization for fibroids.
5.
Computed tomography (CT): CT uses X-rays and computer
technology to generate cross-sectional images of the body. It is less commonly
used in gynecology than ultrasound and MRI, but may be useful in evaluating
complex pelvic masses or identifying bony abnormalities.
6.
Positron emission tomography (PET) scan: PET scans use a
radioactive tracer to produce images of the body. They may be used in the
diagnosis and staging of gynecologic cancers.
The choice of radiological investigation will depend on the specific clinical
scenario, the suspected diagnosis, and the availability of resources.
89. 89. Endoscopy in gynaecology (colposcopy, hysteroscopy, laparoscopy).
Endoscopy is an important diagnostic and therapeutic tool in gynecology. It
involves the use of specialized instruments to visualize and access internal organs,
such as the cervix, uterus, and ovaries. There are several types of endoscopic
procedures used in gynecology, including colposcopy, hysteroscopy, and
laparoscopy.
Colposcopy is a procedure that allows a gynecologist to closely examine the
cervix, vulva, and vagina for signs of abnormal tissue. A colposcope is used to
magnify the area and a special solution is applied to the area to highlight any
abnormal tissue. Biopsies may be taken during the procedure to confirm the
diagnosis.
Hysteroscopy involves the insertion of a thin, flexible tube with a camera
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(hysteroscope) through the vagina and cervix into the uterus. This allows for
visualization of the inside of the uterus and can help diagnose and treat
conditions such as abnormal bleeding, fibroids, and polyps. During the procedure,
instruments can be inserted through the hysteroscope to remove tissue or
perform other treatments.
Laparoscopy is a minimally invasive surgical procedure that involves the insertion
of a thin, flexible tube with a camera (laparoscope) through a small incision in the
abdomen. This allows for visualization of the ovaries, fallopian tubes, and other
pelvic organs. Laparoscopy can be used to diagnose and treat a variety of
conditions, including endometriosis, ovarian cysts, and ectopic pregnancy. During
the procedure, instruments can be inserted through other small incisions to
perform surgical procedures as needed.
Overall, endoscopy in gynecology is a valuable tool for diagnosing and treating a
variety of gynecological conditions.
90. Components contributing to determination of sex. Clinical diagnosis of sex.
The determination of sex in humans is determined by the combination of sex
chromosomes received from the parents. Females have two X chromosomes (XX)
while males have one X and one Y chromosome (XY). The presence of the Y
chromosome in males triggers the development of testes which produce
testosterone and other androgens. These hormones lead to the development of
male genitalia and secondary sexual characteristics. In females, the absence of Y
chromosome results in the development of ovaries and the production of
estrogen.
Clinically, the determination of sex can be achieved through several ways,
including physical examination, genetic testing, and imaging studies. Physical
examination includes the evaluation of external genitalia, breast development,
and distribution of body hair. Genetic testing involves the analysis of
chromosomes obtained from a blood sample or amniotic fluid during pregnancy.
Imaging studies such as ultrasound may also be used to evaluate the presence of
internal reproductive organs. In cases of ambiguous genitalia or disorders of
sexual development, a multidisciplinary approach involving endocrinologists,
geneticists, and urologists may be required for a comprehensive diagnosis.
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91. Physiological pubertal changes and development of secondary sex
characters related to age. Adolescence problems (precocious puberty, delayed
puberty).
Puberty is a stage of development during which physical and physiological
changes occur that lead to sexual maturity. In females, puberty is characterized by
the onset of menstruation and the development of secondary sexual
characteristics such as breast development, pubic and underarm hair growth, and
widening of the hips. The timing of puberty varies among individuals but generally
occurs between the ages of 8 and 13 years.
Precocious puberty refers to the onset of puberty before the age of 8 years in
girls. It can be caused by various factors such as tumors in the brain, ovaries or
adrenal glands, or genetic abnormalities. Delayed puberty, on the other hand,
refers to the absence of pubertal development by the age of 13 years in girls. It
can be caused by hormonal imbalances, genetic disorders, or chronic illnesses
such as malnutrition.
Adolescence is a time of significant physical, emotional, and social changes.
Adolescents may experience a range of issues such as acne, body image concerns,
mood swings, and risk-taking behaviors. It is important for adolescents to receive
appropriate support and guidance during this time to promote healthy
development and prevent negative outcomes such as substance abuse or mental
health problems.
In terms of clinical management, the treatment of precocious puberty and
delayed puberty depends on the underlying cause. For precocious puberty,
treatment may involve medications to suppress the hormones responsible for
early onset of puberty or surgical removal of the tumor causing the hormonal
imbalance. For delayed puberty, treatment may involve hormonal therapy to
stimulate pubertal development. Adolescents experiencing emotional or
behavioral problems may benefit from psychological counseling or other forms of
support.
92. Normal menstrual cycle and menstrual cycle irregularities.
The menstrual cycle is the series of changes that occur in the female reproductive
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system, leading to the preparation of the uterus for pregnancy. A typical
menstrual cycle lasts for 28 days, although it can vary from 21 to 35 days in adult
women. It can be divided into three phases: the follicular phase, ovulation, and
the luteal phase.
During the follicular phase (days 1-14), the anterior pituitary gland secretes
follicle-stimulating hormone (FSH), which stimulates the development of follicles
in the ovaries. These follicles produce estrogen, which causes the endometrium to
thicken in preparation for implantation. As the follicles mature, they produce
increasing amounts of estrogen, which results in a surge of luteinizing hormone
(LH), triggering ovulation.
Ovulation occurs around day 14, when the mature follicle releases an egg into the
fallopian tube. The egg is then available for fertilization by sperm.
During the luteal phase (days 15-28), the remaining follicular cells form the corpus
luteum, which produces progesterone. This hormone helps to maintain the
thickened endometrium in preparation for implantation. If fertilization occurs, the
developing embryo releases human chorionic gonadotropin (hCG), which
maintains the corpus luteum and progesterone production. If fertilization does
not occur, the corpus luteum degenerates, leading to a drop in progesterone and
menstruation.
Menstrual cycle irregularities can occur due to a variety of factors, including
hormonal imbalances, stress, weight changes, medications, and medical
conditions. Some examples of menstrual cycle irregularities include:
1.
Amenorrhea: the absence of menstrual periods. It can be primary (no
period by age 16) or secondary (absence of periods for more than three months in
a woman who previously had regular cycles).
2.
Dysmenorrhea: painful menstrual periods.
3.
Menorrhagia: heavy menstrual bleeding.
4.
Oligomenorrhea: infrequent menstrual periods (less than eight
periods per year).
5.
Polymenorrhea: frequent menstrual periods (more than 12 periods
per year).
6.
Irregular cycles: cycles that vary in length by more than seven to nine
days.
Treatment for menstrual cycle irregularities depends on the underlying cause.
Hormonal imbalances can be treated with hormonal therapy, such as oral
contraceptive pills. Non-hormonal treatments, such as nonsteroidal antiinflammatory drugs (NSAIDs), can help with pain relief. In some cases, lifestyle
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changes, such as weight loss or stress reduction, may also be recommended.
93. Amenorrhoea: definition and classification.
Amenorrhea is a medical term that refers to the absence of menstrual bleeding. It
is classified into two main types: primary amenorrhea and secondary
amenorrhea.
Primary amenorrhea is defined as the absence of menstrual bleeding by the age
of 16 in the absence of secondary sexual characteristics, or by the age of 14 in the
presence of secondary sexual characteristics.
Secondary amenorrhea is defined as the absence of menstrual bleeding for more
than 3 months in women who have previously had regular menstrual cycles, or for
more than 6 months in women who have previously had irregular menstrual
cycles. It can be caused by various factors such as pregnancy, menopause,
hormonal imbalances, thyroid disorders, eating disorders, excessive exercise,
stress, medications, and certain medical conditions.
94. Hypergonadotropic primary amenorrhoea. Turner's syndrome: aetiology,
clinical symptoms, investigations, management.
Hypergonadotropic primary amenorrhea refers to the absence of menstruation in
females beyond the age of 16 years, in association with elevated levels of folliclestimulating hormone (FSH) and luteinizing hormone (LH). Turner syndrome is a
genetic disorder that affects females, characterized by the absence or
abnormality of one of the two X chromosomes.
Aetiology:
Turner syndrome is caused by a random error during the formation of
reproductive cells, resulting in the loss or alteration of the X chromosome. This
condition can also be inherited in rare cases.
Clinical symptoms:
•
Short stature
•
Absent or incomplete development of secondary sexual
characteristics
•
Infertility
•
Heart abnormalities
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•
Kidney abnormalities
•
Thyroid problems
•
Hearing difficulties
•
Learning disabilities
Investigations:
•
Karyotyping to detect chromosomal abnormalities
•
Pelvic ultrasound to evaluate the presence of ovaries and uterus
•
Hormonal assays to determine levels of FSH, LH, estrogen, and other
hormones
•
Echocardiography to evaluate heart function
•
Renal ultrasound to evaluate kidney function
Management:
•
Growth hormone therapy may be used to treat short stature
•
Estrogen replacement therapy may be used to induce puberty and
develop secondary sexual characteristics
•
Fertility treatments such as egg donation or surrogacy may be an
option for women with Turner syndrome who wish to have children
•
Treatment of associated medical conditions such as heart or kidney
problems
95. Eugonadotropic primary amenorrhoea. Testicular feminizing syndrome:
aetiology, clinical symptoms, investigations, management.
Eugonadotropic primary amenorrhea is a condition in which a woman does not
begin menstruating by the age of 16, despite the presence of normal ovaries and
normal levels of pituitary gonadotropins (follicle-stimulating hormone (FSH) and
luteinizing hormone (LH)).
One of the causes of eugonadotropic primary amenorrhea is the testicular
feminization syndrome, also known as Androgen insensitivity syndrome (AIS). AIS
is an X-linked recessive disorder in which a genetic male (XY) has an inability to
respond to androgens, resulting in the development of female external genitalia
and breasts during puberty. The testes remain in the abdomen or inguinal canal,
and most individuals with AIS have a female gender identity.
Clinical symptoms of AIS include primary amenorrhea, normal or tall stature,
absence of pubic or axillary hair, and lack of development of secondary sexual
characteristics, such as widening of the hips, due to the inability to respond to
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androgens.
Investigations for AIS include a karyotype analysis, which typically shows a 46,XY
pattern, and testing for serum testosterone and gonadotropins. Individuals with
AIS have high levels of testosterone and gonadotropins due to the inability of the
testes to respond to feedback inhibition by androgens.
Management of AIS involves psychological support and hormone replacement
therapy with estrogen and progesterone to induce and maintain menstruation
and to prevent osteoporosis. Gonadectomy may also be considered in individuals
with complete androgen insensitivity syndrome to reduce the risk of gonadal
tumors.
96. Hypogonadotropic primary amenorrhoea: causes, clinical features.
investigations and management.
Hypogonadotropic primary amenorrhea refers to a condition where menstruation
does not occur in women due to a lack of ovarian function, caused by a deficiency
in gonadotropin-releasing hormone (GnRH) secretion by the hypothalamus or a
deficiency in pituitary gonadotropin secretion.
Causes of hypogonadotropic primary amenorrhea can include:
1.
Genetic disorders such as Kallmann syndrome or Prader-Willi
syndrome
2.
Acquired conditions such as hypothalamic-pituitary tumors or
traumatic brain injury
3.
Anorexia nervosa or other eating disorders
Clinical features of hypogonadotropic primary amenorrhea can include the
absence of menstruation, lack of development of secondary sexual
characteristics, and low levels of estrogen.
Investigations for hypogonadotropic primary amenorrhea typically involve
measuring hormone levels, such as follicle-stimulating hormone (FSH), luteinizing
hormone (LH), and estradiol, and performing imaging studies, such as MRI of the
brain, to identify any underlying structural abnormalities.
Management of hypogonadotropic primary amenorrhea involves addressing the
underlying cause, such as hormone replacement therapy to replace deficient
estrogen levels or surgical removal of a tumor. In some cases, fertility treatment
may also be necessary.
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97. Secondary amenorrhoea: aetiology. classification, investigations and
treatment.
Secondary amenorrhea refers to the absence of menstruation for at least 3
months in women who have previously had regular menstrual cycles. The causes
of secondary amenorrhea can be classified into different categories, including
hormonal disorders, structural abnormalities, medications, and systemic diseases.
Hormonal disorders that can cause secondary amenorrhea include thyroid
dysfunction, hyperprolactinemia, and ovarian insufficiency. Structural
abnormalities such as uterine adhesions, tumors, and scarring from surgeries can
also lead to secondary amenorrhea.
Certain medications such as hormonal contraceptives and antipsychotics can
cause temporary amenorrhea, while systemic diseases such as chronic kidney
disease and liver disease can also affect menstrual cycles.
Investigations for secondary amenorrhea may include blood tests to assess
hormone levels, imaging studies such as ultrasound or MRI to evaluate the
reproductive organs, and in some cases, biopsy of the endometrial tissue to rule
out malignancy.
Treatment of secondary amenorrhea depends on the underlying cause. Hormonal
imbalances can often be corrected with medications such as synthetic thyroid
hormones, estrogen and progesterone replacement therapy, or medications to
suppress prolactin production. Structural abnormalities may require surgical
intervention, while discontinuation of offending medications or management of
underlying systemic diseases may be necessary for some cases.
98. Adrenogenital syndrome: aetiology, clinical symptoms, investigations,
Management.
Adrenogenital syndrome, also known as congenital adrenal hyperplasia, is a
genetic disorder caused by an enzyme deficiency in the adrenal gland that leads
to a deficiency of cortisol and/or aldosterone, and an overproduction of
androgens. This condition can affect both males and females.
Aetiology:
Adrenogenital syndrome is caused by a genetic defect that results in the impaired
production of enzymes involved in the synthesis of cortisol and/or aldosterone in
the adrenal gland. The most common form of adrenogenital syndrome is caused
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by a deficiency of the enzyme 21-hydroxylase.
Clinical symptoms:
The clinical features of adrenogenital syndrome depend on the severity of the
enzyme deficiency and the level of androgen excess. In females, the excess
androgens can lead to the development of male secondary sexual characteristics,
such as a deepened voice, facial hair growth, and clitoromegaly. In males, the
condition may cause precocious puberty, with early onset of pubic hair,
enlargement of the penis, and accelerated growth. Both males and females may
experience infertility, menstrual irregularities, and acne. In severe cases, lifethreatening adrenal crises may occur.
Investigations:
Diagnosis of adrenogenital syndrome is based on clinical features and confirmed
by laboratory tests, including measurement of serum electrolytes, cortisol,
aldosterone, and androgens, and genetic testing.
Management:
Treatment for adrenogenital syndrome involves hormone replacement therapy to
replace deficient hormones and reduce androgen levels. This therapy typically
involves the use of glucocorticoids and mineralocorticoids to replace cortisol and
aldosterone, respectively. In some cases, surgical interventions may be necessary
to correct genital abnormalities or remove tumors associated with the condition.
Regular monitoring and management of electrolyte imbalances and adrenal crises
are also important aspects of care for individuals with adrenogenital syndrome.
99. Hirsutism: endocrinology, causes, clinical features. investigations and
management.
Hirsutism is a medical condition characterized by excessive hair growth in women
in a male pattern distribution, such as on the face, chest, back, or abdomen. It is
usually caused by an excess of androgen hormones in the body, which can be
produced by the ovaries, adrenal glands, or both.
The causes of hirsutism can be divided into two main categories: non-endocrine
and endocrine. Non-endocrine causes include genetic predisposition, ethnicity,
and medication side effects. Endocrine causes include polycystic ovary syndrome
(PCOS), adrenal gland disorders such as congenital adrenal hyperplasia, and
tumors that produce androgen hormones.
Clinical features of hirsutism include excessive hair growth in a male pattern
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distribution, acne, and oily skin. Other signs of androgen excess may be present,
such as irregular periods, infertility, or deepening of the voice.
Investigations for hirsutism include measurement of androgen hormone levels in
the blood, such as testosterone, dehydroepiandrosterone sulfate (DHEAS), and
androstenedione. An ultrasound of the ovaries may also be performed to
evaluate for the presence of ovarian cysts or PCOS.
Management of hirsutism involves treating the underlying cause, if possible, as
well as addressing the cosmetic concerns of excessive hair growth. Treatment
options may include medications that block androgen production or action, such
as oral contraceptives, anti-androgen medications, or glucocorticoids. Hair
removal methods, such as shaving, waxing, or laser hair removal, may also be
used to manage the cosmetic effects of hirsutism.
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100. Polycystic ovarian discase: actiology. clinical symptoms. investigations,
management.
Polycystic ovarian disease (PCOD), also known as polycystic ovarian syndrome
(PCOS), is a hormonal disorder that affects women of reproductive age. It is
characterized by multiple small cysts in the ovaries and an excess production of
androgens (male hormones) by the ovaries.
- The exact cause of PCOD is unknown, but it is believed to be influenced by
genetics and insulin resistance.
The clinical symptoms of PCOD include irregular menstrual cycles, heavy or
prolonged periods, acne, hirsutism (excessive hair growth on the face and body),
weight gain, and difficulty getting pregnant. Women with PCOD may also have
higher levels of insulin, which can lead to an increased risk of developing type 2
diabetes.
The diagnosis of PCOD is made based on a combination of clinical symptoms,
physical examination, and laboratory investigations. The Rotterdam criteria are
commonly used to diagnose PCOD, which includes the presence of at least two of
the following: irregular periods, excess androgen production, and polycystic
ovaries seen on ultrasound.
The management of PCOD involves a combination of lifestyle modifications,
medications, and surgery (in some cases). Lifestyle modifications include weight
loss, regular exercise, and a healthy diet. Medications that are commonly used to
manage PCOD include oral contraceptives (to regulate menstrual cycles), antiandrogen medications (to reduce hair growth and acne), and medications to
improve insulin sensitivity (to reduce the risk of diabetes).
In cases where lifestyle modifications and medications are not effective, surgery
may be considered. Ovarian drilling is a surgical procedure that is sometimes used
to treat PCOD. It involves making small incisions in the ovaries and using heat or a
laser to destroy a small portion of the ovarian tissue. This can help to reduce
androgen production and restore ovulation.
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101. Hyperprolactinemia: aetiology. clinical symptoms, investigations,
management.
Hyperprolactinemia is a medical condition in which there is an abnormally high
level of the hormone prolactin in the blood. It can be caused by various factors
including prolactinoma (a benign tumor of the pituitary gland that produces
prolactin), other tumors that affect the pituitary gland or hypothalamus,
medications (such as antipsychotics, antidepressants, or certain blood pressure
medications), hypothyroidism, chronic kidney disease, or stress.
The clinical symptoms of hyperprolactinemia in women include amenorrhea
(absence of menstrual periods), galactorrhea (abnormal lactation or breast
discharge), infertility, and reduced libido. In men, it can cause reduced libido,
impotence, and gynecomastia (breast enlargement in men).
The diagnosis of hyperprolactinemia is made by measuring the level of prolactin
in the blood. A single elevated level of prolactin does not necessarily indicate
hyperprolactinemia, as prolactin levels can vary throughout the day and can be
elevated by stress or certain medications. Therefore, repeat testing may be
necessary to confirm the diagnosis.
The management of hyperprolactinemia depends on the underlying cause.
Treatment may include medications such as dopamine agonists (which can
decrease prolactin secretion), surgery to remove pituitary tumors, or radiation
therapy to shrink tumors. Patients with hyperprolactinemia should be followed
closely by an endocrinologist or gynecologist to monitor prolactin levels and
adjust treatment as necessary.
102. Asherman syndrome: causes, clinical symptoms, investigations,
management. Progesterone challenge test.
Asherman syndrome, also known as intrauterine adhesions or synechiae, is a
condition characterized by the presence of adhesions or scar tissue within the
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uterine cavity. This can lead to menstrual abnormalities, infertility, and recurrent
miscarriages.
Causes:
The most common cause of Asherman syndrome is previous uterine surgery, such
as dilation and curettage (D&C), myomectomy, or cesarean section. Other
possible causes include endometrial infections, radiation therapy, or uterine
tuberculosis.
Clinical Symptoms:
Women with Asherman syndrome may experience menstrual abnormalities, such
as decreased or absent periods, pelvic pain or discomfort, infertility, and
recurrent miscarriages.
Investigations:
The diagnosis of Asherman syndrome can be made through a combination of
medical history, physical examination, and imaging studies, such as
hysterosalpingography (HSG), hysteroscopy, and ultrasound. A progesterone
challenge test may also be performed to evaluate the endometrial response to
progesterone.
Management:
The treatment of Asherman syndrome involves the removal of adhesions and
restoration of normal uterine function. This is usually achieved through
hysteroscopic surgery to remove the scar tissue and promote the regrowth of
healthy endometrial tissue. Hormonal therapy, such as estrogen and
progesterone supplementation, may also be used to support endometrial growth
and prevent the formation of new adhesions. In severe cases, surrogacy or
adoption may be considered as alternative options for pregnancy.
103. Premature menopause: actiology, pathophysiology, clinical features,
investigations and management.
Premature menopause, also known as premature ovarian insufficiency or
premature ovarian failure, is a condition in which the ovaries of a woman under
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40 years of age stop functioning properly, leading to infertility and menopausal
symptoms.
The exact cause of premature menopause is not always clear, but it can be caused
by genetic factors, autoimmune diseases, viral infections, chemotherapy or
radiation therapy, and surgical removal of ovaries.
Clinical features of premature menopause include irregular or missed periods, hot
flashes, night sweats, vaginal dryness, decreased libido, mood swings, and
difficulty sleeping.
Investigations for premature menopause may include hormone level testing (e.g.,
follicle-stimulating hormone, luteinizing hormone, estradiol, and progesterone),
genetic testing, pelvic ultrasound, and bone density testing.
Management of premature menopause may involve hormone replacement
therapy to relieve symptoms and prevent long-term health problems associated
with low estrogen levels (e.g., osteoporosis, heart disease). Counseling and
support groups may also be helpful in coping with the emotional aspects of
premature menopause, such as infertility and the loss of reproductive potential.
104. Sheehan's syndrome: causes. clinical symptoms, investigations.
management.
Sheehan's syndrome is a rare condition that occurs when there is damage to the
pituitary gland during or after childbirth. This can lead to a deficiency of one or
more hormones produced by the pituitary gland, including prolactin, growth
hormone, thyroid-stimulating hormone, adrenocorticotropic hormone, folliclestimulating hormone, and luteinizing hormone.
The causes of Sheehan's syndrome are related to severe bleeding during or after
childbirth, which can cause a drop in blood pressure and restrict blood flow to the
pituitary gland. This can result in the death of pituitary gland cells, leading to
hormone deficiencies.
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The clinical symptoms of Sheehan's syndrome can vary depending on which
hormones are affected, but common symptoms include failure to lactate, loss of
pubic and underarm hair, fatigue, weight gain, hypotension, and menstrual
irregularities.
Investigations for Sheehan's syndrome may involve blood tests to measure
hormone levels and imaging studies such as magnetic resonance imaging (MRI) or
computed tomography (CT) scans to evaluate the pituitary gland.
Management of Sheehan's syndrome typically involves hormone replacement
therapy to address the hormone deficiencies. This may include medications such
as cortisol, thyroid hormone, estrogen, and progesterone. Regular monitoring of
hormone levels and symptom control is also important to manage the condition
effectively.
105. Menorrhagia: causes, clinical symptoms, investigations, management.
Menorrhagia refers to abnormally heavy or prolonged menstrual bleeding. It is a
common gynecological problem that can significantly impact a woman's quality of
life. The causes of menorrhagia can be varied, including hormonal imbalances,
structural abnormalities, and underlying medical conditions.
Some of the common causes of menorrhagia are:
• Hormonal imbalances, such as anovulation, perimenopause, or thyroid
disorders
• Uterine fibroids or polyps
• Adenomyosis (a condition where the inner lining of the uterus grows into
the muscle wall)
• Endometriosis (a condition where the inner lining of the uterus grows
outside of the uterus)
• Intrauterine device (IUD) use
• Blood clotting disorders
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• Medications such as anticoagulants or hormonal contraceptives
• Cancer or precancerous conditions of the uterus, cervix, or ovaries
Clinical symptoms of menorrhagia can include:
1. Excessive bleeding that lasts longer than seven days
2. Needing to change sanitary protection every hour or more frequently
3. Passing clots that are larger than a quarter
4. Anemia symptoms such as fatigue, weakness, or shortness of breath
5. Pain during intercourse or menstruation
6. Interference with daily activities
Investigations for menorrhagia may include:
Blood tests to assess hormonal imbalances or blood clotting disorders
Pelvic ultrasound to check for fibroids, polyps, or other structural abnormalities
Endometrial biopsy to assess the thickness and composition of the lining of the
uterus
Hysteroscopy to visualize the inside of the uterus and take a tissue sample if
necessary
The management of menorrhagia depends on the underlying cause and the
severity of the bleeding. Treatment options may include:
Hormonal therapies, such as oral contraceptives or progesterone supplements, to
regulate the menstrual cycle and reduce bleeding
Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and bleeding
Tranexamic acid, a medication that reduces bleeding by promoting blood clotting
Surgical interventions, such as endometrial ablation or hysterectomy, may be
considered for severe or refractory cases.
In some cases, lifestyle modifications such as maintaining a healthy weight,
avoiding alcohol and smoking, and managing stress may also help in managing
menorrhagia.
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106. Menorrhagia: therapeutic measures (conservative treatment, hormone
therapy).
Menorrhagia is a condition characterized by abnormally heavy or prolonged
menstrual bleeding. There are various treatment options available for managing
menorrhagia, including conservative measures and hormone therapy.
Conservative treatments for menorrhagia include:
Nonsteroidal anti-inflammatory drugs (NSAIDs): These drugs can help reduce
menstrual bleeding and relieve menstrual cramps. NSAIDs work by inhibiting
prostaglandin production, which is responsible for menstrual cramps and heavy
bleeding.
Tranexamic acid: This medication helps reduce bleeding by preventing the
breakdown of blood clots.
Iron supplementation: Menorrhagia can lead to iron-deficiency anemia due to
excessive blood loss. Iron supplements can help replace the lost iron and improve
anemia.
Herbal remedies: Certain herbs such as ginger, cinnamon, and turmeric have been
found to have anti-inflammatory and anticoagulant properties, which can help
reduce menstrual bleeding.
Hormone therapy for menorrhagia includes:
Combined oral contraceptives: These are the most commonly used hormonal
therapy for menorrhagia. They work by preventing ovulation and regulating the
menstrual cycle, thereby reducing menstrual bleeding.
Progestin-only contraceptives: These contraceptives contain only progestin
hormone and are used to regulate the menstrual cycle and reduce menstrual
bleeding.
Gonadotropin-releasing hormone (GnRH) agonists: These medications work by
suppressing the production of estrogen and progesterone, which reduces
menstrual bleeding.
Levonorgestrel-releasing intrauterine system (LNG-IUS): This is a small, T-shaped
device that is inserted into the uterus to release the hormone levonorgestrel. The
LNG-IUS can help reduce menstrual bleeding and cramping.
In some cases, surgical interventions such as endometrial ablation or
hysterectomy may be necessary to manage menorrhagia that does not respond to
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conservative or hormonal treatments.
107. Types of surgical treatment of menorrhagia.
Surgical treatment of menorrhagia may be necessary in cases where conservative
measures or hormonal therapy have been unsuccessful or are not appropriate for
the patient. There are several types of surgical procedures that can be performed
to treat menorrhagia, including:
Endometrial ablation: This is a minimally invasive procedure in which the lining of
the uterus is destroyed or removed. It can be done with various methods such as
thermal ablation, microwave ablation, or radiofrequency ablation. This procedure
can be done as an outpatient procedure with minimal recovery time.
Hysterectomy: This is the surgical removal of the uterus and may be
recommended for women who have completed their family or for those who
have other medical conditions that make the uterus unsuitable for continued use.
It can be performed through an abdominal or vaginal approach.
Myomectomy: This is a surgical procedure to remove fibroids from the uterus. It is
often recommended for women who wish to preserve their fertility and have
large fibroids or multiple fibroids that cannot be treated with medication.
Uterine artery embolization: This is a minimally invasive procedure in which the
blood supply to the uterus is blocked to shrink the fibroids and reduce bleeding.
The choice of surgical procedure depends on various factors such as the age of
the patient, her desire for future fertility, the size and location of the fibroids, and
the severity of the symptoms. The risks, benefits, and alternatives of each
procedure should be discussed with the patient before deciding on the most
appropriate treatment.
108. DUB: pathogenesis, classification, pathological anatomy.
DUB stands for Dysfunctional Uterine Bleeding, which is abnormal uterine
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bleeding not associated with any organic pathology. It is a diagnosis of exclusion,
meaning that other causes of abnormal uterine bleeding such as fibroids, polyps,
endometrial hyperplasia, and malignancy should be ruled out first.
The pathogenesis of DUB is not completely understood, but it is thought to be
related to hormonal imbalances that affect the normal cycle of menstruation. This
can result in irregular or heavy bleeding, or bleeding that occurs outside of the
normal menstrual cycle.
DUB can be classified as ovulatory or anovulatory. Ovulatory DUB occurs when
there is an imbalance in the normal hormonal cycle of ovulation, resulting in
abnormal bleeding. Anovulatory DUB occurs when ovulation does not occur,
leading to an imbalance in hormonal levels that can cause irregular, heavy, or
prolonged bleeding.
Pathologically, DUB can present with various findings, such as endometrial
hyperplasia, atrophy, or polyps. However, many cases may show no significant
pathology on examination.
Investigations for DUB may include a detailed history and physical examination,
including a pelvic examination and a Pap smear. Blood tests may be ordered to
assess hormonal levels, such as thyroid function and estrogen and progesterone
levels. Imaging studies, such as transvaginal ultrasound, may also be performed to
evaluate the uterine and endometrial thickness and to exclude any other
underlying pathology.
Management of DUB depends on the underlying cause and the severity of
symptoms. Conservative treatments may include medications such as
nonsteroidal anti-inflammatory drugs (NSAIDs), oral contraceptive pills, or
progestins to regulate menstrual cycles and reduce bleeding. In cases of
anovulatory DUB, cyclic progestin therapy can be particularly effective. In more
severe cases, surgical interventions such as dilation and curettage (D&C),
endometrial ablation, or hysterectomy may be necessary to control symptoms
and prevent further bleeding.
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109. Puberty menorrhagia: causes, clinical symptoms, investigations.
management.
Pubertal menorrhagia refers to heavy or prolonged menstrual bleeding that
occurs during puberty, which is the time when the menstrual cycle starts in girls.
The causes of pubertal menorrhagia can be related to hormonal imbalances,
blood clotting disorders, structural abnormalities of the uterus or cervix, or
certain medications.
Clinical symptoms of pubertal menorrhagia may include heavy bleeding that lasts
for more than seven days, needing to change pads or tampons every hour or two,
passing large blood clots, feeling weak or dizzy, and experiencing fatigue or
shortness of breath.
Investigations for pubertal menorrhagia may include a complete blood count to
check for anemia, blood clotting tests to rule out bleeding disorders, and imaging
studies such as ultrasound or MRI to assess the uterus and ovaries for structural
abnormalities.
The management of pubertal menorrhagia depends on the underlying cause.
Hormonal treatments such as combined oral contraceptives, progestin-only pills,
or intrauterine devices (IUDs) may be prescribed to regulate the menstrual cycle
and reduce bleeding. In some cases, medications such as tranexamic acid or
nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed to reduce
bleeding. If structural abnormalities are identified, surgical procedures such as
hysteroscopy, dilation and curettage (D&C), or myomectomy may be necessary to
treat the underlying condition. In severe cases, hysterectomy may be considered
as a last resort.
110. Premenopausal menorthagia: causes. clinical symptoms, investigations.
management.
Premenopausal menorrhagia refers to heavy menstrual bleeding in women who
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have not yet reached menopause. It can be caused by a variety of factors,
including hormonal imbalances, uterine fibroids, adenomyosis, endometrial
polyps, and bleeding disorders.
Clinical symptoms of premenopausal menorrhagia include prolonged or heavy
menstrual bleeding, passing large blood clots, anemia, and menstrual cycles
shorter than 21 days or longer than 35 days.
Investigations may include blood tests to assess iron levels and screen for
bleeding disorders, ultrasound to assess the uterus and ovaries, and hysteroscopy
or endometrial biopsy to evaluate the lining of the uterus.
Management of premenopausal menorrhagia depends on the underlying cause.
Treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce
menstrual bleeding, hormonal therapy such as birth control pills or progesterone
to regulate menstrual cycles, and surgical procedures such as endometrial
ablation or hysterectomy for more severe cases.
111. Metropathia haemorragica: aetiology: pathological anatomy, clinical
features, investigations and management.
Metrorrhagia is abnormal uterine bleeding that occurs at irregular intervals,
usually between menstrual periods. The term "metropathia haemorrhagica" is
used to describe excessive and prolonged bleeding, often with clots, that is not
associated with any specific pathology. Here is an overview of the condition:
Aetiology:
The exact cause of metropathia haemorrhagica is not fully understood, but it is
thought to be related to hormonal imbalances or changes in the uterine lining. It
is more commonly seen in women who are approaching menopause, but can
occur in women of any age.
Pathological anatomy:
The uterine lining (endometrium) may be thicker than usual, and there may be
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areas of bleeding within it.
Clinical features:
The main symptom of metropathia haemorrhagica is irregular, heavy bleeding
between periods. This may be accompanied by cramping or pain in the lower
abdomen. Women with metropathia haemorrhagica may also experience fatigue
and weakness due to the loss of blood.
Investigations:
The diagnosis of metropathia haemorrhagica is made by ruling out other possible
causes of abnormal uterine bleeding. Tests may include blood tests to check
hormone levels, imaging studies such as ultrasound or MRI, and a biopsy of the
uterine lining.
Management:
The treatment of metropathia haemorrhagica depends on the severity of
symptoms and the underlying cause of the bleeding. In many cases, the bleeding
can be managed with hormonal therapies such as birth control pills or
progesterone. In more severe cases, surgical treatment such as dilation and
curettage (D&C) or hysteroscopy may be necessary to remove any abnormal
tissue in the uterus. In rare cases, a hysterectomy (removal of the uterus) may be
necessary if other treatments are not effective.
112. Ovulatory DUB: irregular ripening and irregular shedding.
Ovulatory dysfunctional uterine bleeding (DUB) is a type of abnormal uterine
bleeding that occurs due to irregular ripening of the endometrium and irregular
shedding during the menstrual cycle. It is commonly caused by hormonal
imbalances, particularly in estrogen and progesterone levels.
During a normal menstrual cycle, the endometrium thickens and matures in
preparation for a potential pregnancy. If fertilization does not occur, the
endometrium is shed as menstrual bleeding. In ovulatory DUB, the endometrium
may not mature and ripen properly due to hormonal imbalances, resulting in
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irregular shedding and abnormal bleeding patterns.
Symptoms of ovulatory DUB may include heavy bleeding, irregular periods,
prolonged bleeding, or bleeding between periods. It can be diagnosed through a
variety of investigations, including blood tests to assess hormone levels, pelvic
ultrasound to evaluate the thickness and appearance of the endometrium, and
endometrial biopsy to examine the tissue for abnormalities.
Management of ovulatory DUB may involve hormonal treatments, such as
combined estrogen-progestin therapy or progestin-only therapy, to regulate the
menstrual cycle and reduce bleeding. In some cases, surgical intervention may be
necessary, such as endometrial ablation or hysterectomy.
113. Postmenopausal bleeding: aetiology, clinical features, investigations and
management.
Postmenopausal bleeding refers to vaginal bleeding that occurs 12 or more
months after a woman's last menstrual period. It is considered abnormal and
requires further evaluation. The following are the aetiology, clinical features,
investigations, and management of postmenopausal bleeding:
Aetiology:
Atrophic vaginitis or endometrial atrophy
Endometrial hyperplasia or cancer
Cervical or vaginal cancer
Trauma or infection
Hormonal therapy
Coagulation disorders
Clinical features:
Vaginal bleeding occurring 12 or more months after the last menstrual period
Blood may be light or heavy, intermittent or continuous
Associated symptoms may include pelvic pain, discharge, or postcoital bleeding
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Investigations:
Transvaginal ultrasound to measure endometrial thickness
Endometrial biopsy or curettage to obtain a tissue sample for pathological
evaluation
Hysteroscopy to visualize the uterine cavity and obtain biopsies or remove any
abnormal growths
Blood tests to assess hormone levels and check for any coagulation disorders
Management:
Treatment depends on the underlying cause
Hormonal therapy may be used to treat atrophic vaginitis or endometrial
hyperplasia
Surgery may be required for endometrial or cervical cancer
In some cases, no treatment may be necessary if the bleeding is due to a benign
cause such as atrophic vaginitis
It is important to promptly evaluate postmenopausal bleeding to rule out any
serious underlying conditions, especially cancer.
114. Biology of the vagina, Natural defence mechanism of the vagina against
infection. Flora of the female genital tract.
The vagina is a muscular tube that extends from the vulva to the cervix of the
uterus. It has a complex microenvironment that is regulated by hormones and a
diverse microbial ecosystem, collectively known as the vaginal flora. The vaginal
flora comprises a variety of microorganisms, including bacteria, fungi, and viruses.
Lactobacillus species, particularly Lactobacillus crispatus, Lactobacillus jensenii,
and Lactobacillus iners, are the dominant species of bacteria in the healthy
vaginal flora. These bacteria produce lactic acid, which helps to maintain an acidic
environment (pH 3.5 to 4.5) that inhibits the growth of pathogenic organisms.
The natural defence mechanisms of the vagina include:
Acidic environment: As mentioned above, the vaginal pH is maintained at an
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acidic level that inhibits the growth of pathogenic organisms.
Mucus secretion: The vaginal epithelium secretes mucus that forms a barrier
against invading pathogens.
Antimicrobial peptides: The vaginal epithelium also produces antimicrobial
peptides that have broad-spectrum activity against bacteria, fungi, and viruses.
Hormonal regulation: The vaginal environment is regulated by hormones,
particularly estrogen, which promotes the growth of Lactobacillus species and
maintains the integrity of the vaginal epithelium.
Immune cells: The vaginal mucosa contains immune cells, including macrophages,
dendritic cells, and T cells, which help to detect and eliminate invading pathogens.
Overall, the complex microenvironment of the vagina plays an important role in
maintaining vaginal health and preventing infections.
115. Inflammatory lesions of the vulva: skin infections.
Inflammatory lesions of the vulva can have various causes, including infections.
Skin infections of the vulva can be caused by bacteria, viruses, fungi, or parasites.
Some common examples include:
Bacterial infections: Bacterial infections of the vulva can cause folliculitis, which is
an inflammation of the hair follicles. Other bacterial infections include cellulitis,
which is a deep skin infection that can cause redness, swelling, and warmth in the
affected area, and abscesses, which are collections of pus that can form in the
skin or deeper tissues.
Viral infections: Viral infections of the vulva include genital warts, which are
caused by the human papillomavirus (HPV), and herpes simplex virus (HSV), which
can cause painful sores.
Fungal infections: Fungal infections of the vulva can cause itching, burning, and
soreness. The most common type of fungal infection is a yeast infection, which is
caused by the overgrowth of Candida species.
Parasitic infections: Parasitic infections of the vulva include pubic lice, which are
tiny insects that can attach to pubic hair and cause itching and redness.
The natural defense mechanism of the vagina against infection includes the
normal flora of the female genital tract. The normal flora consists of bacteria that
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help maintain a healthy environment by producing lactic acid, which helps to
maintain an acidic pH that prevents the growth of harmful bacteria. Lactobacillus
is the most common type of bacteria found in the normal flora of the vagina. In
addition, the vagina is lined with a layer of cells that produce mucus, which helps
to keep the vagina moist and traps harmful bacteria and other pathogens,
preventing them from entering the body.
116. Sexually transmitted diseases of the vulva; molluseum contagiosum,
condylomata acumintata, herpes genitalis (aetiology, symptoms and signs,
diagnosis and treatment).
Sexually transmitted diseases (STDs) of the vulva include molluscum contagiosum,
condylomata acuminate, and herpes genitalis. Here is an overview of each:
Molluscum contagiosum: This is a viral infection caused by the molluscum
contagiosum virus. It typically causes small, raised, round, pink or skin-colored
bumps on the vulva. The bumps may have a dimpled center and can be itchy.
Treatment options include cryotherapy, curettage, or topical agents like
cantharidin, imiquimod, or podophyllotoxin.
Condylomata acuminate: This is a viral infection caused by human papillomavirus
(HPV). It leads to the formation of warty growths on the vulva and perianal area.
The growths may be flat or raised, cauliflower-like, and can cause itching, burning,
or bleeding. Treatment options include cryotherapy, surgical excision, or topical
agents like podophyllin, imiquimod, or trichloroacetic acid.
Herpes genitalis: This is a viral infection caused by the herpes simplex virus (HSV).
It can cause painful blisters or ulcers on the vulva, vagina, or perianal area, along
with flu-like symptoms such as fever and swollen lymph nodes. Herpes is a
recurrent infection, meaning it can come back after treatment. Antiviral
medications like acyclovir, valacyclovir, or famciclovir can help manage symptoms
and reduce the frequency and severity of outbreaks.
It's important to practice safe sex and get regular STD testing to prevent and
detect these infections early.
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117. Trichomoniasis: aetiology, symptoms and signs, diagnosis and treatment.
Trichomoniasis is a sexually transmitted infection caused by a parasite called
Trichomonas vaginalis. Here are some details regarding its aetiology, symptoms,
diagnosis and treatment:
Aetiology:
Trichomoniasis is caused by a single-celled parasite called Trichomonas vaginalis,
which is usually transmitted through sexual contact.
Symptoms and signs:
Many people with trichomoniasis do not have any symptoms. However, common
symptoms can include:
Vaginal discharge that may be frothy, green or yellow in color
Vaginal itching or soreness
Pain or discomfort during sexual intercourse or urination
Strong vaginal odor
Diagnosis:
Trichomoniasis can be diagnosed by a healthcare provider through a physical
exam, review of symptoms and laboratory tests. Laboratory tests may include a
microscopic examination of vaginal discharge or a DNA test.
Treatment:
Trichomoniasis can be treated with antibiotics, such as metronidazole or
tinidazole, which are usually given in a single dose. Sexual partners should also be
treated to prevent re-infection. It is important to complete the entire course of
antibiotics, even if symptoms improve before the medication is finished. It is also
recommended to avoid sexual contact until the infection has cleared.
118. Candidiasis: actiology, symptoms and signs, diagnosis and treatment,
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Candidiasis is a fungal infection caused by the yeast Candida. The most common
species that cause candidiasis is Candida albicans. Here are the details of its
aetiology, symptoms and signs, diagnosis, and treatment:
Aetiology: Candidiasis can occur due to several factors, such as weakened
immune system, hormonal changes, antibiotic use, diabetes, pregnancy, and
tight-fitting clothing. It can also be transmitted sexually.
Symptoms and signs: The symptoms of candidiasis can vary depending on the
location and severity of the infection. The most common symptom is itching and
burning sensation in the affected area. Other symptoms include redness, swelling,
and soreness. In women, candidiasis can also cause vaginal discharge and pain
during sex. In severe cases, the infection can spread to other parts of the body
and cause fever and chills.
Diagnosis: Diagnosis of candidiasis is usually based on the symptoms and physical
examination. The healthcare provider may also take a sample of the affected area
and examine it under a microscope to confirm the presence of Candida. In some
cases, a culture may be done to determine the specific type of Candida causing
the infection.
Treatment: The treatment of candidiasis involves antifungal medications. Topical
antifungal creams and ointments can be used for mild infections, while oral
antifungal medications are used for more severe infections. Over-the-counter
medications such as miconazole and clotrimazole are effective for treating vaginal
candidiasis. For recurrent infections, long-term treatment may be required. It is
also important to identify and address any underlying conditions that may be
contributing to the infection. Additionally, practicing good hygiene and avoiding
tight-fitting clothing can help prevent the infection from recurring.
119. Chlamydiasis: aeriology, symptoms and signs, diagnosis and treatmen
Chlamydia is a sexually transmitted bacterial infection caused by the bacterium
Chlamydia trachomatis. It can infect both men and women, and is often
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asymptomatic, meaning that infected individuals may not experience any
symptoms.
Symptoms in women may include abnormal vaginal discharge, burning or pain
during urination, lower abdominal pain, and pain during sexual intercourse. In
men, symptoms may include discharge from the penis, burning or pain during
urination, and swollen or tender testicles.
Diagnosis is usually made through a urine test or swab of the affected area.
Treatment typically involves a course of antibiotics, such as azithromycin or
doxycycline.
It is important to note that even if symptoms are not present, Chlamydia can still
be transmitted to sexual partners, and untreated infections can lead to serious
complications such as pelvic inflammatory disease, infertility, and ectopic
pregnancy. Therefore, regular STI screening and safe sexual practices are
important for preventing and managing Chlamydia infections.
120. Bacterial vaginosis: aetiology, symptoms and signs, diagnosis, treatment
Bacterial vaginosis (BV) is a common vaginal infection caused by an overgrowth of
certain types of bacteria in the vagina. The exact cause of BV is not fully
understood, but it is thought to result from an imbalance in the normal vaginal
flora, which allows harmful bacteria to multiply and thrive.
Symptoms of BV include a thin, gray or white vaginal discharge with a strong fishy
odor, itching, and burning during urination. However, many women with BV may
not experience any symptoms at all.
Diagnosis of BV is usually made based on a combination of symptoms and
laboratory tests. A healthcare provider will perform a pelvic exam to check for
vaginal discharge and may take a sample of the discharge for laboratory testing. A
"whiff test" may also be performed in which a sample of discharge is mixed with
potassium hydroxide (KOH) solution and examined for the characteristic fishy
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odor.
Treatment for BV usually involves a course of antibiotics, either as an oral
medication or a vaginal cream or gel. Commonly prescribed antibiotics for BV
include metronidazole and clindamycin. Sexual partners of women with BV may
also need to be treated to prevent reinfection.
In addition to antibiotics, certain lifestyle changes may help prevent BV. These
include avoiding douching, using condoms during sexual activity, and avoiding the
use of scented products on the genital area.
121. Non-specific vaginal infections: aetiology, symptoms and signs, diagnosi
and treatment.
Non-specific vaginal infections refer to vaginal infections that are not caused by a
specific pathogen such as bacteria, fungi, or viruses. Instead, they are caused by
imbalances in the vaginal microbiome, which can lead to overgrowth of certain
bacteria or other microorganisms. Here is a brief overview of non-specific vaginal
infections:
Aetiology: Non-specific vaginal infections can be caused by a variety of factors,
including:
Hormonal changes
Antibiotic use
Poor hygiene
Sexual activity
Use of scented products or douching
Stress
Symptoms and signs: The symptoms of non-specific vaginal infections can vary
depending on the severity of the infection, but may include:
Vaginal discharge
Vaginal itching or burning
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Pain or discomfort during sex
Pain or discomfort during urination
Foul odor
Diagnosis: Diagnosis of non-specific vaginal infections is usually made based on a
combination of symptoms, physical examination, and laboratory tests. Your
healthcare provider may perform a pelvic exam and take a sample of vaginal
discharge for laboratory testing to rule out other causes of vaginal infections.
Treatment: Treatment of non-specific vaginal infections typically involves
restoring the balance of the vaginal microbiome. This may include:
Probiotics: Probiotic supplements or foods can help restore healthy bacteria in
the vagina.
Antibiotics: Your healthcare provider may prescribe antibiotics if the infection is
severe or does not respond to probiotics.
Avoiding irritants: Avoid using scented products, douching, or other irritants that
can disrupt the vaginal microbiome.
Overall, it's important to maintain good hygiene practices and to seek medical
care if you experience any symptoms of a vaginal infection.
122. 122. Oestrogen deficiency vaginitis: vulvovaginitis in children and senile
vaginitis.
Oestrogen deficiency vaginitis is a type of vaginitis that occurs due to decreased
levels of estrogen hormone. It can occur in two age groups: prepubertal girls and
postmenopausal women.
In prepubertal girls, oestrogen deficiency vaginitis can occur due to lack of
estrogen production in the body or due to an abnormality in the tissues that
respond to estrogen. The symptoms may include vaginal itching, burning,
discharge, and pain during urination or intercourse.
In postmenopausal women, the vaginal tissues become thinner, drier, and less
elastic due to decreased estrogen levels, which can lead to senile vaginitis.
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Symptoms may include vaginal dryness, itching, burning, and pain during
intercourse.
Treatment for oestrogen deficiency vaginitis involves restoring estrogen levels. In
prepubertal girls, this may involve topical estrogen cream or tablets, while in
postmenopausal women, estrogen replacement therapy may be used. Other
treatments may include lubricants or moisturizers to relieve symptoms.
It is important to note that any vaginal symptoms should be evaluated by a
healthcare provider to determine the underlying cause and appropriate
treatment.
123. Secondary vaginitis and are forms of vaginitis.
Secondary vaginitis refers to inflammation of the vaginal wall that is caused by an
underlying medical condition or factor, such as a bacterial or fungal infection,
hormonal imbalances, or an allergic reaction. Treatment typically involves
identifying and addressing the underlying cause of the inflammation.
There are many forms of vaginitis, including:
Bacterial vaginosis: an overgrowth of bacteria in the vagina that can cause
discharge, odor, and irritation.
Candidiasis (yeast infection): an overgrowth of yeast in the vagina that can cause
itching, burning, and discharge.
Trichomoniasis: a sexually transmitted infection caused by a parasite that can
cause itching, burning, and discharge.
Atrophic vaginitis: inflammation of the vaginal wall due to decreased estrogen
levels, which can occur during menopause or after certain medical treatments.
Chemical vaginitis: inflammation of the vaginal wall due to exposure to irritants,
such as soaps, perfumes, or douches.
Mixed vaginitis: a combination of different types of vaginitis, such as bacterial
vaginosis and yeast infection occurring together.
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124. Acute cervicitis: aetiology, symptoms and signs, diagnosis and treatment.
Acute cervicitis refers to inflammation of the cervix that develops rapidly and
typically presents with symptoms. Here's more information on the aetiology,
symptoms and signs, diagnosis, and treatment of acute cervicitis:
Aetiology:
Infections with various microorganisms, including bacteria, viruses, fungi, and
parasites, are the most common cause of acute cervicitis. The most frequent
bacterial pathogens are Chlamydia trachomatis, Neisseria gonorrhoeae, and
Mycoplasma genitalium, while viral causes include human papillomavirus (HPV),
herpes simplex virus (HSV), and cytomegalovirus (CMV).
Other causes of acute cervicitis can include chemical irritants, allergic reactions,
and trauma to the cervix.
Symptoms and signs:
Symptoms of acute cervicitis can include vaginal discharge (which may be yellow,
green, or gray and have a foul odor), vaginal bleeding or spotting (particularly
after intercourse), pain or discomfort during sex, and pain or discomfort in the
lower abdomen or pelvis.
Signs of acute cervicitis can include redness, swelling, and tenderness of the
cervix, as well as the presence of discharge or bleeding.
Diagnosis:
A physical exam, including a pelvic exam, is typically performed to evaluate for
signs of inflammation or infection of the cervix.
Tests that may be used to diagnose acute cervicitis include a Pap smear to
evaluate for abnormal cervical cells, cultures of cervical secretions to identify the
type of microorganism causing the infection, and blood tests to screen for certain
sexually transmitted infections.
Treatment:
The treatment for acute cervicitis depends on the underlying cause of the
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inflammation or infection.
Antibiotics are typically used to treat bacterial infections, while antiviral
medications may be used to treat viral infections.
Treatment may also involve the use of anti-inflammatory medications to reduce
pain and swelling.
Sexual partners may need to be treated as well to prevent reinfection.
125. Chronic cervicitis: actiology, symptoms and signs. diagnosis and
treatment.
Chronic cervicitis refers to long-standing inflammation of the cervix, which may be
caused by several factors including infection, trauma, or an allergic reaction.
Some common causes of chronic cervicitis include sexually transmitted infections
(such as chlamydia or gonorrhea), bacterial infections (such as Group B
streptococcus), and exposure to chemicals or irritants.
Symptoms of chronic cervicitis may include vaginal discharge, discomfort or pain
during sex, bleeding between periods, and pelvic pain. However, some women
may not experience any symptoms.
Diagnosis of chronic cervicitis involves a physical examination and a pelvic exam.
A healthcare provider may collect samples of cervical discharge for laboratory
testing to identify any potential bacterial or fungal infections. Additionally, a Pap
smear may be performed to check for any abnormal cervical cells that could be
indicative of cervical cancer.
Treatment for chronic cervicitis depends on the underlying cause. Antibiotics may
be prescribed for bacterial infections, antifungal medication may be prescribed
for fungal infections, and antiviral medication may be prescribed for viral
infections. In some cases, topical corticosteroids may be used to reduce
inflammation. It is important to complete the full course of any prescribed
medication, even if symptoms improve, to ensure the infection is fully treated.
Prevention measures for chronic cervicitis include practicing safe sex and using
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barrier methods, such as condoms, to reduce the risk of sexually transmitted
infections. It is also important to maintain good hygiene practices and avoid
exposure to irritants or chemicals that can cause inflammation. Regular
gynecologic check-ups and Pap smears can also help identify and treat any
cervical abnormalities early on.
126. Endometritis and pyometra: causes, clinical forms, symptoms and sings
diagnosis and management
Endometritis and pyometra are two conditions that involve inflammation of the
endometrium, or the lining of the uterus. They can have different causes,
symptoms, and treatments.
Endometritis is an inflammation of the endometrium that can be caused by
infections such as bacterial, viral, or fungal. It can also occur as a result of retained
products of conception after childbirth, miscarriage, or abortion. Symptoms of
endometritis include lower abdominal pain, abnormal vaginal bleeding, fever, and
foul-smelling vaginal discharge. Diagnosis is made through a pelvic exam, imaging
tests, and cultures of the vaginal discharge. Treatment may involve antibiotics,
anti-inflammatory medications, or surgical intervention if necessary.
Pyometra, on the other hand, is a rare but serious condition that occurs when the
uterus becomes filled with pus. It can be caused by infection or hormonal
imbalances, and is most commonly seen in postmenopausal women. Symptoms
of pyometra include fever, abdominal pain, abnormal vaginal discharge, and a
feeling of fullness or pressure in the pelvic region. Diagnosis is made through a
pelvic exam, imaging tests, and analysis of the vaginal discharge. Treatment
typically involves antibiotics, and may also include drainage of the pus or surgical
removal of the uterus in severe cases.
It is important to seek medical attention promptly if you experience any
symptoms of endometritis or pyometra, as both conditions can lead to serious
complications if left untreated.
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127. Pelvic inflammatory discase (PID): aetiology, pathological anatomy of
acute salpingitis, staging. symptoms and signs of acute PID, diagnosis and
differential diagnosis.
Pelvic inflammatory disease (PID) is an infection of the female reproductive
organs, including the uterus, fallopian tubes, and ovaries. It is usually caused by
sexually transmitted infections, such as chlamydia and gonorrhea, although it can
also result from other types of bacteria.
The pathological anatomy of acute salpingitis in PID is characterized by
inflammation and edema of the fallopian tubes, which can lead to scarring and
blockage. In severe cases, pus may accumulate in the tubes, leading to pyosalpinx
or even rupture.
The symptoms and signs of acute PID include lower abdominal pain, fever, vaginal
discharge, painful urination, and painful sexual intercourse. Diagnosis is based on
a combination of clinical findings, laboratory tests, and imaging studies. The
differential diagnosis includes other conditions that can cause similar symptoms,
such as endometriosis, ovarian cysts, and ectopic pregnancy.
The staging of PID is based on the severity and extent of the infection, as well as
the presence of complications such as abscess formation or sepsis. Treatment
typically involves a course of antibiotics to clear the infection, as well as pain
management and supportive care. In some cases, surgery may be necessary to
remove abscesses or repair damage to the reproductive organs.
128. Medical treatment of acute PID.
The medical treatment of acute PID involves the use of antibiotics to eliminate
the bacterial infection. The choice of antibiotics depends on the severity of the
infection, the suspected or identified causative organisms, and any allergies the
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patient may have.
In general, a combination of two antibiotics is used to ensure effective treatment
and to reduce the risk of antibiotic resistance. The antibiotics are usually given
intravenously (IV) in the hospital setting for severe cases, or orally for milder
cases that can be managed on an outpatient basis.
Some commonly used antibiotics for the treatment of acute PID include:
Cefoxitin
Cefotetan
Ceftriaxone
Doxycycline
Clindamycin
Metronidazole
Patients with severe or complicated PID may require longer courses of antibiotics
and close monitoring to ensure resolution of the infection and to prevent
complications such as abscess formation or infertility.
In addition to antibiotics, pain management and supportive care may be needed
to manage symptoms such as fever and abdominal pain. It is also important to
screen sexual partners and treat any other STIs to prevent reinfection.
129. Antibiotics therapy of PID.
Antibiotic therapy is a key component of the treatment of pelvic inflammatory
disease (PID). The choice of antibiotics depends on the severity of the infection,
the causative organisms, and the patient's medical history and allergies. Broadspectrum antibiotics are typically used to provide coverage for a range of
potential pathogens.
Commonly used antibiotics for PID include:
Ceftriaxone: This is a third-generation cephalosporin that is often used in
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combination with doxycycline or azithromycin to cover for gonorrhea and
chlamydia infections.
Doxycycline: This is a tetracycline antibiotic that is often used in combination with
ceftriaxone or azithromycin to cover for gonorrhea and chlamydia infections.
Azithromycin: This is a macrolide antibiotic that is often used in combination with
ceftriaxone or doxycycline to cover for gonorrhea and chlamydia infections.
Metronidazole: This is an antibiotic that is effective against anaerobic bacteria
and is often used in combination with other antibiotics to treat PID.
The duration of antibiotic therapy varies depending on the severity of the
infection and the response to treatment. In general, treatment is continued until
symptoms have resolved and there is evidence of clinical improvement. It is
important to complete the full course of antibiotics to ensure that the infection is
completely eradicated and to prevent the development of antibiotic-resistant
bacteria.
130. Surgical treatment of acute PID.
Surgical treatment of acute PID is reserved for cases where there is an abscess, a
ruptured tubo-ovarian abscess, or the patient does not respond to medical
therapy. The surgical approach may involve laparoscopy or laparotomy. The goal
of surgical treatment is to drain any abscess, remove any infected tissue, and
improve fertility if necessary.
Laparoscopy is the preferred surgical approach for acute PID as it is less invasive
and allows for quicker recovery. During laparoscopy, small incisions are made in
the abdomen, and a laparoscope is used to view the pelvic organs. Any abscesses
can be drained, and infected tissue can be removed using instruments inserted
through the incisions.
Laparotomy is a more invasive surgical approach that involves making a larger
incision in the abdomen to access the pelvic organs. This approach is typically
reserved for cases of severe infection, where there is a risk of rupture of the
abscess or other complications. The surgical goals of laparotomy are the same as
those of laparoscopy, but the recovery time is longer.
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In addition to surgery, antibiotics may be continued after surgery to ensure
complete eradication of the infection. Follow-up appointments with a healthcare
provider are important to monitor recovery and prevent future episodes of PID.
131. Pelvic inflammatory disease (PID): pathological anatomy of chronic PID,
symptoms and signs of chronic PID, diagnosis and differential diagnosis.
Chronic pelvic inflammatory disease (PID) is a condition that develops when acute
PID is not adequately treated or resolved. It is characterized by chronic
inflammation of the pelvic organs, including the uterus, fallopian tubes, ovaries,
and surrounding tissues.
The pathological anatomy of chronic PID shows fibrosis, adhesions, and scarring
of the pelvic organs and tissues. The fallopian tubes may be occluded or distorted,
which can lead to infertility or ectopic pregnancy.
Symptoms of chronic PID may include pelvic pain, abnormal vaginal discharge,
painful intercourse, and irregular menstrual bleeding. However, some women
may have no symptoms at all. Chronic PID can also be asymptomatic and
discovered incidentally during an infertility workup.
Diagnosis of chronic PID is made based on the clinical history, physical
examination, and imaging studies such as transvaginal ultrasound or MRI.
Laparoscopy may also be used to confirm the diagnosis and evaluate the extent of
pelvic adhesions and damage.
Differential diagnosis of chronic PID includes other conditions that cause chronic
pelvic pain and infertility, such as endometriosis, adenomyosis, uterine fibroids,
and ovarian cysts.
Management of chronic PID involves a combination of medical and surgical
interventions. Antibiotics may be prescribed to treat any active infection and
prevent further spread. Surgery may be necessary to remove adhesions, restore
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patency to the fallopian tubes, or remove damaged organs such as the uterus or
ovaries. In some cases, in vitro fertilization (IVF) may be necessary to achieve
pregnancy.
132. Surgical treatment of chronic PID.
Surgical treatment of chronic PID may be necessary in cases where there are
complications such as tubo-ovarian abscesses, pelvic adhesions or blockages in
the fallopian tubes. The surgical procedures may include:
Salpingectomy: Removal of the fallopian tubes, which may be necessary in cases
of severe damage or blockage.
Salpingostomy: Creation of an opening in the fallopian tube to drain an abscess.
Oophorectomy: Removal of the ovaries, which may be necessary if they are
severely damaged or infected.
Hysterectomy: Removal of the uterus, which may be necessary in severe cases of
chronic PID that do not respond to other treatments and where fertility is no
longer desired.
Surgical treatment is generally reserved for cases that are unresponsive to
medical treatment or have complications that require intervention. It is important
to note that surgical treatment may have implications for fertility and should be
discussed with the patient beforehand.
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133. PROGNOSIS AND END RESULTS OF PID.
ANS. PID has a high morbidity; about 20% of affected women become infertile,
40% develop chronic pelvic pain, and 1% of those who conceive have an ectopic
pregnancy.
134. PROPHYLAXIS OF PID.
ANS. Essential steps in prevention are :
• Community- based approach to increase public health awareness.
• Prevention of sexually transmitted infection with the knowledge of healthy
and safer sex.
• Liberal use of contraceptives.
• Routine screening of high risk population.
135. TUBERCULOSIS OF GENITAL TRACT.
ANS. The causative organism is Mycobacterium tuberculosis of human type.
Genital TB is always secondary to primary infection and spreads mostly by the
route of hematogenous spread from the lungs (50%) and LNs.
M/c affected organ is the FT (m/c ampulla).
Fallopian tubes : Starts by interstitial salpingitis of ampullary region and then can
spread medially causing destruction of muscles. Walls get thickened, calcified and
fibrous. Fimbria are everted and the abdominal ostium usually remains patent.
Gives a ‘tobacco pouch appearance’. Perisalpingitis can be seen.
Uterus : Infection from tubes. Cornual ends mostly affected due to dual blood
supply. Endometrial ulceration may lead to Asherman’s synd.
Cervix, ovaries, vulva and vagina are rarely affected.
Diagnosis and investigations : Blood tests, Mantoux test, CXR, diagnostic uterine
curettage.
Clinical diagnosis : Suspect in case of unexplained infertility or amenorrhea,
recurrent PID episodes not responding to ABs. presence of pelvic mass with
nodules in the POD.
Symptoms & signs : infertility; menstrual abN which includes menorrhagia,
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amenorrhea or oligomenorrhea; c/c pelvic pain; vaginal discharge; constitutional
symps like wt. loss, malaise, anorexia, pyrexia, anemia. On p/v examination:
vulvar or vaginal ulcer, thickening of tubes may be felt.
D/d : Pyogenic tubo-ovarian mass; Pelvic endometriosis; Adherent ovarian cyst;
C/c disturbed ectopic pregnancy.
Rx : chemo – anti-TB chemo therapy is treatment of choice.
Surgery in case of no response to chemo, tubercular pyosalpinx, ovarian abscess
or pyometra, persistent menorrhagia and/or c/c pelvic pain.
Type of Sx: ideal is total hysterectomy with B/L salpingo-oopherectomy.
136. MYOMAS OF UTERUS: ETIOLOGY, PATHOLOGICAL ANATOMY, C/F,
DIAGNOSIS & D/d.
Ans. ETIOLOGY : It arises from neoplastic single smooth muscle cell (myocyte) of
myometrium. Thus each myoma is monoclonal. The stimulus can be chromosomal
abnormality or by polypeptide growth factors.
Myoma is a predominantly estrogren dependent tumour.
TYPES : Mostly located in the body of uterus.
A) Body (corporeal) myomas :
1. Interstitial or intramural (75%)
2. Subperitoneal or subserous (15%)
i) Subserous
ii) Broad ligament (pseudo)
iii) Wandering (parasitic)
3. Submucous (5%)
i) Sessile
ii) Pedunculated (polyp)
B) Cervical myomas :
1. Anterior
2. Posterior
3. Central
4. Lateral
C/F : symptoms –
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✓
✓
✓
✓
✓
✓
✓
✓
✓
Majority asymp (75%)
AUB (30%): menorrhagia, metrorrhagia.
Dysmenorrhea
Dyspareunia
Subfertility
Pressure syms (bladder, ureter and rectum)
Recurrent pregnancy loss (miscarriage, PTL)
Lower abd or pelvic pain
Abd enlargement
Signs✓ Palpation- feel is firm, more toward hard; well defined margins; nodular
surface; restricted mobility from above downwards but ccan be moved side
to side.
✓ Percussion- swelling is dull on percussion.
✓ Pelvic examination- Bimanual examination reveals uterus is irregularly
enlarged by the swelling felt per abd.
DIAGNOSIS :
o TVS
o Colour doppler
o Saline infusion sonography
o Hysteroscopy
o HSG
o MRI
o Uterine curettage
o Laparoscopy
D/D :
a)
b)
c)
d)
e)
f)
Pregnancy
Adenomyosis
Myohyperplasia
Ovarian tumor
TO mass
Full bladder
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137. SECONDARY CHANGES: DEGENRATIONS AND OTHER COMPLICATIONS OF
MYOMAS.
Ans.: Degenerations occur as the tumor grows outside its blood supply.
A. Hyaline degeneration- m/c (65%).
B. Cystic degeneration- common in interstitial fibroids. Formed by
liquefaction of areas with hyaline changes.
C. Myxomatous degeneration is common (15%)- occurs mainly in
central part of myoma. Smooth muscle cells undergo myxomatous
changes.
D. Fatty degeneration- fat globules are mainly deposited in muscle cells.
E. Calcific degeneration- usually involves subserous fibroids with small
pedicle. Precipitation of calcium carbonate and phosphate within the
tumor. Womb stone appearance when complete tumor is coverted in
calcific mass.
F. Red degeneration (carneous change)
G. Atrophy
H. Necrosis
I. Infections
J. Vascular changes
K. Sarcomatous changes
COMPLICAIONS :
H’ge
Torsion of subserous pedunculated fibroid
Polycythemia
Persistent menorrhagia, metrorrhagia → severe anemia
Severe infections leading to peritonitis or septicemia.
Sarcoma (rare)
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138. INDICATIONS FOR TREATMENT OF MYOMAS.
Ans.:
Indications for myomectomy :
▪ Persistent uterine bleeding despite medical therapy.
▪ Excessive pain or pressure symptoms.
▪ Size >2 weeks, woman desirous to have a baby.
▪ Unexplained infertility with distortion of the uterine cavity.
▪ Recurrent pregnancy wastage due to fibroid.
▪ Rapidly growing myoma during follow-up.
▪ Subserous pedunculated fibroid
Indications for emergency surgery for fibroid :
▪ Torsion of a subserous pedunculated fibroid.
▪ Massive intraperitoneal haemorrhage following rupture of veins over
subserous fibroid.
▪ Uncontrolled infected fibroid.
▪ Uncontrolled bleeding fibroid.
139. MEDICAL TREATMENT OF MYOMAS.
Ans.: As a temporary palliation, various drugs are used to minimize blood loss and
correct anemia when a definite surgery cannot be undertaken for certain periods.
Antiprogesterones—Mifepristone (RU 486) is very effective to reduce fibroid size
and also menorrhagia. It may produce amenorrhea. It reduces the size of the
fibroid significantly. A daily dose of 25–30 mg is recommended for 3 months. 5 mg
daily dose is also found effective. Long-term therapy is avoided as it causes
endometrial hyperplasia. Asoprisnil is used with success. It is a selective
progesterone receptor modulator. It does not cause endometrial hyperplasia.
Danazol—can reduce the volume of a fibroid slightly. Because of androgenic side
effects, danazol is used only for a period of 3–6 months. Danazol administered
daily in divided doses ranging from 200-400 mg for 3 months minimizes blood loss
or even produce amenorrhea by its antigonadotropin and androgen agonist
actions.
Levonorgestrel-releasing Intrauterine System (LNG-IUS) reduces blood loss and
uterine size. However, this is not recommended when the uterine size is >12
weeks or there is distortion of uterine cavity.
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GnRH agonists—Drugs commonly used are goserelin, luporelin, buserelin or
nafarelin. Mechanism of action is sustained pituitary down regulation and
suppression of ovarian function. Optimal duration of therapy is 3 months.
Addback therapy may be needed to combat hypestrogenic symptoms.
GnRH antagonists—Cetrorelix or ganirelix causes immediate suppression of
pituitary and the ovaries. They do not have the initial stimulatory effect. Benefits
are same as that of agonists . Onset of amenorrhea is rapid. Prostaglandin
synthetase inhibitors—These are used to relieve pain due to associated
endometriosis or degeneration of the fibroid. They cannot improve menorrhagia
due to fibroids.
Non-hormonal options : Tranexamic acid; aromatase inhibitors; prostaglandin
synthetase inhibitos (PSI).
140. SURGICAL TREATMENT OF MYOMAS.
Myomectomy is a surgical procedure performed to remove uterine fibroids, also
known as myomas. Myomectomy is typically performed on women who want to
preserve their uterus and have future pregnancies. Here is some information on
indications, types, techniques, and complications of myomectomy:
Indications:
• Fibroids causing heavy menstrual bleeding and anemia
• Fibroids causing pressure and pain in the pelvis
• Infertility associated with fibroids
• Fibroids causing recurrent miscarriage
Types of myomectomy:
1. Abdominal myomectomy: This is the traditional approach to myomectomy
and involves making a large incision in the abdomen to access the uterus.
2. Laparoscopic myomectomy: This is a minimally invasive approach that
involves making small incisions in the abdomen and using a laparoscope (a
thin, lighted tube with a camera) to guide the surgery.
3. Hysteroscopic myomectomy: This is a minimally invasive approach that
involves accessing the uterus through the cervix and using a hysteroscope
(a thin, lighted tube with a camera) to guide the surgery.
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Techniques:
• Open surgery (abdominal myomectomy) involves making a large incision in
the abdomen and accessing the uterus to remove the fibroids.
• Laparoscopic surgery involves making small incisions in the abdomen and
using specialized surgical instruments to remove the fibroids.
• Hysteroscopic surgery involves accessing the uterus through the cervix and
using a hysteroscope to remove the fibroids.
Complications:
• Bleeding
• Infection
• Injury to adjacent organs such as bladder, bowel or blood vessels
• Scarring
• Adhesion formation
• Uterine rupture during subsequent pregnancies
It is important to discuss the risks and benefits of myomectomy with your doctor
to determine the most appropriate treatment for your individual case.
141.
142. ENDOMETRIOSIS
Ans.: Presence of functioning endometrium (glands and stroma) in sites other
than uterine mucosa is called endometriosis.
Theories of etiology :
I. Retrograde menstruation (Sampson’s theory).
II. Coelomic metaplasia (Meyer & Ivanoff)
III. Direct implantation
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IV.
V.
VI.
VII.
Lymphatic theory (Halban)
Vascular theory
Genetic and immunological factors
Environment theory
Sites :
I. Abdominal
II. Extra-abdominal
III. Remote
Common sites - Ovaries • Pelvic peritoneum • Pouch of Douglas • Uterosacral
ligaments • Rectovaginal septum • Sigmoid colon • Appendix • Pelvic lymph
nodes • Fallopian tubes
Rare and remote sites -  Umbilicus  Abdominal scar  Episiotomy scar 
Lungs  Pleura  Ureter  Kidney  Arms  Legs  Nasal mucosa
CF :
➢ Dysmenorrhea
➢ abN menstruation
➢ Infertility
➢ Dyspareunia
➢ c/c pelvic pain
➢ abd pain
➢ Other Symptoms The symptoms are related to the organ involved.
 Urinary—frequency, dysuria, back pain or even haematuria
 Sigmoid colon and rectum—painful defecation (dyschezia), diarrhea,
constipation, rectal bleeding or even melena
 Chronic fatigue, perimenstrual symptoms (bowel, bladder)
 Haemoptysis (rarely), catamenial chest pain
 Surgical scars—cyclical pain and bleeding
Diagnosis – Clinical diagnosis, serum marker CA 125, Imaging (TVS, MRI, CT,
Colonoscopy), Laparoscopy (gold std).
D/d –
✓ C/c pelvic infection
✓ Ovarian endometrioma (chocolate cysts)
✓ Rupture of chocolate cyst
Treatment – can be preventive or curative.
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Options :  Expectant Management (observation only)
 Medical Therapy: • Hormones • Others
 Surgery: • Conservative • Definitive
 Combined Therapy: • Medical and Surgical
143. MEDICAL MANAGEMENT OF ENDOMETRIOSIS.
Ans.: The aim of the hormonal treatment is to induce atrophy of the
endometriotic implants. The drugs used are combined estrogen and progestogen
(oral pill), progestogens, danazol and GnRH analogues. All the drugs are used
continuously to produce amenorrhea and as such individualization of the dose is
required.
Combined estrogen and progestogen - It causes endometrial decidualization and
atrophy . It may induce amenorrhea. It relieves dysmenorrhea.
Progestogens – High doses may suppress ovulation and induce amenorrhea. Oral
route is commonly used.
Levonorgesteral-releasing-IUCD - reduces dysmenorrhea, pelvic pain, dyspareunia
and menorrhagia significantly. It is specially useful for rectovaginal endometriosis.
Danazol - started from the day 5 of the menstrual cycle. The dose (600–800 mg
daily) is variable and depends upon the extent of the lesions but should be
adequate enough to produce amenorrhea. The patient should use barrier
methods of contraception to avoid virilization of a female fetus in accidental
pregnancy.
GnRH analogues - When used continuously act as medical oophorectomy, a state
of hypoestrinism and amenorrhea. The goal is to maintain a reduced level of
serum estrogen (30–45 pg/mL) so that growth of endometriosis is suppressed.
144. SURGICAL TREATMENT OF ENDOMETRIOSIS.
Ans.: Can be conservative and definitive :
Conservative - planned to destroy the endometriotic lesions in an attempt to
improve the symptoms (pain, subfertility) and at the same time to preserve the
reproductive function.
Laparoscopy is commonly done to destroy endometriotic lesions by excision or
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ablation by electrodiatherapy or by laser vaporization. Conservative surgical
treatment in minimal to mild endometriosis (ablation plus adhesiolysis) improves
the fertility outcome. Laparoscopic uterosacral nerve ablation (LUNA) is done
when pain is very severe.
Definitive surgery - It is indicated in women with advanced stage endometriosis
where there is: (i) No prospect for fertility improvement. (ii) Other forms of
treatment have failed. (iii) Women with completed family. Definitive surgery
means hysterectomy with bilateral salpingo-oophorectomy along with resection
of the endometrial tissues as complete as possible
145. ADENOMYOSIS.
Ans.: Adenomyosis is a condition where there is ingrowth of the endometrium,
both the glandular and stromal components, directly into the myometrium.
Pathological anatomy : Characterized by the extension of endometrial glands and
stroma beneath the endometrial—myometrial interface (EMI). As the submucosa
is absent, endometrial glands lie in direct contact with the underlying
myometrium. It forms nests, deep within myometrium. Subsequently, threre is
myometrial hyperplasia around the endometriotic foci.
Symptoms :➢ Menorrhagia (70%)
➢ Dysmenorrhea (30%)
➢ Dyspareunia
➢ Frequency of urination
➢ Infertility
Signs :➢ Abd exm → A hypogastric mass arising out of the pelvis and occupying the
midline. The size usually does not exceed 14 weeks pregnant uterus.
➢ Pelvic examination → Reveals uniform enlargement of the uterus.
Diagnosis :➢ TVS
➢ Color doppler
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➢ MRI
Treatment :➢ Surgical management:→ (A) Conservative surgery: • Adenomyomectomy •
Uterine mass reduction (Laparotomy or laparoscopy). (B) Hysterectomy
(parous and aged women).
➢ There is little place of hormone therapy. Treatment with progestins or
cyclic estrogen and progestin have got little benefit. Levonorgestrel–
releasing-IUS is found to improve the menorrhagia and dysmenorrhea.
Danazol—loaded (300–400 mg) intrauterine device (IUD) is also found to
improve the symptoms of menorrhagia and dysmenorrhea.
146. Prophylaxis of endometriosis.
Endometriosis is a chronic condition in which the tissue that normally lines the
inside of the uterus (endometrium) grows outside of it, causing pain,
inflammation, and sometimes infertility. Unfortunately, there is no known way to
completely prevent endometriosis from developing. However, there are some
measures that may help reduce the risk of developing the condition or help
manage the symptoms:
✓ Maintain a healthy weight.
✓ Manage stress.
✓ Avoid environmental toxins.
✓ Consider hormonal birth control: Hormonal birth control methods such as
birth control pills, patches, or hormonal IUDs can help reduce the risk of
developing endometriosis by preventing ovulation and reducing the growth
of endometrial tissue outside the uterus.
✓ Surgical options: In some cases, surgery may be recommended to remove
endometrial tissue and prevent its growth. This is typically done through
laparoscopic surgery and may be helpful in reducing pain and other
symptoms.
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147. Acute abdomen: definition, causes.
Acute abdomen in obstetrics refers to the sudden onset of severe abdominal pain
in pregnant women, which may be accompanied by other symptoms such as
vaginal bleeding, fever, and contractions. Acute abdomen in obstetrics is a
medical emergency that requires prompt evaluation and treatment, as it may
indicate a serious underlying condition that requires urgent intervention.
Some of the common causes of acute abdomen in obstetrics include:
1. Ectopic pregnancy: This is a pregnancy that develops outside the uterus,
typically in the fallopian tube. An ectopic pregnancy can cause an acute
abdomen and requires prompt medical attention.
2. Miscarriage: A miscarriage is the loss of a pregnancy before the 20th week.
It can cause an acute abdomen and is often accompanied by vaginal
bleeding.
3. Placental abruption: This is a serious condition in which the placenta
partially or completely separates from the uterus before the baby is born.
Placental abruption can cause an acute abdomen, vaginal bleeding, and can
be life-threatening for both the mother and the baby.
4. Uterine rupture: This is a rare but serious condition in which the uterus
tears during pregnancy or labor. Uterine rupture can cause an acute
abdomen, severe vaginal bleeding, and can be life-threatening for both the
mother and the baby.
5. Ovarian torsion: This is a condition in which the ovary twists on itself, which
can cause an acute abdomen and severe pain. Ovarian torsion is rare but
can occur during pregnancy.
6. Acute appendicitis: Although rare, acute appendicitis can occur during
pregnancy and can cause an acute abdomen.
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148. Follicular hematomas, corpus luteal haematomas, torsion and rupture of
ovarian tumours, torsion of myomas: symptoms and sings, diagnosis and
management.
Ans.: Follicular hematomas and corpus luteal hematomas are both related to the
ovary. A follicular hematoma occurs when bleeding occurs within a developing
follicle in the ovary, while a corpus luteal hematoma occurs when there is
bleeding into a corpus luteum, which is the structure that forms after the release
of an egg from the ovary. These hematomas can present with symptoms such as
abdominal pain, bloating, and vaginal bleeding. Diagnosis is made through
ultrasound imaging, and management typically involves observation and pain
management.
Ovarian tumors can also cause torsion or rupture, leading to symptoms such as
sudden, severe abdominal pain, nausea, and vomiting. Diagnosis is made through
imaging such as ultrasound or CT scan, and management may involve surgery to
remove the affected ovary and tumor.
Torsion of myomas, or fibroids, can also present with sudden, severe abdominal
pain and can be diagnosed through imaging such as ultrasound. Management
may involve surgery to remove the affected fibroid or the uterus if necessary.
Overall, early diagnosis and appropriate management are important in these
gynecological conditions to prevent complications and promote recovery.
149. Ectopic gestation: incidence, aetiology, classification, pathological
anatomy.
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Ectopic pregnancy refers to the implantation of a fertilized egg outside the
uterine cavity, most commonly in the fallopian tube. It is a potentially lifethreatening condition that requires prompt diagnosis and treatment.
The incidence of ectopic pregnancy is approximately 1-2% of all pregnancies, and
the most common risk factors include previous pelvic inflammatory disease,
previous ectopic pregnancy, tubal surgery, assisted reproductive technology, and
smoking.
Ectopic pregnancies can be classified based on their location, with the most
common being tubal ectopic pregnancy. Other locations include the ovary, cervix,
abdominal cavity, and cesarean scar.
Pathologically, ectopic pregnancy is characterized by the presence of chorionic
villi outside the uterine cavity. The implantation of the fertilized egg outside the
uterus can lead to a range of complications, including tubal rupture, hemorrhage,
and shock.
Diagnosis of ectopic pregnancy typically involves a combination of clinical
evaluation, ultrasound imaging, and laboratory tests, including serial serum betahCG measurements. Treatment options depend on the location and severity of
the ectopic pregnancy, as well as the patient's clinical condition. Options may
include medical management with methotrexate or surgical management with
laparoscopy or laparotomy.
150. Tubal pregnancy: pathological anatomy, clinical symptoms, physical signs,
diagnostic investigations, differential diagnosis, management.
Tubal pregnancy, also known as ectopic pregnancy, is a type of pregnancy where
the fertilized egg implants outside of the uterus, most commonly in the fallopian
tube.
Pathological anatomy:
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•
•
The fertilized egg implants and grows in the fallopian tube, which is not
designed to support a developing embryo.
As the embryo grows, the tube may rupture, causing internal bleeding.
Clinical symptoms:
•
•
•
•
Abdominal pain, often on one side
Vaginal bleeding
Missed menstrual period
Signs of shock (if the tube ruptures), including lightheadedness, fainting,
rapid heart beat, and low blood pressure.
Physical signs:
•
•
•
Tenderness and pain on one side of the abdomen or pelvis
Abnormal vaginal bleeding
An enlarged or mass-like structure felt on pelvic exam.
Diagnostic investigations:
•
•
•
Transvaginal ultrasound: This is the most common method for diagnosing
tubal pregnancy. It uses high-frequency sound waves to create an image of
the pelvic organs.
Blood tests: Measuring the levels of the hormone human chorionic
gonadotropin (hCG) can help diagnose ectopic pregnancy.
Laparoscopy: This is a minimally invasive surgical procedure where a small
camera is inserted through a small incision in the abdomen to visualize the
pelvic organs and confirm the diagnosis.
Differential diagnosis:
•
•
•
•
Miscarriage
Ovarian cyst rupture
Appendicitis
Pelvic inflammatory disease.
Management:
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•
•
•
Treatment depends on the location of the ectopic pregnancy, the size of
the embryo, and the overall health of the patient.
In some cases, medication (such as methotrexate) can be used to stop the
growth of the embryo and cause it to be reabsorbed by the body.
If the ectopic pregnancy is large or has caused significant internal bleeding,
surgery (such as a salpingectomy or salpingostomy) may be necessary to
remove the embryo and repair any damage to the fallopian tube.
151. Unruptured ectopic gestation: definition, symptonis and sings, diagnosis.
treatment.
Unruptured ectopic gestation, also known as tubal pregnancy, refers to an ectopic
pregnancy that has not yet ruptured.
Symptoms and signs of an unruptured ectopic gestation are similar to those of a
ruptured ectopic pregnancy, but they may be less severe. These symptoms may
include vaginal bleeding, abdominal or pelvic pain, and shoulder pain. However, in
some cases, an unruptured ectopic pregnancy may have no symptoms and may
be detected only during routine prenatal care or ultrasound.
Diagnosis of an unruptured ectopic pregnancy may involve transvaginal
ultrasound to visualize the gestational sac outside the uterus, as well as blood
tests to monitor pregnancy hormone levels.
Treatment of an unruptured ectopic pregnancy typically involves medical
management with methotrexate, a medication that stops the growth of the
pregnancy and allows the body to reabsorb it. In some cases, surgery may be
necessary if the pregnancy is large or if there is a risk of rupture. Close monitoring
is also important to ensure that the pregnancy is resolving and that there are no
complications.
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152. Surgically administered medical treatment of ectopic pregnancy: criteria
for metotrexate treatment, technique, advantages and disadvantages.
prognosis
Surgically administered medical treatment of ectopic pregnancy involves the use
of methotrexate, a medication that stops the growth of rapidly dividing cells, to
treat ectopic pregnancy that is not ruptured or has minimal bleeding. The criteria
for methotrexate treatment include:
1. The size of the gestational sac: The gestational sac should be less than 4 cm
in diameter and the embryo should be less than 3.5 cm.
2. The level of human chorionic gonadotropin (hCG): The hCG level should be
less than 5000 mIU/mL, and should not have risen by more than 10% over
48 hours.
3. The absence of fetal cardiac activity: Methotrexate is not effective in
treating ectopic pregnancies where there is fetal cardiac activity.
The technique for methotrexate treatment involves a single or multiple injections
of the medication into the muscle or directly into the gestational sac under
ultrasound guidance. The medication stops the growth of the pregnancy, and the
body then reabsorbs the tissue over time.
Advantages of methotrexate treatment include:
1. It is a non-invasive treatment option and does not require surgery.
2. It preserves the woman's fertility.
3. It has a high success rate, with success rates of up to 90% reported in
studies.
Disadvantages of methotrexate treatment include:
1. It may cause side effects such as nausea, vomiting, and abdominal pain.
2. It may require multiple injections over several weeks.
3. It may not be effective in all cases, particularly in cases of larger or more
advanced ectopic pregnancies.
4. It requires close monitoring of the woman's hCG levels and symptoms.
The prognosis for women who receive methotrexate treatment for ectopic
pregnancy is generally good, with a high success rate and low rate of
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complications. However, close monitoring is necessary to ensure that the
pregnancy is resolving appropriately and to identify any potential complications.
153. Interstitial pregnancy: pathological anatomy, clinical symptoms, physical
signs, diagnostic investigations, differential diagnosis, treatment.
Interstitial pregnancy is a rare type of ectopic pregnancy that occurs when the
fertilized egg implants within the interstitial portion of the fallopian tube as it
enters the uterine wall. It represents approximately 2-4% of all ectopic
pregnancies and carries a high risk of maternal morbidity and mortality.
The clinical presentation of an interstitial pregnancy is similar to that of a tubal
pregnancy and includes lower abdominal pain, vaginal bleeding, and amenorrhea.
However, in some cases, the symptoms may be less severe, and the diagnosis may
be delayed.
On physical examination, the uterus may be enlarged, and adnexal mass may be
palpable on bimanual examination. However, the diagnosis of interstitial
pregnancy is usually made with the help of diagnostic imaging, such as
transvaginal ultrasound or magnetic resonance imaging (MRI).
In transvaginal ultrasound, a gestational sac located in the interstitial portion of
the tube, separate from the uterine cavity, is considered diagnostic of interstitial
pregnancy. MRI may provide additional information on the extent of the
pregnancy and the involvement of adjacent structures.
The treatment of interstitial pregnancy depends on the severity of symptoms, the
size of the gestational sac, and the desire for future fertility. Options include
expectant management, medical management with methotrexate, and surgical
management with laparotomy or laparoscopy.
Expectant management may be an option in cases of small gestational sacs with
low levels of human chorionic gonadotropin (hCG) and stable clinical condition.
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However, this approach carries a risk of rupture and severe bleeding, and close
monitoring is necessary.
Medical management with methotrexate is an effective option in selected cases.
The criteria for methotrexate treatment include a hemodynamically stable
patient, a gestational sac with a diameter of less than 3.5 cm, an ectopic mass
that is not growing, and a low level of hCG. Methotrexate is administered by
injection and works by stopping the growth of the ectopic pregnancy.
Surgical management is necessary in cases of rupture, unstable clinical condition,
or failure of medical management. Laparoscopy is the preferred method for
surgical management of interstitial pregnancy, as it allows for better visualization
and preservation of fertility.
The prognosis for interstitial pregnancy depends on the timing of diagnosis and
appropriate treatment. Delay in diagnosis or inappropriate management can
result in severe bleeding, damage to the fallopian tube, and the need for a
hysterectomy. Early diagnosis and appropriate management can result in a
successful pregnancy outcome and preservation of fertility.
154. Cervical pregnancy: clinical symptoms, physical signs, diagnostic
investigations, treatment.
Cervical pregnancy is a rare form of ectopic pregnancy that occurs when the
fertilized egg implants in the cervical canal instead of the uterine cavity. It is a lifethreatening condition that requires prompt diagnosis and management.
Clinical symptoms of cervical pregnancy may include vaginal bleeding, abdominal
pain, and cramping. Physical examination may reveal a soft and enlarged cervix,
and ultrasound imaging can help confirm the diagnosis.
Diagnostic investigations for cervical pregnancy may include transvaginal
ultrasound, hysteroscopy, and magnetic resonance imaging (MRI).
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Treatment for cervical pregnancy usually involves the removal of the fetus and
placenta to prevent severe bleeding and infection. This can be done using several
approaches, including suction curettage, dilatation and curettage (D&C), or
hysteroscopy. In some cases, a cervical cerclage may be placed to prevent future
cervical pregnancies.
It is important to note that cervical pregnancy is a high-risk condition, and
complications can include severe bleeding, infection, and damage to the cervix or
uterus. Women who have had a cervical pregnancy should receive close
monitoring and follow-up care to ensure their health and fertility.
155. Abdominal pregnancy: pathological anatomy, clinical features, diagnosis,
treatment.
Abdominal pregnancy is a rare form of ectopic pregnancy where the fertilized egg
implants in the abdominal cavity outside the uterus. It accounts for less than 1%
of all ectopic pregnancies. Here are some of the clinical features, diagnosis, and
treatment options for abdominal pregnancy:
Clinical features:
•
•
•
•
Lower abdominal pain
Vaginal bleeding
Absence of fetal parts felt on vaginal examination
Abdominal mass
Diagnosis:
•
•
•
Ultrasound imaging to confirm the location of the pregnancy
Elevated serum beta-hCG levels
MRI (magnetic resonance imaging) may also be used to confirm the
diagnosis
Treatment:
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Abdominal pregnancy is considered a life-threatening condition that requires
prompt intervention. Treatment options include:
1. Surgical removal of the pregnancy:
•
•
•
This is the preferred treatment option for abdominal pregnancy.
The surgical approach will depend on the location of the placenta and its
attachment to surrounding organs.
In some cases, a hysterectomy may be necessary to remove the placenta
completely.
Medical management:
•
•
•
In some cases, methotrexate (a chemotherapy drug) may be used to stop
the growth of the pregnancy and dissolve the placenta.
This approach is only used in cases where the pregnancy is small and not
well-attached to surrounding organs.
Close monitoring is required to ensure the success of the treatment.
Expectant management:
•
•
This approach involves close monitoring of the patient's condition and
waiting for the pregnancy to naturally terminate.
It is only used in cases where the pregnancy is small, the patient is stable,
and the risk of bleeding is low.
Overall, the prognosis for abdominal pregnancy is generally poor, with a high risk
of maternal morbidity and mortality. Early diagnosis and prompt intervention are
essential for the best possible outcome.
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156. Ovarian pregnancy: pathological anatomy, clinical features. diagnosis,
treatment.
Ovarian pregnancy is a rare form of ectopic pregnancy in which the fertilized egg
implants in the ovary. It is estimated to occur in approximately 1 in 7,000 to 1 in
40,000 pregnancies.
Pathological anatomy: The implantation of the fertilized egg occurs within the
ovary, and as the pregnancy progresses, a gestational sac is formed. The ovary
may enlarge, and there may be hemorrhage into the ovarian tissue.
Clinical features: The clinical presentation of an ovarian pregnancy is similar to
that of other forms of ectopic pregnancy, including abdominal pain, vaginal
bleeding, and a positive pregnancy test. However, the symptoms may be milder
than in tubal ectopic pregnancy, and the diagnosis may be delayed.
Diagnosis: The diagnosis of ovarian pregnancy is made based on clinical suspicion,
ultrasound findings, and laboratory tests. Ultrasound may show a gestational sac
within the ovary, and serum beta-human chorionic gonadotropin (beta-hCG)
levels may be elevated.
Treatment: The treatment of ovarian pregnancy is typically surgical, with the
removal of the affected ovary (oophorectomy) being the most common approach.
In some cases, conservative surgery, such as partial oophorectomy, may be
attempted in order to preserve ovarian function. In rare cases, medical
management with methotrexate may be attempted, although this is not typically
the first-line treatment for ovarian pregnancy.
The prognosis for ovarian pregnancy is generally good, particularly when
diagnosed and treated promptly. However, there is a risk of ovarian damage or
loss, and fertility may be affected in some cases. Close follow-up is typically
recommended after treatment.
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157. Genital prolapse: aetiology, classification, clinical symptoms,
investigations, differential diagnosis, management and prophylaxis.
Genital prolapse is a condition where there is descent of one or more of the pelvic
organs, including the uterus, vagina, bladder, or rectum, from their normal
anatomical position.
Aetiology:
Genital prolapse is primarily caused by weakness or damage to the muscles,
ligaments, and fascia that support the pelvic organs. Factors that increase the risk
of genital prolapse include pregnancy, childbirth, menopause, aging, obesity,
chronic coughing, heavy lifting, and chronic constipation.
Classification:
Genital prolapse can be classified according to the organs involved, as well as the
severity of the condition. The organs involved can include the uterus (uterine
prolapse), vagina (vaginal prolapse), bladder (cystocele), and rectum (rectocele).
The severity of the condition is typically classified into four grades, with grade I
being the mildest and grade IV being the most severe.
Clinical symptoms:
The symptoms of genital prolapse can vary depending on the organs involved and
the severity of the condition. Common symptoms include a sensation of pressure
or fullness in the pelvic area, a feeling of something protruding from the vagina,
urinary incontinence or urgency, constipation, difficulty with bowel movements,
and discomfort or pain during intercourse.
Investigations:
The diagnosis of genital prolapse is usually made based on a pelvic examination.
Further investigations may include a cystoscopy, to evaluate the bladder, and a
proctoscopy, to evaluate the rectum. Imaging studies, such as ultrasound, MRI or
CT scan, may be necessary in cases of complex prolapse or if malignancy is
suspected.
Differential diagnosis:
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Other conditions that may present with similar symptoms include urinary tract
infections, cystitis, bladder cancer, rectal prolapse, uterine fibroids, and ovarian
cysts.
Management and prophylaxis:
Treatment options for genital prolapse depend on the severity of the condition
and the organs involved.
Conservative treatment measures may include estrogen replacement therapy
may improve minor degree prolapse in postmenopausal women, pelvic floor
muscle exercises (kegel exercises), lifestyle modifications, and pessaries.
In more severe cases, surgery may be necessary. Type of operation depends upon
the organ which is prolapsed.
Prophylaxis includes maintaining a healthy weight, regular exercise, avoiding
heavy lifting, and treating chronic conditions such as constipation and chronic
coughing. Pelvic floor muscle exercises can also be done to prevent genital
prolapse.
158. Retroversion of the uterus: aetiology, symptoms, diagnosis, treatment.
Retroversion of the uterus, also known as tilted or tipped uterus, is a condition in
which the uterus is tilted backward instead of forward.
The cause of retroversion of the uterus is often unknown, but it can be congenital
or acquired as a result of conditions such as endometriosis, fibroids, pelvic
inflammatory disease, or pregnancy.
In many cases, retroversion of the uterus is asymptomatic and does not require
treatment. However, some women may experience symptoms such as lower back
pain, painful intercourse, urinary incontinence, or difficulty inserting tampons.
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Diagnosis of retroversion of the uterus can be done through a pelvic exam or
imaging studies such as ultrasound or MRI.
Corrective treatment : Pessary and surgical.
Pessary is less commonly used in present day gynaecologic practice. Usually,
Hodge-Smith pessary is used. The pessary acts by stretching the uterosacral
ligaments so as to pull the cervix backwards.
The principle of surgical correction is ventro-suspension of the uterus by plicating
the round ligaments of both the sides extraperitoneally to the under surface of
the anterior rectus sheath . This will pull the uterus forwards and maintains it
permanently in the same position.
Women with retroversion of the uterus can take steps to prevent symptoms from
occurring or worsening, such as practicing good posture, doing exercises to
strengthen the pelvic floor muscles, and avoiding heavy lifting.
159. Acute inversion of the uterus: aetiology, pathological anatomy,
symptoms, diagnosis and treatment.
Acute inversion of the uterus is a rare but serious obstetric emergency that occurs
when the uterus turns inside out and prolapses into or beyond the vagina. The
aetiology of acute inversion of the uterus includes the following factors:
1.
2.
3.
4.
Over traction of the uterus during the third stage of labor
Fundal pressure during the third stage of labor
Abnormal attachment of the placenta
Uterine anomalies or tumors
The symptoms of acute inversion of the uterus include sudden, severe abdominal
pain, shock, and heavy vaginal bleeding. The uterus may be palpable as a mass
protruding from the vagina. In some cases, the uterus may be completely inverted
and not palpable.
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Diagnosis of acute inversion of the uterus is usually made based on clinical
presentation and physical examination findings. A pelvic examination will reveal a
prolapsed uterus, which is usually a rounded, smooth mass protruding from the
vagina. Imaging tests such as ultrasound may be used to confirm the diagnosis
and rule out other causes of uterine prolapse.
Immediate treatment of acute inversion of the uterus is necessary to prevent
severe bleeding and shock. Treatment includes replacement of the uterus to its
normal position. This can be done manually, by applying pressure to the fundus
while the patient is under general anesthesia. In some cases, the use of tocolytic
drugs may be necessary to relax the uterus and facilitate replacement. If
conservative measures fail, surgery may be necessary to reposition the uterus.
160. Chronic inversion of the uterus: actiology. pathological anatomy,
symptoms, diagnosis and treatment.
Chronic inversion of the uterus is a rare condition that occurs when the uterus
remains partially or completely inverted after delivery. The causes of chronic
inversion of the uterus may include incomplete or improper management of
acute inversion, uterine tumors, Senile inversion following high amputation of the
cervix. It is probably due to cervical atony and incompetence and congenital
abnormalities of the uterus.
The pathological anatomy of chronic inversion of the uterus may vary depending
on the severity and duration of the condition. The uterus may be partially or
completely inverted, and there may be varying degrees of prolapse of the cervix
and vagina. The condition may also be associated with the formation of adhesions
or scar tissue, which can further complicate treatment.
Symptoms of chronic inversion of the uterus may include pelvic pain, vaginal
discharge, and abnormal bleeding. In some cases, the prolapsed uterus may be
visible or palpable through the vaginal opening. Chronic inversion of the uterus
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can also lead to infertility or difficulty conceiving, as well as other complications
such as infections and bowel or bladder dysfunction.
Diagnosis of chronic inversion of the uterus may involve a physical exam, imaging
studies such as ultrasound or magnetic resonance imaging (MRI), and possibly a
hysteroscopy or laparoscopy to evaluate the uterine tissue and confirm the
diagnosis.
Treatment of chronic inversion of the uterus typically involves surgical
intervention. The goal of treatment is to restore the uterus to its normal position
and function, while minimizing the risk of complications such as bleeding or
infection. The specific approach to treatment may vary depending on the severity
and duration of the condition, as well as the presence of any associated
complications. In some cases, a hysterectomy may be necessary to fully resolve
the condition.
Conservative surgery: Rectification may be done abdominally (Haultain’s
operation — after cutting the posterior ring of the cervix) or vaginally (Spinelli‘s
operation — after cutting the anterior ring of the cervix).
161. Non-neoplastic enlargements of the ovary (follicular cysts. lutein cysts of
the ovary, polycystic ovarian syndrome): aetiology. pathological anatomy,
symptoms, diagnosis and treatment.
Non-neoplastic enlargements of the ovary include follicular cysts, lutein cysts of
the ovary, and polycystic ovarian syndrome (PCOS).
Follicular cysts arise from the unruptured follicles in the ovary. Normally, a follicle
ruptures during ovulation, releasing an egg. If this does not occur, the follicle may
continue to grow and form a cyst. Most of these cysts are asymptomatic, but in
some cases, they can cause pelvic pain, pressure, or bloating. Diagnosis is usually
made through ultrasonography, and most follicular cysts will resolve on their own
without treatment.
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Lutein cysts of the ovary are another type of functional cyst that can form after
ovulation. These cysts can grow to several centimeters in size and may cause
abdominal pain, bloating, or irregular menstrual bleeding. Like follicular cysts,
most lutein cysts will resolve on their own without treatment.
PCOS is a common hormonal disorder that affects women of reproductive age. It
is characterized by multiple small cysts on the ovaries, irregular menstrual cycles,
and high levels of androgens (male hormones) in the body. Women with PCOS
may also experience weight gain, acne, and excess hair growth. Diagnosis is made
through a combination of clinical symptoms, physical examination, and laboratory
tests. Treatment options include lifestyle modifications, such as weight loss and
exercise, and medications to regulate ovulation and hormone levels.
In general, non-neoplastic enlargements of the ovary are benign and can be
managed conservatively. However, in rare cases, these cysts can become large or
twisted, causing severe pain or other complications. In these instances, surgical
intervention may be necessary.
162. Parovarian cysts: pathological anatomy, symptoms, diagnosis and
treatment.
Parovarian cysts, also known as paraovarian cysts or hydatid cysts of Morgagni,
are fluid-filled sacs that develop from the remnants of the Wolffian duct and the
Mullerian ducts, which are structures that form during embryonic development.
They are typically small and benign, and most women with parovarian cysts do
not experience any symptoms. However, if the cyst grows larger, it may cause
symptoms such as pelvic pain, discomfort, or a feeling of heaviness in the lower
abdomen.
Parovarian cysts can be diagnosed using imaging techniques such as ultrasound,
CT scans, or MRI. In some cases, a doctor may perform a laparoscopy to visualize
the cyst directly and determine its size and location. The treatment for parovarian
cysts usually depends on the size of the cyst and the severity of symptoms. Small
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cysts that do not cause any symptoms may not require any treatment and can be
monitored with regular check-ups. Larger cysts or cysts that cause symptoms may
require surgical removal, which is typically done using laparoscopy or laparotomy.
In summary, parovarian cysts are small, benign cysts that develop from the
remnants of embryonic ducts. They can cause symptoms such as pelvic pain and
discomfort, and can be diagnosed using imaging techniques. Treatment may
include monitoring, or surgical removal if the cyst is large or causes symptoms.
163. Ovarian tumours: epidemiology, pathology, classification.
Ovarian tumors are neoplasms that arise from the ovary. They can be benign
(non-cancerous) or malignant (cancerous). Ovarian tumors are relatively common
and can affect women of all ages, although they are more common in women
over the age of 50.
The majority of ovarian tumors arise from the epithelial cells that cover the
surface of the ovary. These tumors are known as epithelial ovarian tumors and
account for approximately 90% of all ovarian tumors. Other types of ovarian
tumors include germ cell tumors, which arise from the cells that give rise to eggs,
and sex cord-stromal tumors, which arise from the cells that produce hormones.
Ovarian tumors can be classified as benign, borderline (also known as low
malignant potential), or malignant. Benign ovarian tumors are non-cancerous and
do not spread to other parts of the body. Borderline tumors have some features
of cancer, but they do not invade surrounding tissue or spread to other parts of
the body. Malignant ovarian tumors are cancerous and can spread to other parts
of the body.
The symptoms of ovarian tumors can vary depending on the type of tumor and
whether it is benign or malignant. Common symptoms of ovarian tumors include
abdominal pain, bloating, and a feeling of fullness or pressure in the abdomen.
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Other symptoms may include changes in bowel or bladder habits, abnormal
vaginal bleeding, and weight loss.
Diagnosis of ovarian tumors typically involves a combination of imaging studies,
such as ultrasound or CT scans, and blood tests to measure tumor markers. If an
ovarian tumor is suspected, a biopsy may be performed to confirm the diagnosis.
Treatment for ovarian tumors depends on the type of tumor and whether it is
benign or malignant. Benign ovarian tumors may not require treatment, but may
be surgically removed if they are causing symptoms. Borderline tumors may also
be surgically removed, but may require additional treatment such as
chemotherapy. Malignant ovarian tumors typically require surgical removal and
may also require chemotherapy and/or radiation therapy.
164. Characteristics of borderline ovarian tumours.
Borderline ovarian tumors, also known as ovarian tumors of low malignant
potential (LMP), are a group of tumors that exhibit some characteristics of both
benign and malignant tumors. These tumors have the potential to recur and
metastasize, but they do not invade the surrounding tissue as deeply as malignant
tumors. Borderline ovarian tumors are relatively uncommon, accounting for
approximately 10-15% of all ovarian tumors.
Histologically, borderline ovarian tumors show an abnormal growth pattern of the
cells that line the inside of the ovary. They often have papillary projections, which
can be seen under a microscope. The cells have abnormal nuclei and mitotic
figures, but they do not exhibit the stromal invasion seen in true malignant
tumors.
Borderline ovarian tumors can present with similar symptoms as other ovarian
tumors, including abdominal pain, bloating, and irregular menstrual cycles.
However, they are often detected incidentally on imaging studies or during
surgery for other conditions.
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The treatment of borderline ovarian tumors involves surgical removal of the
affected ovary and any other involved tissues. Chemotherapy may be
recommended in certain cases. The prognosis for patients with borderline ovarian
tumors is generally good, with a 5-year survival rate of over 90%. However,
follow-up monitoring is necessary, as recurrence and metastasis can occur.
165. Epithelial tumours: pathological anatomy, symptoms and sings, diagnosis
and differential diagnosis, treatment.
Epithelial tumors are a type of ovarian tumor that arise from the surface
epithelium of the ovary. They account for the majority of ovarian tumors and can
be benign, borderline, or malignant.
Pathological anatomy:
Epithelial tumors are classified into serous, mucinous, endometrioid, clear cell,
transitional cell, and undifferentiated subtypes based on their histology. They are
characterized by the presence of cystic or solid masses on the ovary.
Symptoms and signs:
Epithelial tumors may present with symptoms such as abdominal distension,
pelvic pain, abnormal vaginal bleeding, and urinary frequency or urgency.
However, many cases are asymptomatic and are detected incidentally on imaging
studies.
Diagnosis and differential diagnosis:
Diagnosis of epithelial ovarian tumors is made through imaging studies such as
ultrasound or CT scan, as well as blood tests to measure tumor markers such as
CA-125. A biopsy or surgical removal of the tumor may be necessary to confirm
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the diagnosis. Differential diagnosis includes other types of ovarian tumors, such
as germ cell tumors and stromal tumors, as well as other conditions that may
cause similar symptoms.
Treatment:
Treatment of epithelial ovarian tumors depends on the stage and grade of the
tumor as well as the patient's age and overall health. Surgery is the mainstay of
treatment and involves removal of the tumor and affected ovary and fallopian
tube. Chemotherapy may be recommended for advanced or high-grade tumors,
and targeted therapy may be used for tumors that express certain molecular
markers.
166. Teratoma: types, pathological anatomy, symptoms and sings, diagnosis
and differential diagnosis, treatment.
Teratoma, also known as a dermoid cyst, is a type of ovarian tumour that arises
from germ cells, which are the cells that give rise to eggs. There are two main
types of teratomas: mature and immature.
Mature teratomas, also called benign teratomas or dermoid cysts, are the most
common type of teratoma. They are composed of mature tissues from all three
embryonic layers (ectoderm, mesoderm, and endoderm), and may contain hair,
teeth, bone, and other tissue types. Mature teratomas are usually asymptomatic
and are often discovered incidentally on imaging studies. If they cause symptoms,
it is usually due to their size, which can cause abdominal pain or discomfort.
Diagnosis is typically made through imaging studies, such as ultrasound or CT
scan. Treatment is surgical removal, which is curative.
Immature teratomas are rare and are composed of immature or embryonic
tissues. They are more likely to be cancerous or malignant, and tend to occur in
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younger women. Symptoms are similar to those of mature teratomas, but may
also include hormonal disturbances.
Diagnosis is made through imaging studies and biopsy.
Treatment involves surgical removal of the tumour, along with chemotherapy and
radiation therapy in some cases.
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167. Feminizing tumours of the ovary: pathology, clinical features, diagnosis and
treatment.
Ans: Granulosa cell and theca cell:
⚫ Granulosa theca cell cancers include ovarian tumors, which consist of granulosa
cells, theca cells, and fibroblasts in variable combinations.
⚫ Granulosa cells in the sex cords produce sex steroids and several peptides
needed for folliculogenesis and ovulation.
⚫ They also give rise to granulosa theca cell tumors (GCT), which form about 5
percent of ovarian neoplasms and are the commonest sex cord-stromal tumors
of the ovary (70 percent).
Pathology: Attempts to explain the etiology of sex cord-stromal
tumors resulted in two theories. The first one suggests the origin of these
neoplasms from the genital ridge mesenchyme. The second theory suggests
that these tumors originate from precursors within the mesonephric and
coelomic epithelium. However, the exact pathophysiology has not been
elucidated so far.
•
diagnosis: Gross appearance
⚫ Tumours vary in size, from tiny spots to large masses, with an average of 10 cm
in diameter.
⚫ Tumours are oval and soft in consistency.
⚫ On cut-section, histology reveals reticular, trabecular areas with interstitial
haemorrhage and Call–Exner bodies-small cyst like spaces interspersed within
a Graafian follicle.
Tumour marker
Inhibin, a hormone, has been used as biomarker for granulosa cell tumours.
Treatment: Surgery
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⚫ Surgery (unilateral oophorectomy) is the primary treatment for early stage GCT
tumors. Stage I (confined to the ovary) is the most common presentation and
surgery is mostly curative.
⚫ As with other tumors of mesenchymal origin, lymphadenectomy has not been
considered to play a role in the management of these patients.
⚫ Adjuvant therapies, traditionally chemotherapy, are given in cases of high stage
disease (Stage Ic or higher)
⚫ Since overproduction of estradiol from the tumor is a feature of granulosa cell
tumors, accompanying uterine pathology is common.
⚫ The process of addressing atypical hyperplasia or endometrial carcinomas
subsequently would lead to computerized tomography, hysterectomy, and
resection of a unilateral adnexal tumor.
Chemotherapy
Endocrine therapies
⚫ Endocrine therapies were initially introduced with the rationale of interrupting
hormone receptor signaling to achieve antitumor effect in a mechanism that is
analogous to what is done in the treatment of hormone receptor positive breast
cancer.
⚫ Initial regimens included tamoxifen, and later progestins, in order to modulate
estrogen receptor function.
⚫ Later, regimens added gonadotropin-releasing hormone agonists to suppress
ovarian function.
Radiation therapy
168. Virilizing tumours: pathology, clinical features, diagnosis, treatment.
Ans: Sertoli-Leydig cell and
Hilus cell :
⚫ Sertoli leydig cell tumor (arrhenoblasteras or androblastomas)
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androgen secreting tumor
⚫ Less frequent
⚫ It generally occurs in women under 30 years of age.
⚫ These tumors are comprised of Sertoli cells which are normally found in testes
and Leydig cells which secrete testosterone.
The clinical manifestations:
⚫ include the onset of amenorrhea, loss of breast tissue, virilizing effects, such as
hirsutism, deepening of the voice, clitoromegaly, and a defeminizing
⚫ change in body habitus to a muscular build.
⚫ diagnosis is by the exclusion of virilizing adrenal tumors and the identification
of a tumor in one ovary.
Treatment is by the excision of the affected ovary.
169. Complications of ovarian tumours.
Ans: Complications of ovarian cancer may include bowel obstruction, perforated
colon, urinary problems, fluid in the membranes of the lungs, and bone pain.
•
Infection You have a higher risk of developing an infection after surgery.
Symptoms may include fever, chills, sweats, cough, shivering, or swelling or
redness around the incision.
Vaginal Bleeding After your procedure, you might experience some vaginal
bleeding, similar to a light period, typically for a few days to a few weeks.
•
Blood Clots You may be at risk for developing a blood clot in your pelvis or
legs. To help prevent this, your medical team will encourage you to get up and walk
around as soon as possible after your operation. You may also be given injections
to thin your blood or be asked to wear special stockings.
•
Bleeding in the Abdomen or Pelvis You’ll likely lose some blood during
surgery, and there’s a small chance you could bleed internally afterward.
•
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Leg Swelling If your surgeon removes your lymph nodes, you may experience
fluid buildup in your legs or, rarely, in your genital area. Tell your doctor if this
occurs.
•
Bladder or Bowel Issues When surgeons operate on the pelvis or abdominal
area, there’s a risk of damaging the bladder or bowel.
•
Colostomy Bag or Catheter During ovarian cancer debulking surgery (a
technique to remove as much of the tumor as possible), your surgeon may remove
part of the colon or bladder. Afterward, you may need to wear a colostomy bag to
collect stool or a catheter to remove urine. These fixes are usually temporary.
•
Infertility If you have surgery to remove both your ovaries, you won’t be able
to get pregnant. Your doctor can tell you about possible ways to preserve
your fertility or other options.
•
Early Menopause Having your ovaries removed during surgery results
in menopause if you haven’t already gone through it.
•
170. Diagnosis of ovarian tumours.
Ans:
•Pelvic exam. During a pelvic exam, your doctor inserts gloved fingers into your
vagina and simultaneously presses a hand on your abdomen in order to feel
(palpate) your pelvic organs. The doctor also visually examines your external
genitalia, vagina and cervix.
* Imaging tests. Tests, such as ultrasound or CT scans of abdomen and pelvis, may
help determine the size, shape and structure of ovaries.
* Blood tests. Blood tests might include organ function tests that can help
determine overall health. blood test for tumor markers that indicate ovarian
cancer. For example, a cancer antigen (CA) 125 test can detect a protein that's
often found on the surface of ovarian cancer cells. These tests can't tell whether
you have cancer, but they may provide clues about diagnosis and prognosis.
* Surgery. Sometimes doctor can't be certain of your diagnosis until you undergo
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surgery to remove an ovary and have it tested for signs of cancer.
* Genetic testing. testing a sample of your blood to look for gene changes that
increase the risk of ovarian cancer. Knowing you have an inherited change in your
DNA helps your doctor make decisions about your treatment plan. You may wish
to share the information with your blood relatives, such as your siblings and your
children, since they also may have a risk of having those same gene changes.
171. Treatment of ovarian tumours.
Ans:
SURGERY
⚫ The type of operation you have depends on your cancer and if it's spread.
Ovarian cancer is more treatable if it’s diagnosed early.
⚫ If your cancer is in the early stages (has not spread outside of your ovaries), you
may have surgery to remove:
* both ovaries and the fallopian tubes (bilateral salpingo-oophorectomy)
* the opening to your womb from your vagina (cervix) and your womb (abdominal
hysterectomy)
⚫ If the cancer has spread to other parts of your body, you may need more
surgery to remove as much of it as possible.
⚫ This surgery may include removing parts of the bowel.
Chemotherapy
⚫ Chemotherapy is medicine that kills cancer cells.
⚫ It may be given before and after surgery, or it may be used on its own.
⚫ It may also be used for ovarian cancer that has come back.
Radiotherapy
Radiotherapy uses high-energy rays of radiation to kill cancer cells.
You may have radiotherapy for ovarian cancer to:
* treat advanced cancer if other treatments are not right for you
* help with symptoms, such as bleeding, pain or discomfort
Targeted therapies
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⚫ Targeted therapies are medicines that only target things that help cancer cells
to grow or survive.
⚫ They may be an option for advanced ovarian cancer that has come back.
Hormone therapy
⚫ Some ovarian cancers need the hormone oestrogen to grow.
⚫ Hormone treatments can block the production of oestrogen to stop some
cancers from growing.
⚫ These medicines are rarely used.
172. Ovarian cancer: pathology, spread, staging, clinical features, stagin, staging
investigations, management, results. Metastatic carcinomas.
Ans:
Pathology
Histology of ovarian tumours presents wide variations and
poses the greatest clinical challenge. These may be grouped
as follows:
⚫ Epithelial ovarian cancers account for 80–90% of ovarian cancers.
⚫ Nonepithelial cancers account for 10–20%.
These include malignancies of: (i) germ cell origin, (ii)
sex cord stromal cell origin, (iii) metastatic cancers and
(iv) rare malignancies like lipoid cell tumours, sarcomas
Metastatic Carcinomas
⚫ Ovarian metastases are commonly from the primary growth in the
gastrointestinal tract, notably the pylorus, colon and, rarely, the small bowel;
they occasionally occur from the gall bladder and pancreas.
⚫ They may also occur in late carcinoma of the breast, as seen in 30% of all
autopsy material from breast cancer.
⚫ Carcinomas of the corpus (10%) and cervix (1%) also metastasize to the ovary
owing to the close relationship of their lymphatic drainage.
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⚫ Carcinoma of the corpus is 10 times more likely to metastasize to the ovary than
the cervix. P
⚫ The reason for this is that the ovarian lymphatics drain the corpus directly
whereas the cervical metastases tend to bypass the ovarian lymphatics and
travel by way of the hypogastric and aortic glands.
Clinical Features
⚫ The clinical features are not specific in early stages, resulting in late diagnosis
in 70% cases. A woman with a malignant ovarian tumour is either an adolescent
or of menopausal or postmenopausal age of low parity.
⚫ A family history of breast or ovarian tumour may be relevant.
⚫ Initially, the woman is asymptomatic. The tumour however grows rapidly and
develops symptoms.
⚫ Abdominal discomfort and pain, abnormal or postmenopausal bleeding and an
abdominal lump are the characteristic features.
⚫ Weight loss, cachexia and anaemia are the symptoms and signs of advanced
stage of cancer.
⚫ The malignant ovarian tumours are often bilateral, solid and present with
ascites.
⚫ The only benign tumours that cause ascites (Meigs’ syndrome) are ovarian
fibroma, Brenner tumour and rarely granulosa cell tumour.
⚫ The tumours are often fixed in the late stage and intraperitoneal metastasis
may be palpable abdominally.
⚫ The vaginal examination may reveal fixed nodules in the pouch of Douglas,
apart from adnexal masses felt separate from the uterus.
⚫ Unilateral nonpitting oedema of the leg, pleural effusion and enlarged liver are
suggestive of advanced stage of the disease.
⚫ Peritoneal tuberculosis mimics ovarian cancer with raised CA-125.
Investigations
⚫ The investigations to confirm the diagnosis and nature of the tumour are
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described in the chapter dealing with benign ovarian tumours. Further, to
confirm or refute malignancy:
✓ CT and MRI indicate the extent of the tumour spread.
✓ Tissue markers mentioned earlier suggest the histological nature of the tumour,
as well as decide the duration of postoperative chemotherapy or need for
radiotherapy.
✓ CA-125 is raised in epithelial tumours.
✓ Barium meal, barium enema and breast examination are required when
metastatic tumour is suspected. X-ray of chest and liver scan are required to
detect metastatic growth.
✓ Ultrasound shows a solid tumour with echogenic or cystic areas, a thick capsule
with papillary projectors and a thick septum measuring more than 5 mm in a
malignant tumour.
➢ The tissue markers are useful during chemotherapy to decide the response and
the duration of therapy in postoperative follow-up.
➢ Fine-needle aspiration cytology (FNAC) and ascetic fluid cytology yield a high
false-negative report.
➢ CT and MRI diagnose dermoid, endometriosis and extent of spread of ovarian
malignancy as well as assess lymph node involvement.
➢ Since these only pick up lymph nodes enlarged more than 1 cm, some employ
lymphography if CT and MRI give negative lymph node involvement, because
lymphography can pick up nodes as small as 5 mm.
➢ Since debulking surgery is undertaken even in advanced stages, diagnostic
laparoscopy has lost its importance.
Management
✓ Laparotomy and maximal reduction is the primary and gold standard treatment
in all ovarian malignant tumours.
✓ Surgical staging is followed by definitive surgery or debulking followed by
chemotherapy or radiotherapy.
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✓ Surgical staging involves systemic exploration of the undersurface of the
diaphragm, liver, stomach, bowel and omentum.
✓ The para-aortic lymph nodes should be palpated. 3Ascitic fluid or peritoneal
wash should be collected in heparinized bottles for cytology.
✓ The ovaries and uterus should be studied and definitive surgery planned.
✓ Debulking. Optimal debulking surgery is now considered the standard
treatment for all stages of ovarian cancer.
✓ The reasons for this recommendation are as follows:
➢ Despite well-developed chemotherapy available, recurrence is common.
➢ Debulking reduces the amount of chemotherapeutic drugs, reduces resistance
to the drugs and improves the blood flow to the residual tumour, thus allowing
the chemotherapeutic drugs to reach the tumour tissue.
➢ The incidence of recurrence is therefore less and disease-free interval
prolonged.
➢ Reduces ascites and symptoms.
➢ Borderline malignancy. Total abdominal hysterectomy and bilateral salpingooophorectomy (TAH and BSO) should be done in older women, and
conservative ovariotomy in young women, provided peritoneal wash is
negative.
➢ Frozen section may give false-negative report due to freezing.
➢ Instead, lately, imprint cytology of the specimen gives 90% sensitivity and 80%
specificity, takes 20 min, is simple and less expensive.
➢ No postoperative chemotherapy is required, but follow-up is mandatory in
young women.
➢ In a young woman, conservation of uterus allows IVF and donor egg use.
Stages I and II. The operable cases (Stages I and II) : should undergo total
hysterectomy and bilateral salpingooophorectomy with omentectomy.
✓ Advanced and inoperable case (Stages III and IV) will benefit from debulking
surgery and removal of the tumour.
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✓ Postoperative chemotherapy and radiotherapy improve the survival and quality
of life.
✓ The purpose of maximal debulking surgery is to reduce the amount of
malignant tissue to be subjected to chemotherapy and relieve the woman of
her symptoms.
✓ The response to chemotherapy improves with smaller residual tissue and thus
remission period and survival is enhanced.
✓ Pre-operative cisplatin followed by surgery is lately employed.
Lymphadenectomy. Lately some oncologists believe additional lymphadenectomy
improves the survival.
✓ The lymph nodes mainly involved are para-aortic lymph nodes.
✓ Postoperative chemotherapy and radiotherapy depend upon the staging and
the type of tumour.
✓ The duration of chemotherapy is judged by the level of tissue markers.
Interval Surgery
✓ Some advanced and bulky tumours are initially treated by chemotherapy for
three cycles.
✓ This is followed by debulking surgery and postoperative chemotherapy as
dictated by tissue marker.
✓ Laparoscopic surgery is lately undertaken by expert laparoscopists.
The disadvantages of laparoscopy are as follows:
➢ Possibility of spillage during surgery with recurrence.
➢ Port-site metastasis in 1–1.5% cases. Use of endospecimen bag, lavage and use
of intraperitoneal chemotherapy may reduce the risk.
Second-Look Surgery
The following is the role of second-look surgery:
➢ To detect the presence of any residual tumour following a planned course of
chemotherapy and decide if further chemotherapy is required.
➢ With the availability of tissue markers for vast majority of ovarian tumours in
the follow-up, the importance of second-look surgery is losing ground and
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surgical morbidity is also eliminated.
➢ Besides, microscopic residual tumours may not be detected (false-negative
findings) at laparoscopy
✓ Following a 3–6 month course of chemotherapy in an inoperable case, secondlook surgery may enable TAH and BSO or debulking procedure.
✓ In a recurrent tumour.
✓ Instead of laparotomy, second-look laparoscopy is another alternative.
✓ Combination of surgery, radiotherapy and chemotherapy has improved the
salvage rate and quality of life considerably.
✓ The terminal stages require analgesics and sedation.
◆ Recurrent tumour. If the tumour recurs following treatment, the following
options are applicable depending upon the type of tumour, size and its
histology.
✓ Second-look surgery and removal of the lesion—for a single-site recurrence.
✓ Chemotherapy—for visceral metastasis.
✓ Radiotherapy—preferably for nodal metastasis.
✓ Intraperitoneal chemotherapeutic drug may be instilled in a small residual
tumour, at the end of surgery.
✓ The trial with chemotherapeutic drugs intraperitoneally is on.
✓ Stem cell therapy may have a role in future.
✓ Dysgerminoma and granulosa cell tumour respond well to both chemotherapy
and radiotherapy.
✓ In a young woman, fertility-retaining surgery of unilateral ovariotomy (if
unilateral) is followed by chemotherapy rather than radiotherapy which
destroys the other ovary.
✓ In the older woman, hysterectomy and bilateral removal of ovaries may be
followed by radiotherapy.
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result:
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173. Erosion of cervix uteri (congenital erosion, erosion associated with chronic
cervicitis. hormonal erosion): definition, pathology, symptoms and sings,
differential diagnosis, treatment
Ans: Definition
⚫ Cervical ectopy is a condition where the squamous epithelium of the ectocervix
is replaced by columnar epithelium, which is continuous with the endocervix.
Etiology
⚫ Congenital
⚫ Acquired
Congenital
⚫ At birth, in about one-third of cases, the columnar
epithelium of the endocervix extends beyond the external
os.
⚫ This condition persists only for a few days until the
level of estrogen derived from the mother falls.
⚫ Thus, the congenital ectopy heals spontaneously.
Acquired
Hormonal:
⚫ The squamocolumnar junction (SCJ) is not
static and its movement, either inwards or outwards is
dependent on estrogen.
⚫ When the estrogen level is high, it moves out so that the columnar epithelium
extends onto the vaginal portion of the cervix replacing the squamous
epithelium.
⚫ This state is observed during pregnancy and amongst ‘pill users’. The
squamocolumnar junction returns back to its normal position after 3 months
following delivery and little earlier following withdrawal of ‘pill’.
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Infection:
⚫ The role of infection as the primary cause of
ectopy has been discarded.
⚫ However, chronic cervicitis may be associated or else the infection may
supervene on an ectopy because of the delicate columnar epithelium which is
more vulnerable to trauma and infection.
Pathogenesis
⚫ In the active phase of ectopy, the squamocolumnar
junction moves out from the os.
⚫ The columnar epithelium of the endocervix maintains its continuity while
covering the ectocervix replacing the squamous epithelium.
⚫ The replaced epithelium is usually arranged in a single layer
(flat type) or may be so hyperplastic as to fold inwards to
accommodate in the increased area—a follicular ectopy.
⚫ At times, it becomes heaped up to fold inwards and
outwards—a papillary ectopy.
⚫ Underneath the epithelium, there are evidences of round cell infiltration and
glandular proliferation.
⚫ The features of infection are probably secondary rather than primary.
⚫ The columnar epithelium is less resistant to infection than the squamous
epithelium.
⚫ During the process of healing, the squamocolumnar junction gradually moves
up towards the external os.
⚫ The squamous epithelium grows beneath the columnar epithelium until it
reaches at or near to its original position at the external os.
⚫ Alternatively, the replacement is probably by squamous metaplasia of the
columnar cells.
⚫ The possibility of squamous metaplasia of the reserve cells is also likely During
the process, the squamous epithelium may obstruct the mouth of the
underlying glands (normally not present in ectocervix) → pent up secretion →
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retention cyst → nabothian follicle.
⚫ Alternatively, the epithelium may burrow inside the gland lumina.
⚫ This process of replacement by the squamous epithelium is called
epidermidization.
Clinical Features
Symptoms: The lesion may be asymptomatic. However,
the following symptoms may be present.
⚫ ™Vaginal discharge—The discharge may be excessively
mucoid. It may be mucopurulent, offensive and irritant in presence of infection;
may be even blood-stained due to premenstrual congestion.
⚫ Contact bleeding specially during pregnancy and
‘pill use’ either following coitus or defecation may be
associated.
⚫ ™Associated cervicitis may produce backache, pelvic
pain and at times, infertility.
Signs: Internal examination reveals:
„ Per speculum—There is a bright red area surrounding
and extending beyond the external os in the ectocervix.
⚫ The outer edge is clearly demarcated.
⚫ The lesion may be smooth or having small papillary folds.
⚫ It is neither tender nor bleeds to touch.
⚫ On rubbing with a gauze piece, there may be multiple oozing spots (sharp
bleeding in isolated spots in carcinoma).
⚫ The feel is soft and granular giving rise to a grating sensation.
Differential Diagnosis
The diagnosis is confused with:
Ectropion: The lips of the cervix are curled back to expose
the endocervix. This may be apparent when the lips of the
cervix are stretched by the bivalve speculum.
Early carcinoma: It is indurated, friable and usually
ulcerated which bleeds to touch. Confirmation is by
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biopsy.
Primary lesion (chancre): The ulcer has a punched-out
appearance.
Tubercular ulcer: There is indurated ulcer with caseation
at the base. Biopsy confirms the diagnosis.
Management
Guidelines: All cases should be subjected to cytological
examination from the cervical smear to exclude dysplasia
or malignancy
Symptomatic cases
⚫ Detected during pregnancy and early puerperium,
the treatment should be withheld for at least 12 weeks
postpartum. In pill users, the ‘pill’ should be stopped
and barrier method is advised.
⚫ Persistent ectopy with troublesome discharge should
be treated surgically by—
(i)
thermal cauterization,
(ii)
cryosurgery, and
(iii)
laser vaporization
⚫ All the methods employed are based on the principle of
destruction of the columnar epithelium to be followed by
its healing by the squamous epithelium.
174. Ectropion of the cervix: definition, pathology, symptoms and sings,
treatment.
Ans: EVERSION (ECTROPION) :
⚫ In chronic cervicitis, there is marked thickening of the cervical mucosa with
underlying tissue edema.
⚫ These thickened tissues tend to push out through the external
os along the direction of least resistance.
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⚫ The entity is most marked where the cervix has already been lacerated.
⚫ In such conditions, the longitudinal muscle fibers are
free to act unopposed.
⚫ Due to this, the lips of the cervix curl upwards and outwards to expose the red
looking endocervix so as to be confused with ectopy .
⚫ As a result the SCJ lies extermal to the cervical os.
175. Cervical polypi: pathology, symptoms and sings. differential diagnosis,
treatment.
Ans: MUCOUS POLYP
⚫ The most common type of benign uterine polyp is
mucous one.
⚫ It may arise from the body of the uterus or
from the cervix
Risk factors: Hormone replacement therapy, tamoxifen
therapy, diabetes, hypertension, obesity, and increased
patient age are the important risk factors.
Pathogenesis
Body
A part of the thick endometrium projects into the cavity
and ultimately attains a pedicle.
Naked eye appearance: It shows a small polyp size of
about 1–2 cm, looks reddish and feels soft. The pedicle
may at times be long enough to make the polyp protruded
from the cervix.
Benign:
Mucous
Fibroid
Placental
Malignant:
De novo
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Secondary changes of benign polyp
Symptoms
The patients are usually in reproductive period.
The chief complaints are:
⚫ Intermenstrual bleeding, often continuous, specially
in fibroid polyp arising from the body Colicky pain in the lower abdomen due to
uterine contraction in an effort to expel the polyp out of the
uterine cavity.
⚫ Excessive vaginal discharge which may be offensive
⚫ Sensation of something coming down when the polyp
becomes big distending the vagina
⚫ It may remain asymptomatic also.
Signs
General examination reveals varying degrees of anemia.
Per vaginam
⚫ The uterus may be bulky.
⚫ The cervix may be patulous and the tip of the polyp
is felt or else, the polyp is felt distinctly outside the
external os.
Speculum examination: It reveals the size and color
of the polyp which is usually pale; may be hemorrhagic.
⚫ Whereas, the attachment of the pedicle to the cervix can
be visualized but attachment higher up may be at times
difficult to locate.
Investigations
⚫ Transvaginal sonography (TVS), the polyp is seen as
an echogenic mass.
⚫ Saline infusion sonography (gold standard), the polyp
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is seen as a echogenic mass much better compared to
TVS?
⚫ Hysteroscopy—to visualize the uterine polyp and
simultaneously polypectomy could be done.
⚫ Hysterography—to detect the filling defect in a fibroid
polyp.
⚫ Examination under anesthesia and exploration of
the uterine cavity by curette or ovum or ring forceps
can help in diagnosis of an uterine polyp.
⚫ In all cases, following polypectomy histological examination
should be done.
⚫ Sound test—to differentiate a fibroid polyp from
chronic inversion, sound test is done.
⚫ If an uterine sound is passed all round between the pedicle and the
dilating cervical canal, it is a polyp.
⚫ In complete chronic inversion, the sound cannot be passed.
PLACENTAL POLYP
⚫ A retained bit of placental tissue when adherent to the
uterine wall gets organized with the surrounding blood
clots.
Clinical Features
⚫ There is history of recent childbirth or abortion. Irregular
bleeding per vaginam and offensive vaginal discharge are present dated back to
the pregnancy events.
MANAGEMENT OF A POLYP
⚫ Endometrial polyp may be removed by doing hysteroscopy and resection.
⚫ It can also be removed by uterine curettage or using ring or ovum forceps. In
cases of recurrence and patients who have completed the family, hysterectomy
is justified.
⚫ The causes of recurrence of polyps are:
(1)
Incomplete removal;
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(2) Persistence of the
cause leading to polyp formation;
(3) Malignancy.
⚫ Cervical polyps are removed by twisting of the pedicle.
⚫ The base of the pedicle should be cauterized to prevent recurrence.
⚫ Hysteroscopy is useful to locate the postion, size, and the base of the polyp.
⚫ Submucous fibroid polyps can be resected out hysteroscopically as an
outpatient basis
⚫ Endometrial polyps that cause infertility, postmenopausal bleeding or
abnormal uterine bleeding should be removed hysteroscopically under direct
vision.
⚫ It is superior to blind avulsion.
⚫ After the polyp is removed, endometrium is curetted to rule out
coexisting pathology (5%).
Histology
⚫ Histologically the polyp may be adenomatous (80%),
cystic, fibrous, vascular and fibromyomatous.
⚫ There may be ulceration of the dependent portion of the polyp.
Malignant change of an endometrial polyp is extremely
rare (0.5%).
⚫ Big Fibroid Polyp Lying in the Vagina One should be sure that it is a polyp and
not uterine inversion or fibroid with inversion.
Diagnosed polyp: Removal of polyp by morcellement (piecemeal) followed by
trans fixation suture on the pedicle and removal of the redundant pedicle
distal to the ligature.
Associated with chronic uterine inversion—The incision is made close to the
fibroid and to enucleate it.
⚫ When hysterectomy is indicated, the polyps of such type
are expected to be infected and are to be removed first.
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⚫ Antibiotics are to be administered.
⚫ The general condition of the patient is to be improved and hysterectomy should
be done at a later date.
⚫ The polyps should be sent for histological examination after its removal.
176. Dysplasia and cervical intraepithelial neoplasia (CIN): pathological anatomy,
clinical features, diagnosis, treatment. Screening for cancer (Pap test).
Ans:
pathology: The process of carcinogenesis starts at the ‘transformation zone’ (TZ).
The zone is not static but in a dynamic
state. Two mechanisms are involved in the process of replacement of
endocervical columnar epithelium by squamous epithelium.
⚫ By squamous metaplasia of the subcolumnar reserve cells
⚫ Squamous epidermidization by ingrowth of the squamous epithelium of the
ectocervix under the columnar epithelium.
diagnosis:
⚫ Cytologic screening (Scheme-3): Exfoliative cytology (Papanicolaou and Traut,
1943) has become the gold standard for screening. The smear should contain
cells from SCJ, TZ, and the endocervix. Ayre’s spatula and an endocervical brush
is used for the purpose. Cells are spread on a single slide and fixed immediately.
⚫ High risk HPV-DNA (HR HPV-DNA) testing is useful in cervical screening
⚫ Visual inspection with acetic acid (VIA)
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⚫ Colposcopy
⚫ Cervicography
⚫ Biopsy with or without colposcopy
treatment: TREATMENT OF CIN
Preventive Definitive
⚫ Preventive: HPV vaccines, Prevention of HPV Infection.
⚫ Definitive Treatment
⚫ The treatment modalities depend on: Age of the patient, Desire for
reproduction, Risk factors present, Degree of dysplasia Facilities available for
follow up such as colposcopy and/or cytology.
⚫ Local ablative methods
Cryotherapy Cold coagulation
Electrodiathermy Laser vaporization
⚫ Excisional methods
Large loop (electrosurgical) excision of transformation zone (LLETZ).
Cone excision—using a knife or laser.
Hysterectomy—abdominal or vaginal.
screening for cancer:
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177. Carcioma of the cervix: actiology, epidemiology, predisposing risk factors,
pathology, staging, clinical features, diagnosis and differential diagnosis,
treatment
ans:
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Epidemiology: In India, the
prevalence is more amongst the comparatively younger age group. Carcinoma
cervix is rare in women who are sexually not active (nuns, virginal women). Male
circumcision is only partially protective against cervical carcinogenesis.
Pathology: The site of the lesion is predominantly in the ectocervix (80%) and the
rest (20%) are in the endocervix.
Naked Eye
Exophytic: These arise from the ectocervix and form
friable masses almost filling up the upper vagina in late
cases.
Ulcerative: The lesion excavates the cervix and often
involves the vaginal fornices.
Infiltrative: These are found in endocervical growth.
They cause expansion of the cervix, so that it becomes
barrel-shaped.
Histopathology
The most common variety is squamous cell carcinoma (75–80%) either welldifferentiated or moderately or poorly differentiated. These arise from the
ectocervix. The sources of the squamous epithelium which turn into malignancy
are—squamocolumnar junction, squamous metaplasia of the columnar
epithelium.
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:
diff diag: DIFFERENTIAL DIAGNOSIS
The growth needs to be differentiated from:
Cervical tuberculosis
Syphilitic ulcer
Cervical ectopy
Products of conception in incomplete abortion
Fibroid polyp
treatment: The types of treatment employed for the invasive
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carcinoma are as follows:
Primary surgery
Primary radiotherapy
Chemotherapy
Combination therapy.
178. Cancer cervix and pregnancy.
Ans:
CARCINOMA OF CERVIX AND PREGNANCY: Incidence of invasive carcinoma of the
cervix is about one in 2500 pregnancies.
Diagnosis is often late. Cone biopsy may be necessary
for confirmation. Complications of cone biopsy include:
Hemorrhage, abortion, preterm labor, and infection.
⚫ LEEP has no superiority over cone biopsy.
Management
⚫ The following points are taken into consideration before actual management:
(A) Period of gestation, (B) survival of the fetus and (C) wishes of the patient,
and (D) histology.A. Patient with microinvasive carcinoma may be followed up
to term. Patient is revaluated following delivery and treated as in the
nonpregnant state. B. Advanced stage: In the first trimester, treatment :
modality is the same as in the nonpregnant state (chemoradiation). In late
pregnancy, following maturity, fetus is delivered by classical cesarean section.
Subsequent treatment with either radical surgery or radiotherapy or
chemoradiation is the same as in the nonpregnant state.
Prognosis
Clinical stage of the disease is the single most important prognostic factor. Stage
for stage survival outcome appears to be no different between pregnancy and
nonpregnant state.
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179. Endometrial carcinoma: predisposing factors, pathology, staging, clinical
features, differential diagnosis, treatment and results.
ans:
predisposing factors:estrogen: persistent stimulation of endometrium, age,
parity, late menopause, corpus cancer syndrome, obesity, unopposed estrogen
stimultion, unopposed estrogen replacement therapy, polycystic ovarian disease,
tamoxifen, family history, fibroid, endometrial hyperplasia.
Pathology:
naked eye: a) localised b) diffuse
Microscopic appearances: The following varieties are noted:
Adenocarcinoma (endometrioid 80%) (Fig. 24.11)
Adenocarcinoma with squamous elements
Papillary serous carcinoma (5–10%) (virulent)
Mucinous adenocarcinoma (1–2%)
Clear cell adenocarcinoma (< 5%)
Secretory carcinoma (1%)
Squamous cell carcinoma
Mixed carcinoma
Undifferentiated carcinoma (1–2%).
Endometrial carcinoma are of two types based upon
biological and histological behavior
clinical features: Symptoms:
Postmenopausal bleeding (75%) which may be slight, irregular or continuous. The
bleeding at times may be excessive.
In premenopausal women, there may be irregular and excessive bleeding.
At times, there is watery and offensive discharge due to pyometra.
Pain is not uncommon. It may be colicky due to uterine contractions in an attempt
to expel the polypoidal growth.
Few patients (< 5%) remain asymptomatic.
In late cases there may be pelvic pressure, pain or
⚫ abnormal bleeding.
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180. Strategies to reduce the incidence of genital tract malignancies
ans:
There have been advances in strategies evolved to reduce the incidence of genital
cancers. The following are notable amongst these:
1. The role and value of periodic ‘Pap smear’ tests is well-established in reducing
the incidence of invasive carcinoma of the cervix.
2. Evaluation of abnormal Pap tests with colposcopy directed biopsies enables the
diagnosis of intraepithelial cancers and diagnosis of early invasive cancer of the
cervix. (secondary prevention)
3. The practice of preferring total over subtotal hysterectomy for benign diseases
(fibroids, adenomyosis, abnormal uterine bleeding—AUB) protects against risk of
future cervical stump carcinoma estimated to occur in 1–2% of cases.
4. Early diagnosis of sexually transmitted diseases (STDs) and their eradication.
Herpes and HPV infections render an individual prone to cancer of vulva and the
cervix. Barrier contraceptives protect against STD as well as cervical cancer.
(primary prevention)
5. HPV vaccine is now available which may eradicate lower genital tract
malignancies in young women. The available vaccine is type specific and
therefore, protective in only 60–70%.
6. The treatment of cervical dysplasia by CO2 laser/conization for CIN lesions will
reduce the incidence of cancer cervix.
7. Addition of progestogens to oestrogens in hormone replacement therapy (HRT)
reduces the risks of uterine endometrial cancer.
8. Thorough investigation of a woman with postmenopausal bleeding often brings
to light early
unsuspected endometrial/ovarian/tubal cancers.
9. The practice of routine removal of both ovaries when performing hysterectomy
for benign conditions after the age of 50 years is a prophylaxis against risk of
future ovarian cancer. Prophylactic oophorectomy in a genetically predisposed
woman is recommended, though premature menopause remains the risk. This
also reduces breast cancer by 50%.
10. Early diagnosis of ovarian cancer is the primary objective for long-term
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survival, though this is not obtained as of today. Seventy-five per cent tumours
are advanced when diagnosed.
11. Oral combined pills reduce the incidence of uterine and ovarian cancer by 40–
50%. The effects last for
10 years after stoppage of oral pills. Barrier contraceptives prevent cervical
cancer.
12. Gene study can select women at high risk for cancer.
13. Evaluation of adnexal masses with scans, Doppler velocimetric studies and CA125 tumour marker to diagnose ovarian cancer.
14. Hysteroscopy/laparoscopy/selective biopsies of suspicious lesions.
15. Routine mammography for all women over the age of 40 years, earlier
whenever clinical examination reveals a doubtful lump, or in women with strong
family history of breast cancer.
181. Menopause and climacteric: detinition, demography, age. Pathophysiology
and hormone levels of climacteric. Anatomical changes of menopause.
ans: Menopause is defined as the time of cessation of ovarian function resulting
in permanent amenorrhoea. It takes 12 months of amenorrhoea to confirm that
menopause has set in, and therefore it is a retrospective diagnosis.Climacteric is
the phase of waning ovarian activity, and
may begin 2–3 years before menopause and continue for 2–5 years after it. The
climacteric is thus a phase of adjustment between the active and inactive ovarian
function and occupies several years of a woman’s life, and it involves physical,
sexual and psychological adjustments.
Demography
⚫ Sixty million women in India are above the age of 55 years. With women living
longer than before, a majority would spend one-third of their life in the
postmenopausal stage.
⚫ The health problems cropping up during this period and related to oestrogen
deficiency of menopause are now obvious and better understood. It is
important therefore to address all these menopause-related diseases and apply
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prophylactic measures so that these women can lead an enjoyable and healthy
life. An average Indian woman now lives up to 65 years of age, whereas in
developed countries a lifespan up to 80 years is possible.
Age
Menopause sets in when the follicular number falls below 1000. Menopause
normally occurs between the ages of 45 and 50 years, the average age being 47
years. It is not uncommon, however, to see a woman menstruate well beyond the
age of 50. This delayed menopause may be related to good nutrition and better
health. Late menopause is also common in women suffering from uterine fibroids
and those at high risk of endometrial cancer. Menopause setting before the age
of 40 is known as premature menopause.Menopausal age is not related to
menarche, race, socioeconomic status, number of pregnancies and lactation, or
taking of oral contraceptives. It is however directly associated with smoking and
genetic disposition. Smoking induces premature menopause.
Pathophysiology During climacteric, ovarian activity declines. Initially, ovulation
fails, no corpus luteum forms and no progesterone is secreted by the ovary.
Therefore, the premenopausal menstrual cycles are often anovulatory and
irregular. Later, Graafian follicles also fail to develop, oestrogenic activity is
reduced and endometrial atrophy leads to amenorrhoea. Cessation of ovarian
activity and a fall in the oestrogen and inhibin levels cause a rebound increase in
the secretion of FSH and LH by the anterior pituitary gland. The FSH level may rise
as much as 50-fold and LH 3–4 fold. Menopausal urine has become an important
commercial source of human menopausal gonadotropin (hMG). With further
advancing years, gonadotropin activity of the pituitary
gland also ceases, and a fall in FSH level eventually occurs.
Hormone Levels
There is 50% reduction in androgen production and 66% reduction in oestrogen at
menopause. The oestrogen level may remain low at 10–20 pg/mL. Some
oestrogen comes from the ovary, but most of it is oestrone (E1) derived from
peripheral conversion of androstenedione secreted by the ovary, and its level
varies between 30 and 70 pg/mL. The ovary also secretes a small amount of
testosterone which causes mild hirsutism at menopause. The FSH appears in high
concentration in the urine (more than 40 IU/l). E2/E1 ratio maintained over 1 in
the premenopausal period is reduced to less than 1 in the menopausal age,
causing an oestrogen deficiency state. Oestrogen level of over 40 pg/mL exerts
bone and cardiotrophic effect, but the level below 20 pg/mL may predispose to
osteoporosis and ischaemic heart disease. Low level of growth hormone causes
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ovarian failure.
Risk factors for menopause-related diseases are as follows:
◆ Early menopause.
◆ Surgical menopause or radiation.
◆ Chemotherapy especially alkalytic agents.
◆ Smoking, caffeine, alcohol.
◆ Family history of menopausal diseases (genetic).
◆ Drugs related such as GnRH, heparin, corticosteroids and clomiphene
(antioestrogen) when given over a prolonged period (over 6 months) can lead
to oestrogen deficiency.
◆ Diabetes
Anatomical Changes
⚫ The genital organs undergo atrophy and retrogression.
⚫ The ovaries shrink and their surfaces become grooved and furrowed.
⚫ The tunica albuginea thickens.
⚫ The menopausal ovary measures less than 2 3 1.5 3 1 cm in size (8 mL in volume)
as seen on ultrasound.
⚫ Fifteen years later, it should not measure more than 2 mL.
⚫ The plain muscle in the fallopian tube undergoes atrophy, cilia disappear from
the tubal epithelium and the tubal plicae are no longer prominent.
⚫ The uterus becomes smaller through atrophy of its plain muscle, so that the
connective tissues are more conspicuous.
⚫ The endometrium is represented by only the basal layer with its compact
deeply stained stroma, and a few simple tubular glands.
⚫ The lymphoid tissue and the functional layer disappear.
⚫ It is common for the endometrial glands to dilate before menopause sets in,
and cystic glandular hyperplasia reported in some premenopausal women
causes metropathia haemorrhagica, with irregular heavy bleeding.
⚫ The pre-existing fibromyoma gradually shrinks.
⚫ The cervix becomes smaller and its vaginal portion is represented by a small
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⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
⚫
prominence at the vaginal vault.
The cervical stenosis and pyometra are not uncommon.
The vaginal fornices gradually disappear as the cervix shrinks after the
menopause.
The vagina becomes narrow and its epithelium becomes pale, thin and dry and
gets easily infected causing senile vaginitis.
The vulva atrophies and the vaginal orifice narrow and this can cause
dyspareunia.
The skin of the labia minora and vestibule becomes thin, pale and dry, and there
is considerable reduction in the amount of fat contained in the labia majora.
The pubic hair is reduced and becomes grey.
The red patches seen around the urethra and introitus are caused by senile
vulvitis, and a urethral caruncle may be produced.
The pelvic cellular tissue becomes lax and the ligaments that support the
uterus and vagina lose their tone, and these conditions predispose to prolapse
of the genital organs, stress incontinence of urine and faecal incontinence.
Apart from the atrophy of the genital organs, general disturbances that develop
are almost certainly caused by alterations in the endocrine balance maintained
during the childbearing period.
Fat is deposited around the breasts, hips and abdomen.
Although the mammary glandular tissue atrophies, deposition of fat often
makes the breasts more pendulous.
Whereas, glandular tissue constitutes 30% of the breast volume, it is reduced
to only 5% after the menopause.
The skin wrinkles and hair grow around the chin and lips.
Hypertension, cardiac irregularities and tachycardia are at times noticed after
menopause.
Arthritis and osteoporosis of the vertebral bones, upper end of the hip joint and
wrist are related to oestrogen deficiency after menopause.
Tooth decay, keratoconjunctivitis and cataract are related to menopausal
oestrogen deficiency
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182. Menopausal symptoms. Investigations.
Ans: In majority, apart from cessation of menstruation,no
more symptoms are evident. In some women, symptoms
appear. The important symptoms and the health
concerns of menopause:
⚫ Vasomotor symptoms
⚫ urogenital atrophy
⚫ Osteoporosis and fracture
⚫ Cardiovascular disease
⚫ Cerebrovascular diseases
⚫ Psychological changes
⚫ Skin and hair
⚫ Sexual dysfunction
⚫ Dementia and cognitive decline.
Vasomotor symptoms:
⚫ The characteristic symptom of menopause is ‘hot flush’.
⚫ Hot flush is characterized by sudden feeling of heat followed by profuse
sweating.
⚫ There may also be the symptoms of palpitation, fatigue
and weakness.
The physiologic changes with hot flashes
are perspiration and cutaneous vasodilation.
⚫ Both these two functions are under central thermoregulatory
control.
⚫ Low estrogen level is a prerequisite for hot flash.
⚫ Hot flash coincides with GnRH pulse secretion with
⚫ increase in serum LH level.
Genital and urinary system:
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⚫ Steroid receptors have been
identified in the mucous membrane of urethra, bladder,
vagina and the pelvic floor muscles.
⚫ Estrogen plays an important role to maintain the epithelium of vagina, urinary
bladder and the urethra.
⚫ Estrogen deficiency produces atrophic epithelial changes in these organs.
⚫ This may cause dyspareunia and dysuria.
Dyspareunia: Estradiol deficiency leads to vaginal dryness or atrophy.
⚫ Estrogen replacement reverses atropic changes.
⚫ It can be given orally or vaginally.
⚫ 17 β-estradiol tablet or conjugated equine estrogen (CEE) cream is effective in
relieving symptoms. Risks of endometrial hyperplasia is less with vaginal tablets
than that of cream.
⚫ Vaginal lubricants (water soluble) and moisturisers (K-Y jelly) are commonly
used.
Vagina: Minimal trauma may cause vaginal bleeding.
⚫ Dyspareunia, vaginal infections, dryness, pruritus and leucorrhea are also
common.
⚫ The urinary symptoms are urgency, dysuria and recurrent urinary tract infection
and stress incontinence.
Sexual dysfunction: Estrogen deficiency is often associated with decreased sexual
desire.
⚫ This may be due to psychological changes (depression anxiety) as well as
atrophic changes of the genitourinary system.
⚫ Skin and hair: There is thinning, loss of elasticity and wrinkling of the skin.
⚫ Skin collagen content and thickness decrease by 1–2% per year. ‘Purse string’
wrinkling around the month and ‘crow feet’ around the eyes are the
characteristics.
⚫ Estrogen receptors are present in the skin and maximum are present in the
facial skin.
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⚫ Estrogen replacement can prevent this skin loss during menopause.
⚫ After menopause, there is some loss of pubic and axillary hair and slight balding.
⚫ This may be due to low level of estrogen with normal level of testosterone.
⚫ Psychological changes: There is increased frequency of anxiety, headache,
insomnia, irritability, dysphasia and depression.
Osteoporosis and fracture: Following meno-pause there is decline in collagenous
bone matrix resulting in osteoporotic changes.
⚫ Bone mass loss and microarchitectural deterioration of bone tissue occurs
primarily in trabecular bone (vertebra, distal radius) and in cortical bones.
⚫ Bone loss increases to 5% per year during menopause.
Detection of osteoporosis: Computed tomography (CT) and specially the dualenergy X-ray absorptiometry (DEXA) are reliable methods to assess the bone
mineral density.
Cardiovascular and cerebrovascular effects: vascular atherosclerotic changes,
vasoconstriction and thrombus formation. Risks of ischemic heart disease,
coronary artery disease and strokes are increased.
183. Management of menopause. HRT: drugs, dosage and route of
administration. Cardioprotective effect of HRT. Treatment of osteoporosis.
ans: Hormone Therapy (HT)
The HT is indicated in menopausal women to overcome the short-term and longterm consequences of estrogen deficiency.
Indications of Hormone Therapy
✓ Relief of menopausal symptom
✓ Relief of vasomotor symptoms
✓ Prevention of osteoporosis
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✓ To maintain the quality of life in menopausal years.
◆ Special group of women to whom HT should be prescribed:
✓ Premature ovarian failure
✓ Gonadal dysgenesis
✓ Surgical or radiation menopause.
HT and Osteoporosis
⚫ HT prevents bone loss and stimulate new bone formation.
⚫ HT increases BMD by 2–5% and reduces the risk of vertebral and hip fracture
(25–50%).
⚫ Estrogen is found to play a direct role, as receptors have been found in the
osteoblasts.
⚫ Women receiving HT should supplement their diet with an extra 500 mg of
calcium daily. Total daily requirement of calcium in postmenopausal women is
1.5 g.
⚫ HT is thought to be cardiovascular protective.
⚫ LDL on oxidation produces vascular endothelial injury and foam cell
(macrophage) formation.
⚫ These endothelial changes ultimately lead to intimal smooth muscle
proliferation and atherosclerosis.
⚫ Estrogen prevents oxidation of LDL, as it has got antioxidant properties.
In postmenopausal women, there is some amount of insulin resistance and
hyperinsulinemia.
⚫ Hyperinsulinemia induces atherogenesis.
⚫ Estrogen improve glucose metabolism.
⚫ Dose: interval may be modified as daily for initial 2–3 months then it may be
changed to every other day for another 2–3 months and then every third day
for the next 2–3 months.
⚫ It may be stopped thereafter if symptoms are controlled.
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⚫ Oral estrogen regime: CEE, 0.3 mg or 0.625 mg is given daily for woman who
had hysterectomy.
⚫ ‰Estrogen and cyclic progestin: For a woman with intact uterus, estrogen is
given continuously for 25 days and progestin is added for last 12–14 days.
‰Continuous estrogen and progestin therapy:
⚫ Continued combined therapy can prevent endometrial hyperplasia.
⚫ There may be irregular bleeding with this regimen.
‰Transdermal administration
⚫ Subdermal implants
⚫ Transdermal patch: It contains 3.2 mg of 17 β- estradiol, releasing about 50 µg
of estradiol in 24 hours.
⚫ Physiological level of E2 to E1 is maintained.
⚫ It should be applied below the waist line and changed twice a week.
⚫ Skin reaction, irritation and itching have been noted with their use.
⚫ Vaginal cream
⚫ Progestins
‰Tibolone: Tibolone is a steroid (19-nortestosterone derivative) having weak
estrogenic, progestogenic and androgenic properties. It prevents osteoporosis,
atrophic changes of vagina and hot flashes.
⚫ It increases libido.
⚫ Endometrium is atrophic.
⚫ A dose of 2.5 mg per day is given.
‰Testosterone: Androgen replacement in women with hypoactive sexual desire
disorder (HSDD) is found beneficial.
⚫ It improves mood, bone, muscle mass and quality of life.
⚫ Short-term use is suggested.
Parathyroid hormone (PTH): Recombinant PTH (teriparatide) is given by injection
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(SC) to prevent osteoporosis and fracture.
⚫ It increases the number of osteoblast cells and their activity and reduces
apoptosis of osteoblast cells.
⚫ PTH is safe and well-tolerated.
⚫ At low daily doses (20 µg/day, SC) teriparatide, its anabolic effects
predominate. Side effects are leg cramps, nausea and headache.
⚫ Use for more than 2 years is not recommended.
Duration of HT Use
⚫ Generally, use of HT for a short period as long as the benefits outweigh the
risks.
⚫ Individual woman need counseling with annual or semiannual review.
Reduction of dosage should be done as soon as possible.
⚫ Menopausal women should maintain optimum nutrition, ideal body weight and
perform regular exercises.
⚫ Individual woman should be informed with updated knowledge as regard the
relative merits and possible
Progress in Hormone Therapy
⚫ Low Dose HT: Women with intact uterus with 0.3 mg CEE and MPA 1.5 mg is
found effective to control the vasomotor symptoms.
⚫ Similarly 1 mg of estradiol and norethisterone acetate 0.5 mg orally, are also
effective and have significant bone sparing effect.
⚫ Progestogen is added in the HT to minimize the adverse effects of estrogen.
⚫ Hormone therapy should be used with lowest effective dose and for the short
period of time as possible.
⚫ Dose interval may be modified before stopping the therapy.
⚫ To minimize the systemic adverse effects of progestogen, LNG-IUS is being
used.
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⚫ It is primarily used as a contraceptive.
⚫ Estrogen component is delivered by oral or by transdermal route or as an
implant.
⚫ A small size LNG-IUS has been developed that releases 10 µg LNG per day.
⚫ This reduced size LNG-IUS is suitable for the postmenopausal women as the size
of the uterus is also small.
184. Oestrogen: actions, preparations, indications, contraindications, side effects.
Ans:Natural estrogens are 18-carbon atom steroids.
Estradiol is the most active natural estrogen in human uses.
• Natural • Synthetic
Natural
(a) It is available in the form of water soluble conjugated
estrogen as Premarin [conjugated equine estrogen (CEE)].
It is obtained from the urine of pregnant mares. It is available as tablets 0.3 mg,
0.625 mg, and 1.25 mg and as injection of 20 mg ampoules for IM or IV injection.
(b) Estradiol valerate used for priming the endometrium in donor oocyte
program.
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Synthetic
� Oral � Injectable � Cream/gel
�
Pessary � Implant � Patch
Oral: This is the best route for synthetic preparations.
• Ethinyl estradiol (Lynoral): 0.01 mg and 0.05 mg daily
is commonly used
• Estradiol valerate: 1–2 mg
• CEE: 0.3 or 0.625 mg
• Estriol succinate (Evalon): 1–2 mg.
Injectable: � Estradiol ester as progynon depot (Schering): 10 mg ampoule.�
Estradiol benzoate or dipropionate: 1 mg and 5 mg ampoule.
Cream: � Vaginal cream–dienestrol (0.1 mg/g), Estriol (1 mg/g). �Percutaneous
cream delivers 3 mg of estradiol in each daily 5 g applicator of cream.
Gel: 17β-estradiol gel, 1 mg to be applied once daily over the skin of the lower
trunk.
Pessary: Dienestrol or estradiol acetate pessary (inserted for 90 days).
Implants: � Subcutaneous implants of 50 mg and 100 mg of 17β-estradiol effect
lasts for 6 months.
Transdermal patch: It contains 17β-estradiol releasing about 0.05–0.1 mg of
estradiol in 24 hours. Patch should be applied below the waist line and changed
twice a week.
Therapy
• Replacement therapy • Pharmacotherapy
Replacement therapy
Ovarian hypofunction:Estrogen daily × 21 days followed by norethisterone or
medroxyprogesterone 5 mg × last 10 days.
• Cyclic or continuous therapy in the form of estradiol or
conjugated estrogens
• Postmenopausal hormone replacement therapy (HRT)
in a symptomatic women
„ To reduce vasomotor symptoms
„ To prevent osteoporosis
„ To prevent cardiovascular disease.
Pharmacotherapy
Oral contraception
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Vaginitis
Senile or atrophic vaginitis—either vaginal cream or oral
estrogens may be equally effective.
Vulvovaginitis in childhood, foreign body in the
vagina or sexual assault—low dose of oral estrogen or
vaginal cream helps in increasing the vaginal defence.
Intersex state
⚫ In Turner’s syndrome (45, XO) or gonadal dysgenesis (46, XY), estrogen therapy
is helpful for the growth and development of the secondary sexual characters.
⚫ In androgen insensitivity syndrome (46, XY), after gonadectomy supplementary
estrogen therapy is indicated to prevent regression of the breast development,
osteoporosis and cardiovascular complications.
⚫ The estrogen is used cyclically as ethinyl estradiol 0.01 mg twice daily for 25
days.
⚫ However, in prolonged use, progestogen in the form of medroxyprogesterone
acetate 10 mg daily is added from day 16–25, to minimize the adverse effects
of estrogen.
⚫ Alternatively, a combined oral ‘pill’ may be prescribed.
Dysfunctional uterine bleeding (DUB)
⚫ The estrogen in pharmacological doses causes rapid growth of endometrium.
⚫ As such, acute bleeding can be stopped by oral conjugated estrogen in a dose
of 10 mg a day.
⚫ The bleeding usually stops within 24 hours.
⚫ Alternatively, 25 mg may be given intravenously every 4 hours for 3 doses.
Delayed puberty
⚫ If the breast development fails to start even at the age of 14, 10 µg of estrogen
daily may be of help.
⚫ In cases of irregular bleeding or when the breast development is welladvanced,
progestogens may be added
Cervical mucus hostility
⚫ To improve the quality of the cervical mucus in infertility, low dose of estrogen
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(ethinyl estradiol 0.01 mg) may be given cyclically, from day 1–14.
An Adjunct with Clomiphene Therapy
In cases of hypoestrogenic state with hypomenorrhea, small dose of estrogen is of
help to improve the quality of the cervical mucus.
Genuine stress incontinence (GSI) in postmenopausal women to improve the tone
of collagen tissue.
Adverse Effects
Minor ailments are:
™Nausea, vomiting Breast tenderness Breakthrough bleeding Weight gain.
Major effects include: Increased incidence of endometrial carcinoma,
thromboembolism, cerebral thrombosis, and hemorrhage.
To minimize breakthrough bleeding and prevent endometrial carcinomas and
vascular complications, progestogens should be combined with estrogen therapy.
CONTRAINDICATIONS OF ESTROGEN THERAPY
• Undiagnosed genital bleeding
• History of venous thromboembolism
• Active liver disease
• Severe hypertension
• Organic heart disease
• Estrogen dependent neoplasia (breast)
185. Progesterone: actions, preparations, classification, therapeutic applications,
contraindications, side effects.
ans: Progesterone is the natural hormone produced by the theca cells of the
corpus luteum and the placenta.
⚫ It is metabolized in the liver and excreted in the urine as sodium pregnanediol
glucuronide.
Natural progesterone is not active orally and is given only by intramuscular
injection in an oil
base.
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⚫ Progesterone acts on target tissues only when the latter are primed with
oestrogen, as oestrogen produces progesterone receptors.
⚫ A large number of synthetic compounds which can be taken orally have been
marketed in recent years.
Preparations
Progestogens are synthetic compounds belonging to two main groups—the
oestrone or 19-norprogestins which are structurally similar to testosterone and
pregnane or 17-acetoxy compound structurally similar to progesterone.
The oestrone compounds are mainly incorporated in oral contraceptive pills, and
pregnane compounds used in pregnancy and AUB.
Classification
✓ Pure progesterone—Oral and vaginal micronized progesterone have no
adverse effect on lipid profile.
✓ Pregnane (derived from progesterone molecule), lynestrenol (allyloestrenol),
medroxyprogesterone, megestrol acetate.
✓ Estrane (derivative of testosterone)—Norethisterone, norethandriol (first
generation).
✓ Gonane—Levonorgestrel, norgestrel (second generation). They reduce the
level of SHBG, have androgenic, anti-E effect.
✓ Third-generation progesterone (desogestrel, gestodene, norgestimate). These
are less androgenic and cause less metabolic disorders, but increase the risk of
thrombosis.
✓ Hybrid drospirenone (3 mg equivalent to 25 mg spirinone) now used in oral pills
for acne and PCOS.
✓ Yasmin contains 30 µg of EE2 (21 days), Janya contains 20 µg EE2 for 24 days in
a cycle.
✓ Hybrids (drospirenone) have anti-androgens, antimineral corticosteroid effect;
are used in premenstrual tension; causes hyperkalaemia by decreasing
potassium excretion in the urine, less water retention and weight gain.
✓ These have no influence on lipid profile and have a very good control on
menstrual cycles.
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✓ Micronized progesterone—Oral tablet (100 mg) causes vomiting, giddiness and
liver damage.
✓ Micronized vaginal tablet (100 mg) is without these oral side effects, but causes
vaginal irritation.
✓ Progestogens are administered:
✓ Orally—Singly or with oestrogen
✓ Intramuscular injection monthly, three-monthly as contraceptives.
✓ Implants—Norplant (contraceptives).
✓ IUCD impregnated with levonorgestrel (Progestasert, Mirena).
✓ Vaginal tablet and rings.
✓ Skin patches.
✓ Crinone 8% (90 mg) vaginal gel is a micronized progesterone in dilute emulsion
system.
Therapeutic Applications
⚫ Pure progesterone as injection in oil or micronized vaginal or oral capsules are
used in threatened and recurrent abortions, and in corpus luteal phase
deficiency (CLPD).
⚫ High doses of injections are used in advanced endometrial cancer.
⚫ Contraception—Oral in combination with oestrogen, minipills and injectables
are used as contraceptives.
⚫ Implants (Norplant) are effective over 5 years.
⚫ IUCDs impregnated with progesterones are available (Mirena). Mirena is
effective for 5 years.
✓ Abnormal uterine bleeding.
✓ Dysmenorrhoea, premenstrual tension syndrome.
✓ Endometriosis. Though danazol is the drug of choice, owing to the cost and
hirsutism, progestogens continue to be employed in endometriosis.
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✓ Endometrial ablation in AUB. Prior to the TCRE (transcervical resection of
endometrium), endometrial shrinkage is achieved by progestogens given over
4 to 6 weeks.
✓ Amenorrhoea. Progesterone challenge test—A single injection of 100 mg
progesterone will induce withdrawal bleeding if endometrium is primed by
oestrogen. Oral tablets also work. (Primolut-N 5 mg tid 3 3 days)
✓ Post-coital pill—Levonorgestrel 0.75 mg tablet given within 72 h of unprotected
coitus and repeated 12 h later will prevent pregnancy in 98% cases.
✓ With oestrogen in HRT.
✓ Postponement of menstruation—5 mg norethisterone tid for 4 to 5 days or
longer will delay onset of menstruation (starting 3 days prior to anticipated
period).
✓ Allyl progesterone is used in abortions
✓ Progestogens are used as ‘add back’ therapy with GnRH to prevent
osteoporosis and allow prolonged GnRH therapy.
Contraindications
✓ Undiagnosed vaginal bleeding.
✓ Breast cancer, breast tumour.
✓ Thromboembolism.
Side Effects
✓ Nausea, vomiting.
✓ Headache, mastalgia, water retention, cramps in the legs, weight gain.
✓ Hirsutism in androgen-related compounds.
✓ Depression.
✓ Increased low-density lipoproteins and cardiovascular accidents.
✓ Deep venous thrombosis, pulmonary embolism with desogestrel and
gestodene.
✓ Breast tumours, cancer.
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✓ Medroxyprogesterone acetate causes bone loss.
✓ Increase in LDL and decrease in HDL.
186. Androgens (danazol, gestrinone): actions, preparations, indications, side
effects.
Ans: Danazol:
⚫ Danazol is an isoxazole derivative of 17-alpha ethinyl testosterone.
⚫ It has got both androgenic and anabolic properties.
⚫ It is strictly antigonadotropin but acts as an androgen agonist
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Mode of Action
The mechanism of action is complex and includes the following:
⚫ ™Acting on the hypothalamo-pituitary-gonadal axis → depression of frequency
of GnRH pulses →suppression of pituitary FSH and LH surge.
⚫ There is, however, no change in the basal gonadotropin level.
⚫ Due to this reason the word 'pseudomenopause' seems misnomer; while the
estrogen level is reduced but unlike menopause, the gonadotropins remain
⚫ static in base levels.
⚫ Reduces the liver synthesis of sex hormone-binding globulin (SHBG) and as
such, free testosterone is increased which in turn has got direct action on
endometrial atrophy.
⚫ Acts directly on the ovaries, inhibiting the enzymes responsible for
steroidogenesis.
⚫ Estrogen level is low.
⚫ Binds with steroid receptors on the endometrium and also in the ectopic
endometrial sites.
⚫ Immunologic effects of danazol include decrease in serum immunoglobulins
(Igs), interleukin-1 (Il-1) and tumor necrosis factor (TNF) production. This effect
helps in the regression of endometriosis.
The net result is production of an hypoestrogenic
and hyperandrogenic state.
Precautions
It should be commenced in the early follicular phase of
the menstrual cycle. Barrier method of contraception
should be used to avoid being administered during
early pregnancy following accidental ovulation. There
is a chance of virilization of the female offspring. It is
contraindicated in liver disease.
Dose
Depending upon the indication and response, the dose
varies from 200–800 mg daily orally.
Side Effects
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The side effects are mostly related to hypoestrogenic and
androgenic activity. However, most of these effects revert
back to normal soon following stoppage of the therapy. It
is recommended that the patient should discontinue the
treatment, if they develop hirsutism or hoarseness of voice.
Gestrinone
Gestrinone is a derivative of 19-norethisterone. It is an
androgen-agonist and progesterone agonist-antagonist. It
markedly reduces SHBG levels and thus increases the free
testosterone. It reduces the secretion of FSH and LH. It has
a much longer half-life and the dose required to produce
equivalent results, is much smaller than danazol.
Dose
2.5 mg twice weekly starting on first day of cycle with
second dose 3 days later, repeated on same two days
preferably at same time each week.
Side Effects
This are the same to those of danazol but usually less
marked
187. Antioestrogens (clomiphene citrate, tamoxifen): mode of actions,
indications, contraindications, side effects.
Ans: Clomiphene
✓ Clomiphene citrate is a nonsteroid triphenylethylene compound with a
structure similar to that of stilbestrol.
✓ The commercially available form is a mixture of two isomers, enclomiphene—a
potent antiestrogen and zuclomiphene—a weak antiestrogen.
Mode of Action
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✓ In the hypothalamus, clomiphene citrate binds to estrogen receptors, occupies
the nuclear site for a long time (weeks).
✓ The negative feedback of endogenous estrogen is thus prevented.
✓ The frequency of pulsatile GnRH secretion is thereby increased which in turn
results in rise of pulse frequency of both LH and FSH.
✓ Antiestrogenic effects are observed at the level of cervix and endometrium.
Indications
✓ Anovulatory infertility where other factors have been excluded.
✓ Induction of ovulation—the ideal case is one of normogonadotropicnormoprolactinemic disorders of ovulation.
✓ Assisted reproductive techniques in producing superovulation.
✓ Male infertility with defective spermatogenesis due to hypogonadotropic
hypogonadism.
Mode of Administration
Adjuvant drugs: Adjuvant drugs are used when there is failure with clomiphene
therapy.
Contraindications
✓ Patients who are hypogonadotropic and hypoestrogenic.
✓ Presence of cystic ovaries.
Side Effects
✓ These include visual disturbances, headache, hot flashes, breast tenderness,
abdominal discomfort, loss of hair, rashes, ovarian enlargement and multiple
pregnancy.
✓ Hyperstimulation syndrome is less likely.
Results
✓ While successful induction can be achieved by 90%, pregnancy rate is about
50%.
✓ The reduced pregnancy rate may be due to its antiestrogenic effect on
endometrium cervical mucus and the oocyte.
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✓ There may be the presence of other factors for infertility including luteal phase
defect (LPD) and luteinized unruptured follicle (LUF).
✓ Chance of multiple pregnancy ranges 0–5%.
Aromatase Inhibitors
⚫ It inhibits the enzyme aromatase in the granulosa cells of ovarian follicles. It
suppresses estrogen synthesis.
⚫ Letrozole, 2.5 mg given from D3 to D7 increases the release of gonadotropins
from the pituitary and stimulates development of ovarian follicle.
⚫ Letrozole suppresses ovarian estradiol secretion and reduces estrogen induced
negative feedback.
⚫ As a result, levels of FSH rises.
⚫ Intraovarian androgens are increased which increase FSH sensitivity.
⚫ As opposed to clomiphene, it has no peripheral antiestrogenic effects on the
endometrium and the cervical mucus.
⚫ Half-life of letrozole is 45 hours.
⚫ Letrozole is used either as a firstline therapy (alternative to clomiphene) or in
clomiphene-resistant women with anovulatory infertility.
⚫ Pregnancy rates are comparable or better than that of clomiphene.
⚫ Multiple pregnancy rates are low (monofollicular development).
⚫ However risk of fetal congenital malformations with letrozole, needs
authentication with randomized prospective trials.
⚫ Anastrozole, another aromatase inhibitor is found to be effective in reducing
the growth of pelvic endometriosis and in pain relief.
⚫ Aromatase inhibitors are primarily used for the treatment of breast cancer in
postmenopausal women.
Tamoxifen (SERMs)
⚫ Tamoxifen [Selective estrogen receptor modulators (SERMs)], is similar to
clomiphene both structurally and functionally.
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⚫ It has got both estrogen antagonist and agonist effects.
⚫ It is a competitive inhibitor to estrogen at the receptor site.
⚫ Antiestrogenic function of raloxifene is more selective in uterus and breasts.
⚫ It decreases antithrombin III and increases the SHBG level (agonist action).
Venous thromboembolism (VTE) is increased.
⚫ It can be used for induction of ovulation in doses of 20 mg per day for 5 days,
in cases of intolerance to clomiphene.
⚫ It is widely used for the treatment of benign breast diseases.
⚫ In postmenopausal breast carcinoma, it is given in doses of 10 mg twice daily
for 2 years as an adjuvant therapy.
⚫ It is effective both in estrogen receptor positive and negative cases.
⚫ In recurrent endometrial carcinoma, it inhibits the binding of estradiol to the
estrogen receptor.
⚫ Tamoxifen increases the progesterone receptors.
⚫ A dose of 20–40 mg per day has been used.
⚫ Low grade tumors and hormone receptor positive tumors have got better
response.
Raloxifene therapy (60 mg a day) is effective in regression of endometriosis.
Side Effects
Hot flashes, vaginal dryness, risks of thromboembolism and risks of endometrial
carcinoma on prolonged use.
188. Antiprogesterone
(mifiprestone):
contraindications, side effects.
therapeutic
applications,
Ans: Mifepristone RU486
⚫ It is a competitive antagonist of progesterone and glucocorticoid receptors
⚫ It is a derivative of 19-nortestosterone.
⚫ It binds competitively to progesterone receptors and nullifies the effect of
endogenous progesterone.
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⚫ As a result, there is an increased release of prostaglandins from the
endometrium, resulting in menstrual bleeding or termination of early
pregnancy.
⚫ Three important biochemical characters of RU 486 are high affinity for
progesterone receptors, long half-life and active metabolites.
Uses
Therapeutic abortion: It is an effective abortifacient upto 7 weeks. Combination of
prostaglandins as vaginal pessary 48 hours after RU 486, increases its efficacy.
Dose
Tab 200 mg (1 tab = 200 mg) orally, followed immediatly or upto 72 hours later by
misoprostol 400 µg (PGE1) oral or 800 mg vaginal pessary, sublingual or buccal.
Success rate is 95–100%.
Emergency contraception: A single dose of 10 mg is to be taken on 27th day of
the cycle irrespective of the day and number of intercourse. Efficiency is 95–
100%.
Induction of labor: Mifepristone has been used for cervical ripening. It is given
orally.
Uterine fibroids: Mifepristone therapy (5–50 mg daily) for 12 weeks is given.
Shrinkage of leiomyomas volume occurs by about 50%. It reduces the symptoms
(pain relief) also.
Endometriosis: A dose of 50 mg/day for 6 months is found to reduce pelvic pain
and the extent of spread.
Ectopic pregnancy: Injection of mifepristone into the ectopic pregnancy
(unruptured sac) is used as a medical management.
Cushing’s syndrome: As it blocks the glucocorticoid receptors.
Side Effects
✓ Minor side effects are nausea, vomiting, headache and cramp.
✓ There is risk of ongoing pregnancy (failure of medical induction of abortion) in
about 1% of cases.
✓ Evacuation of the uterus should be done for such a failure.
✓ Other side effects are: Vasomotor symptoms (40%), endometrial hyperplasia
(due to unopposed estrogen effect).
✓ Asoprisnil, a SPRL is found to avoid estrogen deficiency symptoms.
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Contraindications
• Age >35 years
• Heavy smoker
• Adrenal insufficiency
• Corticosteroid therapy.
189. Antiandrigens (ciproterone acetate, spironolactonc, flutamide. finasteride):
therapeutic applications, dosages, side effects.
Ans: Antiandrogens
⚫ Cyproterone acetate
⚫ Spironolactone
⚫ Flutamide
⚫ Finasteride
Cyproterone Acetate
✓ Cyproterone acetate is an
hydroxyprogesterone (17-OHP)].
antiandrogenic
progestogen
[17-
✓ It inhibits gonadotropin secretion and also acts as a competetive androgen
receptor antagonist.
✓ It decreases 5α-reductase activity and reduces LH secretion.
✓ It induces hepatic enzymes and increases the metabolic clearance of plasma
androgens.
✓ It also acts as a potent progestogen having agonist effects on progesterone
receptors.
Uses
It is used in the idiopathic hirsutism or hyper-androgenic state.
Dose
⚫ Cyproterone acetate, 2 mg is most frequently used in combination with ethinyl
estradiol.
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✓ Available preparation (COCs) containing cyproterone acetate, 2 mg and ethinyl
estradiol, 35 µg may be given from day 5 for 21 days.
Treatment
It is to be continued for at least 6 months.
Side effects
⚫ Weight gain, loss of libido, mastalgia.
⚫ Spironolactone: It is an androgen receptor antagonist.
⚫ It is an antialdosterone diuretic.
⚫ It also inhibits androgen biosynthesis from ovary and adrenal.
• Inhibits 5α-reductase activity
• It competes with androgen at the receptor sites.
Dose
✓ The dose varies from 25–150 mg per day.
✓ This may produce hyponatremia and hyperkalemia for which initial monitoring
of serum potassium and creatinine is necessary at doses above 100 mg per day.
Important side effects
Menstrual irregularity (DUB), fatigue, diuresis, and electrolyte imbalance
(hyperkalemia).
Flutamide
✓ It is a non steroidal androgen receptor antagonist.
✓ It blocks the androgen receptor sites.
✓ Dose of 250 mg daily for 6 months is optimum.
✓ Important side effects are dry skin, decreased libido and hepatotoxicity.
Finasteride
⚫ It inhibits 5α-reductase activity. A dose of 5 mg daily is effective for hirsutism
without any side effects.
⚫ Ketoconazole inhibits the enzyme for androgen synthesis.
⚫ A dose of 200 mg daily is adequate to reduce the level of androgens.
⚫ Dexamethasone and for other antiandrogens
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190. Pituitary hormones: therapeutic uses, side effects.
ans: Pituitary Hormones
Gonadotropins
The anterior pituitary gland secretes follicle-stimulating hormone (FSH), LH and
prolactin.
Therapeutic Uses
Therapeutic uses of gonadotropins are:
⚫ Induction of ovulation in anovulatory infertility.
⚫ Those who fail to respond to clomiphene are treated with FSH and LH.
⚫ Infertility caused by pituitary hypofunction also needs this therapy.
⚫ The dose is adjusted according to ultrasonic findings of follicular growth and E2
level.
⚫ The treatment is started on the second day of the cycle and continued until
ovulation occurs.
⚫ Induction of multiple ovulation using hyperstimulation protocols for infertile
women going through ART as in in vitro fertilization, GIFT, zygote intrafallopian
transfer (ZIFT) and ICSI
⚫ Hypogonadotrophic hypogonadism in males.
⚫ Cryptorchism.
⚫ In primary and secondary amenorrhoea caused by pituitary failure in
hypogonadotropic hypogonadism.
⚫ hCG is used in CLPD, infertility and early abortions
⚫ No teratogenicity is reported.
⚫ 250 µg recombinant hCG is equal to 5000 IU of hCG with less local side effects.
Side Effects
The side effects are:
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✓ Hyperstimulation syndrome.
✓ Multiple pregnancy in 10%.
✓ Local reaction at the site of injection, fever, arthritis.
Anti-FSH and anti-LH are in the process of being developed as contraceptives.
191. Gonadotropin-releasing hormones and its analogues: praparations, clinical
uses, side effects.
ans: Gonadotropin Releasing Hormone (GnRH)
⚫ The GnRH is also named as luteinizing hormone releasing hormone (LHRH).
⚫ GnRH is a decapeptide and is concerned with the release, synthesis and storage
of both the gonadotropins (follicle-stimulating hormone (FSH) and LH) from the
anterior pituitary.
⚫ The divergent patterns of FSH and LH in response to a single GnRH are due to
modulating influence of the endocrine environment specially the feedback
effects of steroids on anterior pituitary gland.
⚫ GnRH is secreted by the arcuate nucleus of the hypothalamus in a pulsatile
fashion.
⚫ Developmentally, these neurons originated from the olfactory area.
⚫ The half-life of GnRH is very short (2–4 minutes).
⚫ This is due to the cleavage of amino acid bonds between 5–6, 6–7 and 9–10 in
circulation.
⚫ GnRH is secreted into the portal circulation in pulsatile fashion.
⚫ This pulse secretion varies in frequency and amplitude at different phases of
menstrual cycle.
⚫ GnRH stimulates anterior pituitary for synthesis, storage and secretion of
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gonadotropins.
⚫ There is decrease in receptor sensitivity when gonadotroph cells
(adenohypophysis) are exposed to GnRH stimulation continually.
⚫ This is called ‘down regulation’.
⚫ On the contrary, intermittent exposure of GnRH to gonadotrophs, increase the
receptor sensitivity.
⚫ This is called ‘up-regulation’.
⚫ This variable response of anterior pituitary gonadotrophs to GnRH
have been utilized in different clinical situation to get therapeutic benefits.
uses: GnRH agonists are useful in:
Suppression of spontaneous ovulation as part of controlled ovarian
hyperstimulation, which is an essential component in in vitro fertilisation(IVF).
Typically, after GnRH agonists have induced a state of hypoestrogenism, exogenous
FSH is given to stimulate ovarian follicle, followed by human chorionic
gonadotropins (hCG) to trigger oocyte release. GnRH agonists routinely used for
this purpose are: buserelin, leuprorelin, nafarelin, and triptorelin.[8]
•
Final maturation induction after having performed controlled ovarian
hyperstimulation. Usage of GnRH agonist for this purpose necessitates using
a GnRH antagonist instead of a GnRH agonist for suppression of spontaneous
ovulation, because using GnRH agonist for that purpose as well inactivates the axis
for which it is intended to work for final maturation induction.
•
Treatment of cancers that are hormonally sensitive and where a
hypogonadal state decreases the chances of a recurrence. Thus they are commonly
employed in the medical management of prostate cancer and have been used in
patients with breast cancer.
•
•
Delaying puberty in individuals with precocious puberty.
Delaying puberty pending treatment decisions in children with gender
dysphoria.
•
241 | P a g e
Management
estrogenproduction.
•
of
female
disorders
that
are
dependent
on
Women
with menorrhagia, endometriosis, adenomyosis,
or uterine
fibroids may receive GnRH agonists to suppress ovarian activity and induce a
hypoestrogenic state.
•
Suppressing
sex
hormone
especially transgender women.
•
levels
in transgender
people,
Severe cases of hyperandrogenism, such as in congenital adrenal
hyperplasia.
•
As part of the pharmacologic treatment of paraphilic disorders in sexual
offenders or men with a high risk of sexual offending.
•
side effects: Common side effects of the GnRH agonists and antagonists include
symptoms of hypogonadism such as hot flashes, gynecomastia, fatigue, weight
gain, fluid retention, erectile dysfunction and decreased libido.
Long term therapy can result in metabolic abnormalities, weight gain, worsening
of diabetes and osteoporosis.
192. Bromocriptine: therapeutie applications, doses, side effects.
Ans:
Bromocriptine
Bromocriptine, a synthetic ergot derivative (lysergic acid derivative of ergoline)
and a powerfuldopamine agonist. It suppresses prolactin while promoting the
secretion of gonadotropins. It thus induces menstruation, ovulation and promotes
pregnancy. It also suppresses lactation.
⚫ Bromocriptine is available as parlodel, proctinal, cabergoline, serocrip tablets.
⚫ Pergolide is now also available as a vaginal tablet and intramuscular injection
by the name parlodel-LAR (glycolipid microspheres).
242 | P a g e
Contraindications
Hypertension, cardiovascular disease.
Therapeutic Applications
Bromocriptine’s therapeutic uses are:
✓ Suppression of lactation—2.5–5 mg daily orally.
✓ Cyclical mastalgia.
✓ Anovulatory infertility caused by hyperprolactinaemia
✓ Treatment of microadenoma and preoperatively in macroadenoma to shrink
the tumour prior to surgery.
In infertility due to hyperprolactinaemia, 70% to 90% ovulate and menstruation is
established, 70% pregnancy rate is also encouraging. If pregnancy follows, the
treatment should be discontinued,mthough no teratogenic effect is reported in
the fetus.
In pregnancy, the level of prolactin rises and the followup is mainly by fundus
examination which suggests optic nerve pressure by the tumour. Bromocriptine
can be continued during pregnancy if the tumour appears to increase in size as
suggested by fundus examination. Cabergoline is safe during pregnancy.
Dose
The dose starts with 1.25 mg at bedtime and gradually increases to 2.5 mg bid or
more as required. The effect lasts 12 h.
In those who cannot tolerate the oral drug or in resistant cases, the vaginal tablet
or cream is to be used daily. Alternately, the long-acting tablet in the name of
cabergoline (dostinex) is available. Starting with an initial dose of0.25 mg twice
weekly, the dose is gradually built up to 1 mg twice weekly. It acts at a D2
receptor site.Parlodel-LAR monthly intramuscular injection, used in the
initial dose of 50 mg increasing to 100 mg if necessary, causes acute reduction in
prolactin level by 30% to 80%, reduction in tumour volume by 25% with minimal
side effects.Quinagolide 25–150 µg daily in divided doses followed by
maintenance dose 75 µg daily.
Side Effects
The side effects are seen in 10%:
⚫ Nausea, vomiting; the patient is advised to take the tablet at night.
⚫ Hypotension and dizziness due to postural hypotension.
⚫ Nasal congestion, headache, constipation.
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Results
The drugs normalize prolactin level in 86% of idiopathic hyperprolactinaemia and
77% in microadenoma. The macroadenoma shrinks in 70%. Some require surgery.
193. Physiology of conception.
Ans: Factors Essential for Conception
⚫ Healthy spermatozoa should be deposited high in the vagina at or near the
cervix (male factor).
⚫ The spermatozoa should undergo changes (capacitation, acrosome reaction)
and acquire motility (cervical factor).
⚫ The motile spermatozoa should ascend through the cervix into the uterine
cavity and the fallopian tubes.
⚫ There should be ovulation (ovarian factor).
⚫ The fallopian tubes should be patent and the oocyte should be picked up by the
fimbriated end of the tube (tubal factor).
⚫ The spermatozoa should fertilize the oocyte at the ampulla of the tube.
⚫ The embryo should reach the uterine cavity after 3–4 days of fertilization.
⚫ The endometrium should be receptive (by estrogen, progesterone, IGF-l,
⚫ cytokines, integrins) for implantation, and the corpus luteum should function
adequately.
PHYSIOLOGICAL CONSIDERATION
⚫ Due to anovulation, infertility is the rule prior to puberty and after menopause.
⚫ But it should be remembered that the girl may be pregnant even before
menarche and pregnancy is possible within few months of menopause.
⚫ Conception is not possible during pregnancy as the pituitary gonadal axis is
suppressed by hCG and hence, no ovulation.
⚫ During lactation, infertility is said to be relative.
⚫ Despite the fact that the patient is amenorrheic during lactation, ovulation and
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conception can occur.
⚫ However, in fully lactating women (breastfeeding 5–6 times a day and spending
60 minutes in 24 hours), pregnancy is unlikely up to 10 weeks postpartum.
194. Vaginismus: definition, aethiology, pathogenesis, symptoms and
sings,treatment.
ans: Vaginismus
Definition
Vaginismus is defined as the psychogenically mediated
involuntary spasm of the vaginal muscles including the
levator ani muscles and/or the thigh adductor muscles.
This results in inability of penetrative sexual intercourse.
Etiology
Primary: Nothing has entered into the woman’s vagina
ever. However, the vagina is normal anatomically and
physiologically. The cause is mostly psychosexual in
origin. There is often presence of a subconscious fear
of sexual intercourse (sexual phobias).
Secondary: Vaginismus usually appear after childbirth
or any other event in life. There is usually some local
painful lesions. Such lesions include vulvitis, lacerations
of the hymen, tender scar on the perineum or narrow
vaginal introitus. The entity is usually transient and is
relieved, when the cause is removed.
Clinical Presentation
The woman with vaginismus avoids vaginal examination
and smear. She might present with painful sexual
intercourse or with infertility.
Diagnosis
While diagnosis of the secondary one is not so difficult
but to find out the cause of the primary one, examination
under anesthesia may be required. If the two fingers can
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be easily introduced through the vaginal introitus, the
caliber of the vagina is proved normal.
Treatment
primary
Secondary
Primary: The following guidelines are prescribed :
⚫ Psychodynamic therapy: Main causes of fear are
removed. To educate and to gain confidence of the
husband and wife. This may take time.
⚫ Behavioral therapy: Dilatation of the vaginal
introitus digitally followed by introduction of
gradually increasing size of the dilators is to be
done. Plastic vaginal trainers (pseudopenises) with
graduated sizes can help her to remove her fear. This
will gain her confidence that her vagina is anatomically
of normal caliber.
⚫ Vaginal dilators: Daily introduction of the dilators
(pseudopenises) for 1–2 weeks and to keep it inside
for 10–15 minutes is enough before she is allowed to
attempt coital act.
⚫ Surgery: A classic case of vaginismus needs no surgery.
However, surgery may be required, if the hymen is found
tight—hymenectomy or Fenton’s operation (operation to
enlarge the introitus), if the introitus is narrow
Secondary: The local lesion is to be treated medically or
surgically.
195. Dyspareunia: definition, causes, investigations and treatment.
246 | P a g e
Ans: Dyspareunia
Definition
Dyspareunia means that the coital act is difficult and or
painful. Apareunia is inability to practice coitus. The two
are most often interchangeable. Dyspareunia is the most
common sexual dysfunction.
Etiology:
Male causes:
The following male factors are responsible:
⚫ Impotence
⚫ Premature ejaculation
⚫ Congenital anatomic defect of the penis
⚫ Lack of technique of coital act.
Female causes
Depending upon the site of pain, the dyspareunia may be
either:
⚫ Superficial or entrance
⚫ Vaginal
⚫ Deep.
Superficial: Any lesion of the lower part of the labia
minora or around the fourchette may be responsible.
Causes of Superficial Dyspareunia
Norrow introitus
Tough hymen
Bartholin's gland cysts
Tender perineal scar
Vulvar infection
Urethral pathology
Vulvar vestibulitis syndrome
Vaginal: Burning pain along the barrel of vagina either
during or following intercourse is the presenting
complaint. Common causes are:
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⚫ Vaginitis
⚫ Vaginal septum
⚫ Tender scar—following gynecologic operation or
⚫ delivery
⚫ Secondary vaginal atresia
⚫ Tumor
⚫ Vaginal atrophy (menopause).
Deep: The patient experiences pain while the penis
penetrates deep into the vagina. As the vagina is insensitive
to pain, deep dyspareunia usually results from pathology of
paravaginal tissues or other pelvic organs. Such lesions are:
⚫ Endometriosis, specially on rectovaginal septum
⚫ Chronic cervicitis
⚫ Chronic PID
⚫ Retroverted uterus—mostly acquired and fixed
⚫ Prolapsed ovary in the pouch of Douglas.
Treatment
Treatment depends upon the cause. Too often, sex
education of both the partners relieves the symptom.
The infective lesions of the vulva and or vagina are
to be treated. Tender scar on the perineum or the vagina
is to be excised. The treatment of vaginismus has been
mentioned earlier.
196. Infertility and sterility: issues involved, theoretical considerations.
Psychological problems in infertulity.
Ans:
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⚫ Infertility is defined as a failure to conceive within one or more years of regular
unprotected coitus.
⚫ Primary infertility denotes those patients who have never conceived.
Secondary infertility indicates previous pregnancy but failure to conceive
subsequently.
⚫ Fecundability is defined as the probability of achieving a pregnancy within one
menstrual cycle. In a healthy young couple, it is 20%.
⚫ Fecundity is the probability of achieving a livebirth within a single cycle.
197. Male infertility: spermatogenesis and its endocrine control. Causes,
classification of infertility, investigations, treatment of male infertility.
Ans: Male Infertility
The treatment of male is indicated in: (i) Extreme oligospermia; (ii) Azoospermia;
(iii) Low volume ejaculate and (iv) Impotency.
⚫ Management is often difficult and unsatisfactory.
To improve spermatogenesis the following measures may be helpful.
⚫ General care: Improvement of general health, reduction of weight in obese,
avoidance of alcohol and heavy smoking.
⚫ Medications that interfere spermatogenesis should be avoided.
⚫ In hypogonadotropic-hypogonadism, the disorders of spermatogenesis can be
treated with the following therapy with varying success.
✓ hCG 5000 IU intramuscularly once or twice a week is given to stimulate
endogenous testosterone production.
✓ hMG or pure FSH (75–150 IU) is added to hCG when there is no sperm in the
ejaculate with hCG alone.
✓ Dopamine agonist (cabergoline) is given in hyperprolactinemia to restore
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normal prolactin and testosterone level. This improves libido, potency and
fertility.
✓ Pulsatile GnRH therapy in infertile male with GnRH deficiency (Kallmann’s
syndrome) is effective.
✓ It is administered by minipump infusion.
✓ Target is to maintain normal adult 'male' LH levels.
✓ Cases with hypogonadotropic hypogonadism may also respond with GnRH
therapy.
Hypergonadotropic-hypogonadism, no form of medical treatment can improve
fertility in men .
✓ Treatment options available are insemination with donor sperm or adoption
when no sperm is available. IVF with ICSI may be done in cases with severe
oligospermia.
✓ Clomiphene citrate 25 mg orally daily for 3 months is given. It increases serum
level of FSH, LH and testosterone.
✓ Presence of antisperm antibodies in the male and its significance is unclear.
Currently intrauterine insemination (lUI) is the choice of treatment for such
cases
Leukocytospermia: Genital tract infection needs prolonged course of antibiotics.
✓ Generally doxycycline or erythromycin is given for a period of 4–6 weeks,
depending on the response.
✓ However, leukocytospermia does not always predict infection and it may not
have any effect on fertility.
Retrogradeejaculation:Phenylephrine(D-adrenergic agonist) is used to improve
the tone of internal urethral sphincter.
✓ Sperm may be recovered from the neutralized urine. Processed spermatozoa
could be used for lUI.
Teratospermia, asthenospermia: Specific causes are unknown. No treatment is
available. Donor insemination (AID) is the option.
Genetic abnormality: Artificial insemination with donor sperm (AID) is the option
as no other treatment is available.
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Surgical
✓ When the patient is found to be azoospermic and yet testicular biopsy shows
normal spermatogenesis, obstruction of vas must be suspected.
✓ This should be corrected by microsurgery—vasoepididymostomy or
vasovasostomy.
✓ After vasovasostomy patency is obtained in about 80% of cases and pregnancy
rate is about 50%.
✓ Surgery for varicocele for improvement of fertility is not helpful. Hydrocele is
corrected by surgery.
✓ Orchidopexy in undescended testes should be done between 2–3 years of age
to have adequate spermatogenesis in later life.
Impotency
✓ Psychosexual treatment may be of help.
✓ Hyperprolactinaemia needs further investigation and treatment.
✓ For erectile dysfunction sildenafil (25–100 mg) or tadalafil (10–20 mg) is
currently advised.
✓ A single dose (depending on response) is given orally one hour before sexual
activity.
✓ In unresponsive cases, artificial insemination is to be thought of use.
Assisted Reproductive Technology (ART) for Male Infertility Prospect of male
infertility has improved significantly with the advent of ART.
✓ IUI, TESE, PESA, MESA and intracytoplasmic sperm injection (ICSl) are now the
treatment available for infertile males.
198. Female infertility: Aetiology, investigations.
Ans: aetiology:
Ovulation disorders
Ovulating infrequently or not at all accounts for most cases of infertility. Problems
with the regulation of reproductive hormones by the hypothalamus or the
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pituitary gland or problems in the ovary can cause ovulation disorders.
* Polycystic ovary syndrome (PCOS). PCOS causes a hormone imbalance, which
affects ovulation. PCOS is associated with insulin resistance and obesity, abnormal
hair growth on the face or body, and acne. It's the most common cause of female
infertility.
* Hypothalamic dysfunction. Two hormones produced by the pituitary gland are
responsible for stimulating ovulation each month — follicle-stimulating hormone
(FSH) and luteinizing hormone (LH). Excess physical or emotional stress, a very
high or very low body weight, or a recent substantial weight gain or loss can
disrupt production of these hormones and affect ovulation. Irregular or absent
periods are the most common signs.
* Primary ovarian insufficiency. Also called premature ovarian failure, this is
usually caused by an autoimmune response or by premature loss of eggs from
your ovary, possibly as a result of genetics or chemotherapy. The ovary no longer
produces eggs, and it lowers estrogen production in women under age 40.
* Too much prolactin. The pituitary gland can cause excess production of prolactin
(hyperprolactinemia), which reduces estrogen production and can cause
infertility. This can also be caused by medications you're taking for another
condition.
Damage to fallopian tubes (tubal infertility)
Damaged or blocked fallopian tubes keep sperm from getting to the egg or block
the passage of the fertilized egg into the uterus. Causes of fallopian tube damage
or blockage can include:
* Pelvic inflammatory disease, an infection of the uterus and fallopian tubes due
to chlamydia, gonorrhea or other sexually transmitted infections
* Previous surgery in the abdomen or pelvis, including surgery for ectopic
pregnancy, in which a fertilized egg implants and develops somewhere other than
the uterus, usually in a fallopian tube
Endometriosis
Endometriosis occurs when tissue that typically grows in the uterus implants and
grows in other places. This extra tissue growth — and the surgical removal of it —
can cause scarring, which can block fallopian tubes and keep an egg and sperm
from uniting.
Endometriosis can also disrupt implantation of the fertilized egg. The condition
also seems to affect fertility in less-direct ways, such as damage to the sperm or
egg.
Uterine or cervical causes
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Several uterine or cervical causes can interfere with the egg implanting or
increase the risk of miscarriage:
* Benign polyps or tumors (fibroids or myomas) are common in the uterus. Some
can block fallopian tubes or interfere with implantation, affecting fertility.
However, many women who have fibroids or polyps do become pregnant.
* Problems with the uterus present from birth, such as an unusually shaped
uterus, can cause problems becoming or remaining pregnant.
* Cervical stenosis, a narrowing of the cervix, can be caused by an inherited
malformation or damage to the cervix.
* Sometimes the cervix can't produce the best type of mucus to allow the sperm
to travel through the cervix into the uterus.
Unexplained infertility
In some cases, the cause of infertility is never found. A combination of several
minor factors in both partners could cause unexplained fertility problems.
Although it's frustrating to get no specific answer, this problem can correct itself
with time. But you shouldn't delay treatment for infertility.
INVESTIGATIONS:
* Ovulation testing. An at-home, over-the-counter ovulation prediction kit detects
the surge in luteinizing hormone (LH) that occurs before ovulation. A blood test
for progesterone — a hormone produced after ovulation — can also document
that you're ovulating. Other hormone levels, such as prolactin, also might be
checked.
* Hysterosalpingography. During hysterosalpingography (his-tur-o-sal-ping-GOGruh-fee), X-ray contrast is injected into your uterus and an X-ray is taken to check
for problems inside the uterus. The test also shows whether the fluid passes out
of the uterus and spills out of your fallopian tubes. If any problems are found,
you'll likely need further evaluation.
* Ovarian reserve testing. This testing helps determine the quality and quantity of
eggs available for ovulation. Women at risk of a depleted egg supply — including
women older than 35 — might have this series of blood and imaging tests.
* Other hormone testing. Other hormone tests check levels of ovulatory
hormones as well as thyroid and pituitary hormones that control reproductive
processes.
* Imaging tests. A pelvic ultrasound looks for uterine or fallopian tube disease.
Sometimes a sonohysterogram, also called a saline infusion sonogram, or a
hysteroscopy is used to see details inside the uterus that can't be seen on a
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regular ultrasound.
Depending on your situation, rarely your testing might include:
* Laparoscopy. This minimally invasive surgery involves making a small incision
beneath your navel and inserting a thin viewing device to examine your fallopian
tubes, ovaries and uterus. A laparoscopy can identify endometriosis, scarring,
blockages or irregularities of the fallopian tubes, and problems with the ovaries
and uterus.
* Genetic testing. Genetic testing helps determine whether there any changes to
your genes that may be causing infertility.
199. Tubal infertility: tests for tubal patency, newer diagnostics techniques,
management of tubal infertility.
Ans:
tubal infertility: is female infertility caused by diseases, obstructions, damage,
scarring, congenital malformations or other factors which impede the descent of
a fertilized or unfertilized ovum into the uterus through the Fallopian tubes and
prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of
infertility cases. Tubal factor is one complication of Chlamydia trachomatis
infection in women.
Tests for tubal patency:
x Dilatationandinsufflationtest(DI)
x Hysterosalpingography(HSG)
x Salineinfusionsonography
x Hysterosalpingocontrastsonography(Hycosy)
x Sonohysterosalpingography
x Laparoscopyandchromopertubation
x Falloposcopy
x Salpingoscopy
Diagnosis: In the presence of biologic effects of progesterone in the early luteal
phase:
x Sonography: Persistence of echo-free dominant follicle beyond 36 hours after
LH peak.
x Laparoscopy: Failure to observe a stigma of ovulation. x Ovarian biopsy:
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Conclusive proof is determination of
ovum amidst the structure of corpus luteum.
Management: For women with infections of mild to moderate severity, parenteral
and oral therapies are prescribed . Typical antibiotics used are cefoxitin or
cefotetan plus doxycycline, and clindamycin plus gentamicin. An alternative
parenteral regimen is ampicillin/sulbactam plus doxycycline. Once infection has
been eliminated, surgery may be successful in opening the lumen of the fallopian
tubes to allow a successful pregnancy and birth.
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200. Anovulation: tests of ovulation (basal body temperature, endometrial
biopsy, fern test, ultrasound, hormonal study). Management of anovulation.
The ovarian activity is totally dependent on the gonadotropins and the normal
secretion of gonadotropins depends on the pulsatile release of GnRH from
hypothalamus. As such, ovarian dysfunction is likely to be linked with disturbed
hypothalamo-pituitaryovarian axis either primary or secondary from thyroid or
adrenal dysfunction. Thus, the disturbance may result not only in anovulation but
may also produce oligomenorrhea or even amenorrhea. Other causes of
anovulation are: Polycystic ovarian syndrome, elderly women and women with
premature ovarian failure
A. Basal body temperature (BBT) Observation:There is “biphasic pattern” of
temperature variation in ovulatory cycle. If pregnancy occurs, the rise of
temperature sustains along with absence of the period. In anovulatory
cycle, there is no rise of temperature throughout the cycle
Clinical importance: Maintenance of BBT chart during investigation is of help in
determining ovulation and timing of post-coital test, endometrial biopsy, cervical
mucus or vaginal cytology study for ovulation. It also helps the couple to
determine the most fertile period, if the cycle is irregular
B. Endometrial biopsy Endometrial tissues to detect ovulation (endometrial sampling) can easily be
obtained as an outpatient procedure using instruments such as Sharman curette
or Pipelle endometrial sampler. Dilatation and curettage is, however reserved in
cases where bulk endometrial study is required as in endometrial tuberculosis.
Findings: Evidences of secretory activity of the endometrial glands in the second
half of the cycle give not only the diagnosis of ovulation but can predict the
functional integrity of the corpus luteum. Subnuclear vacuolation is the earliest
evidence appearing 36–48 hours following ovulation.
Cause: The secretory changes are due to the action of progesterone on the
estrogen primed endometrium.
C. Fern test –
during the midcycle, the cervical mucus is obtained by a platinum loop or pipette
and spread on a clean glass slide and dried. When seen under low power
microscope, it shows characteristic pattern of fern formation. It is due tohigh
sodium chloride, low protein content in the mucus, high estrogen in the
midmenstrual phase prior to ovulation. After ovulation with increasing
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progesterone, the ferning disappears completely after 21st day. Thus, the
presence of ferning even after 21st day suggests anovulation and its
disappearance is presumptive evidence of ovulation
D. Ultrasound
Ultrasound has now become the standard and indispensable proce dure for
monitoring maturation of the Graafian follicle and in de tecting imminent
ovulation in IVF, IUI and in timing intercourse. This requires daily ultrasonic
visualization of ovaries from the 10th to 16th day of the menstrual cycle. It is
noninvasive, accurate and safe. Apart from follicular study for ovulation, pelvic
pathology if any can be picked up and endometrial thickness measured. The
follicle grows at the rate of 1-2 mm daily to reach 20 mm or more when follicular
rupture and ovulation occur at midcycle. The sudden disappearance of the follicle,
presence of free fluid in the pouch of Douglas and growth of corpus luteum are
evident. Endometrial thickness of 8-10 mm is the normal response of
endometrium to progesterone. A lesser thickness indicates corpus luteal phase
deficiency (CLPD).
E. hormonal study
• Plasma concentration – of progesterone rises after ovulation and reaches the
peak of 15 ng/mL at mid-luteal phase (22-23rd day) and then declines as the
corpus luteum degenerates. A low level of the plasma progesterone below 5
ng/mL at mid-luteal phase, suggests corpus LPD and prompts hormonal
therapy.
• LH – surge from the anterior pituitary gland occurs about 24 hours prior to
ovulation Radioimmunoassay of the morning sample of urine and blood gives
the LH results in 3 hours. Not only does the LH surge help in predicting
ovulation, but the approximate time of ovulation can be gauged and ruits
around this time can improve the chances of conception Ganging the time of
ovulation has therapeu uc applications in IVF and in artificial insemination. I
kits are now available.
• Hyperprolactinemia – It is seen in pituitary adenoma, hyperplasia,
hypothyroidism and with the usage of drugs, Le, metoclopramide, cimettdine, methyldopa. Hyperprolactinemia (more than 25 ng/ ml) will require X-ray
of pituitary lossa or CT scan, and it fundus examination to exclude a neoplasm.
Macroadeno mas may require surgery. Microadenomas and hyperprolac
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tinaemia respond to Bromocriptine and allied drugs (sce chapter on Hormonal
Therapy).
• FSH – Raised FSH level is seen in ovarian failure. Low FSH level indicates
pituitary dysfunction and anovulation. Normal FSH level in the preovulatory
phase is 1-8 mlL ml nd LH level at ovulation is 1-5 mit /mL FSH level 251l/ml
clomiphene on day 3 fails ovulation,
• Thyroid Tests – These should be done especially in case of by perprolacti
naemia Hypothyroidism with raised TSH level is related to
hyperprolactinaemia. Ovarian reserve or premature failure includes both
qualitative and quantitative estimation of FSH LH.
Management of anovulation
• Clomiphene Citrate
• Letrozole 2.5 mg (nonsteroidal aromatase inhibitor)
• In PCOD, ovulation is ideally induced with a combination of CC and h MG
• GnRH
• Prednisolone
• Hyperprolactinemia
• Laparoscopic Ovarian Drilling – In women with PCOD in whom induction of
ovulation with medical line of treatment fails, laparoscopic ovarian drilling of
follicles with monopolar cautery/laser has yielded satisfactory results.
201. Newer reproductive technologies: In-vitro fertilization (IVF), gamete
intratallopian transfer (GIFT) technique, micro-assisted fertilization (MAF)
technique, MESA amd PESA. 202.
i.
IVF. This is the most commonly done ART procedure. It involves ovulation
induction, oocyte retrieval and fertilization of the oocytes in the laboratory:
embryos are then cultured for 3-5 days followed by their transfer to the
endometrial cavity (ET).
Indications
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⎯ Idiopathic or unexplained male and female infertility.
⎯ Immunological factor in male and female.
⎯ Blocked fallopian tubes or failed tubal surgery.
⎯ Failed intrauterine or fallopian insemination.
⎯ Mild endometriosis.
⎯ Abnormal semen findings.
⎯ Donor semen or sperm.
ii. GIFT. This involves ovarian stimulation and egg retrieval, followed by
laparoscopically guided transfer of a mixture of two ova and 50.000 sperms
into each of the fallopian tubes. This procedure came with a big bang and
popularity, however, is no longer in use.
Indications
⎯ Unexplained infertility.
⎯ Failed IUI.
⎯ Male infertility.
⎯ Immunological factor in male.
⎯ Immunological factors in the cervix.
⎯ Donor semen required (rare).
iii. Epididymal or testicular aspiration or biopsy.
⎯ This is the latest technology employed in azoospermia caused by blocked vas.
The former can be done under local anaesthesia, but testicular biopsy requires
general anaesthesia.
⎯ Cryopreservation of semen of the husband and embryos for future fertility is
required if the man has to undergo radiation or chemotherapy for malignancy.
Alternately, epididymal or testicular aspiration technique is employed. In the
latter situation, repeat aspiration can be avoided and sperms cryopreserved.
ICSI now supersedes zonal tech- niques because of following reasons:
⎯ It is more successful in improving fertility.
⎯ Spermatozoa as well as spermatids can be employed. Histopathology and
karyotype study is possible.
⎯ Cryopreservation saves cost and stress of repeated perfor mance in each cycle.
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⎯ The low success rate is attributed to older age of the woman undergoing the
procedure. Because of the cost and stress of the procedure, women opt for
these only if other methods fail.
⎯ We have come a long way in male infertility from initial donor insemination,
artificial insemination of washed semen to IVF and ICSI with improved success.
202. Peritoneal disorders: causes, investigations and treatment.
GOOGLE ANS
Peritonitis is a serious condition that starts in the abdomen. That's the area of the
body between the chest and the pelvis. Peritonitis happens when the thin layer of
tissue inside the abdomen becomes inflamed. The tissue layer is called the
peritoneum. Peritonitis usually happens due to an infection from bacteria or
fungi.
There are two types of peritonitis:
• Spontaneous bacterial peritonitis. This infection is caused by bacteria.
It can happen when someone has liver disease, such as cirrhosis, or
kidney disease.
• Secondary peritonitis. Peritonitis can happen due to a hole, also called
a rupture, inside an organ in the abdomen. Or it can be caused by
other health conditions.
Symptoms of peritonitis include:
• Belly pain or tenderness.
• Bloating or a feeling of fullness in the abdomen.
• Fever.
• Upset stomach and vomiting.
• Loss of appetite.
• Diarrhea.
• Reduced urine.
• Thirst.
• Not able to pass stool or gas.
• Feeling tired.
• Confusion.
If you get peritoneal dialysis, peritonitis symptoms also may include:
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•
•
Cloudy dialysis fluid.
White flecks, strands or clumps — which are called fibrin — in the
dialysis fluid.
Causes
The two main types of peritonitis are primary spontaneous peritonitis, an infection
that develops in the peritoneum; and secondary peritonitis, which usually develops
when an injury or infection in the abdominal cavity allows infectious organisms into
the peritoneum. Both types of peritonitis are life-threatening. The death rate from
peritonitis depends on many factors, but can be as high as 40% in those who also
have cirrhosis. As many as 10% may die from secondary peritonitis.
The most common risk factors for primary spontaneous peritonitis include:
Liver disease with cirrhosis. Such disease often causes a buildup of abdominal fluid
(ascites) that can become infected.
Kidney failure getting peritoneal dialysis. This technique, which involves the
implantation of a catheter into the peritoneum, is used to remove waste products in
the blood of people with kidney failure. It's linked to a higher risk of peritonitis due
to accidental contamination of the peritoneum by way of the catheter.
Common causes of secondary peritonitis include:
•
•
•
•
•
•
•
A ruptured appendix, diverticulum, or stomach ulcer
Digestive diseases such as Crohn's disease and diverticulitis
Pancreatitis
Pelvic inflammatory disease
Perforations of the bowel, stomach, intestine, gallbladder, or appendix
Surgery
Trauma to the abdomen, such as an injury from a knife or gunshot wound
Noninfectious causes of peritonitis include irritants such as bile, blood, or foreign
substances in the abdomen, such as barium.
Primary peritoneal cancer is rare cancer that forms in a thin layer of tissue lining
your abdomen (belly). This tissue is called the peritoneum
• Primary peritoneal cancer starts inside the cells that make up the
peritoneum.
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•
Secondary peritoneal cancer starts elsewhere in your body and spreads to
the peritoneum.
Symptoms in the early stages, they may include:
•
•
•
•
•
•
•
Abdominal and/or pelvic pain.
Abnormal vaginal bleeding or discharge.
Bloating or sense of fullness in the abdomen or pelvis.
Bowel changes (increased constipation and/or gas) or rectal bleeding.
Frequent urination.
Indigestion, loss of appetite or feeling full before you finish eating.
Unintended weight gain or weight loss.
As peritoneal cancer grows, additional symptoms may develop, including:
•
•
•
•
•
Fatigue.
Fluid buildup in the abdomen (called ascites).
Nausea or vomiting.
Shortness of breath (dyspnea).
Swelling of your legs.
Diagnostic tests for peritonitis may include:
• Blood and urine tests
• Exploratory surgery
• patients who have a combination of abdominal pain and a clouding of the
peritoneal fluid, which is caused by a buildup of infection-fighting white blood
cells.
• Blood tests: These look for a chemical made by certain cancer cells called
CA-125. The level of this chemical may be high in people with peritoneal
cancer. Blood tests may also look for increased levels of a protein called
HE4, which may also be produced by peritoneal cancer cells.
• Imaging tests: Ultrasound, MRI or CT scan look for tumors. But peritoneal
cancer can be hard to see using these tests.
• Laparoscopy: Your provider can perform a laparoscopy to make a diagnosis.
This procedure involves several very small incisions in the abdomen. During
the procedure, they can do a biopsy to take a sample of abnormal tissues.
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•
•
These tissues are then examined under a microscope by a pathologist to
identify if cancer is present.
Paracentesis: If you have ascites, your provider may take a sample of
abdominal fluid for testing. Providers often perform peritoneal paracentesis
during a laparoscopy.
Pelvic exam: An exam of your vagina, cervix, uterus, fallopian tubes,
ovaries, and rectum to look for any abnormal areas or lumps.
Treatment
If you're diagnosed with peritonitis, you'll be admitted to a hospital. Typically, you'll
immediately start receiving intravenous antibiotics or antifungal medications to treat
the infection. Additional supportive treatments will be necessary if organ failure
from sepsis develops as a complication of the infection. Such treatments may include
intravenous fluids, drugs to maintain blood pressure, and nutritional support.
Treatment of peritoneal cancer depends on the stage of cancer, where the
primary tumor started, how far it has spread, and the patient's overall health. In
some cases, we might use surgery to remove as much of the cancer as
possible. Chemotherapy and radiation therapy are also options for certain
patients.
203. Unexplained infertility: causes, investigations and treatment.
Unexplained infertility is defined when no obvious cause for infertility has been
detected following all standard investigations. These include semen analysis,
ovulation detection, tubal and peritoneal factors, endocrinopathy, and PCT.
Overall incidence is 10–20%. With expectant management about 60% of couples
with unexplained infertility will conceive within a period of 3 years. IVF and ET
may be an option for those who fail to respond
The incidence is extremely variable and largely dependent on the magnitude of
the indepth investigation protocol extended to the couple. The reported
incidence varies from 10–30%. About 40% of these couples become pregnant
within 3 years without having any specific treatment.
Therapy: The prospect of spontaneous conception decreases with increasing age
of the woman and the duration of infertility. The recommended treatment for
unexplained infertility are induction of ovulation, lUI, Superovulation combined
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with lUI and Assisted Reproductive Technology (see below).
Combined factor: The faults detected in both the partners should be treated
simultaneously and not one after the other.
Sperm dysfunction and its biological function are now detected on computerassisted semen analysis (CASA). Abnormal acrosome reaction and sperm–oocyte
fusion defects have been identified by CASA and male infertility problems better
understood. It has been observed that 20% of such unexplained infertile couples
succeed in having a baby in due course of waiting. Perhaps newer and advanced
technology in this field may yield a better pregnancy rate of 40–50% in future,
albeit at a high cost
204. Birth control and problems of overpopulation. Demographic problems in
India and in Russia.
Today, as ever, there is a pressing need for limiting the family size at a personal
level and for the control of population at a national level. The need of birth
control at a personal level has arisen through increased cost of living, scarcity of
accommodation, a desire for better education of children in the present
competitive world, and an overall desire for an improved standard of living.
The population in India has been growing rapidly. The socio-economic problems
of overpopulation are too well known to be discussed here. World population is
also a major problem with more than 6.3 billion living on this earth and 26
children born every second.
Reproductive health and medical grounds are now the other considerations for
birth control. It is reckoned that a woman below 20 years is not physically grown
to produce a child. If she does reproduce, she becomes a high-risk case during
pregnancy and labour, and is likely to deliver a low birth weight (LBW) newborn.
Spacing birth, 3 years apart, is considered beneficial for both the mother and the
child. Birth control is thus seen as a woman’s health measure. A multiparous
woman from a low-income group generally suffers from malnutrition and is also
predisposed to prolapse, stress incontinence, chronic cervicitis and cancer of the
cervix. The spacing of childbirth and limiting the number of pregnancies are
strongly desirable for this reason.
The previous two caesarean sections is indication of a repeat caesarean section in
a subsequent pregnancy which exposes the woman to further surgical risks. In
India, it is customary to suggest sterilization operation at the time of the third
caesarean section, and sometimes during the second caesarean section. Other
indications for sterilization include the mentally retarded woman and the one
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suffering from serious psychiatric disorders like schizophrenia. A woman who has
given birth to a child with a genetic disorder needs genetic counselling and may
be advised against future pregnancy
There has always been a need felt for avoiding unwanted pregnancies and
restricting family size among the married couples. Such a desire and need has
always been higher among women than men. The risks associated with repeated
and unwanted pregnancies have serious long-term effects on the health of
women and at times the entire family. Nowadays, there is a pressing need for
limiting the family size at a personal level and for the control of population at the
national level. The need of birth control at a personal level has arisen through an
increased cost of living, scarcity of accommodation, a desire for better education
of children in the present competitive world and an overall desire for an improved
standard of living.
There are following three approaches to limiting family size:
• Contraceptives - prevent fertilization
• Emergency contraception - prevents implantation
• Medical termination of pregnancy (MTP) – abortion
Benefits of fertility control are interrelated. Benefits are improved quality of life,
better health, less physical and emotional stress of life, better education, job, and
economic opportunities. Benefits are enjoyed by the couple, the children, other
family members, the community and the country
Contraception and fertility control are not synonymous. Fertility control includes
both fertility inhibition (contraception) and fertility stimulation. While the fertility
stimulation is related to the problem of the infertile couples, the term
contraception includes all measures, temporary or permanent, designed to
prevent pregnancy due to the coital act.
Birth control can be done by contraceptive method – A method or a system which
allows intercourse and yet prevents conception is called a contraceptive method.
METHODS OF CONTRACEPTION
1. Natural methods:
• Abstinence during the fertile phase.
• Withdrawal method (coitus interruptus).
• Breastfeeding (lactational amenorrhoea method [LAM]).
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2. Barrier contraceptives:
• Condoms by male and females.
• Spermicidal agents
• Diaphragm, or the cervical cap in the vagina, use of a female condom.
• Hormones which alter the cervical mucous and prevent entry of sperms
into the cervical canal.
3.
4.
5.
6.
7.
8.
Intrauterine contraceptive devices (IUCDs).
Suppression of ovulation with hormones hormonal contraceptives.
Interceptive agents (postcoital contraception).
Immunological methods.
Suppression of spermatogenesis in males.
Surgical sterilization.
Problems of overpopulation
• Depletion of Natural Resources
• Accelerated Habitat Loss
• Amplified Climate Change and Global Warming
• Loss of Biodiversity
• Depreciation of Fresh Water
• Lower Life Expectancy and Diminished Quality of Life
• Emergence of New Pandemics and Epidemics
• Intensive Farming Practices
• Rise in Unemployment, Crime Rate, and Violence
Demographic problems in India
According to the 2022 edition of the United Nations World Population Prospects
(WPP), India is projected to surpass China as the world’s most populous country
in 2023. India is currently at a stage of demographic transition with a substantial
percentage of the youth population. with fertility rates down to as low as 1.19
⎯ Unfulfilled Educational Requirements
⎯ Low Human Development Parameters
⎯ Jobless Growth
⎯ Absence of Proper Policies
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⎯ Rise in the Share of Elderly Population
Demographic problems in Russia
Some of the objective reasons for Russia's demographic problems reflect
historical dynamics: the number of women of childbearing age is falling, and the
average age at which women are having children is rising steadily in modernized,
urban, well-educated populations
Recent demographic trends in Russia have caused widespread public concern.
Russia is experiencing unusually high death rates from nonnatural causes, many
related to alcoholism. Life expectancy, especially among working-age males, has
dropped precipitously. The Russian fertility rate has declined to among the
world's lowest, while its abortion rate is the highest. As a result, for the first time
in Russian history, the annual number of deaths has exceeded the number of
births (see Figure 1). Compounding these challenges, the population is aging
rapidly—a trend that will accelerate over the next two decades—and immigration
continues to increase, posing thorny political and social problems for a nation
historically accustomed to a net outflow of people.
205. Contraception: definition and classification.
A method or a system which allows intercourse and yet prevents conception is
called a contraceptive method.
METHODS OF CONTRACEPTION
1. Natural methods:
• Abstinence during the fertile phase.
• Withdrawal method (coitus interruptus).
• Breastfeeding (lactational amenorrhoea method [LAM]).
2. Barrier contraceptives:
• Condoms by male and females.
• Spermicidal agents
• Diaphragm, or the cervical cap in the vagina, use of a female condom.
• Hormones which alter the cervical mucous and prevent entry of sperms
into the cervical canal.
3. Intrauterine contraceptive devices (IUCDs).
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4.
5.
6.
7.
8.
Suppression of ovulation with hormones hormonal contraceptives.
Interceptive agents (postcoital contraception).
Immunological methods.
Suppression of spermatogenesis in males.
Surgical sterilization.
a) Temporary Methods –
⎯ Intrauterine Contraceptive Devices (IUCDs)
b) Steroidal Contraception’s –
⎯ Combined Oral Contraceptives (Pills)
⎯ Progestogen only Contraceptions
⎯ Emergency Contraception (EC)
c) Sterilization
⎯ Couple Counseling
⎯ Male Sterilization
⎯ Female Sterilization
d) Barrier Methods
⎯ Condom (Male)
⎯ Female Condom (Femidom)
⎯ Diaphragm
⎯ Vaginal Contraceptives
⎯ Fertility Awareness Method
⎯ Contraceptive Counseling and Prescription
⎯ Sterilization Counseling
e) Ongoing Trials
⎯ Transcervical Sterilization
⎯ Male Contraception Methods
206. Natural methods of family planning.
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• Natural family planning is a form of birth control that doesn't involve pills
or devices. As a result, it doesn’t have side effects.
FERTILITY AWARENESS METHOD
• With these methods, you track your fertility, which is when you are most
likely to get pregnant
a) Rhythm Method – The method is based on identification of the fertile
period of a cycle and to abstain from sexual intercourse during that period.
The methods to determine the approximate time of ovulation and the
fertile period include— (a) recording of previous menstrual cycles (calendar
rhythm) (b) noting the basal body temperature chart (temperature rhythm)
and (c) noting excessive mucoid vaginal discharge (mucus rhythm). Users of
temperature rhythm require abstinence until the third day of the rise of
temperature. Users of mucus rhythm require abstinence on all days of
noticeable mucus and for 3 days thereafter.
b) Coitus Interruptus (Withdrawal) – Coitus Interruptus (Withdrawal) (Table
30.12) It is the oldest and probably the most widely accepted contraceptive
method used by man. It necessitates withdrawal of penis shortly before
ejaculation.
c) Breastfeeding, Lactational Amenorrhea (LAM) – Prolonged and sustained
breastfeeding offers a natural protection of pregnancy. This is more
effective in women who are amenorrheic than those who are
menstruating. When the women is full breastfeeding, a contraceptive
method should be used in the 3rd postpartum month and with partial or no
breastfeeding, she should use it in the 3rd postpartum week
d) Fertility awareness-based methods are: (1) Natural contraception (rhythm
method, coitus interruptus, and LAM) (2) Barrier method (condoms,
diaphragm, and spermicides)
207. Barrier contraceptives.
These methods prevent sperm deposition in the vagina or prevent sperm
penetration through the cervical canal. The objective is achieved by
mechanical devices or by chemical means which produce sperm
immobilization, or by combined means.
Types of Barrier Methods
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a) Mechanical
• Male — Condom
• Female — Condom, diaphragm, cervical cap
b) Chemical
• (Vaginal contraceptives)
• Creams — Delfen (nonoxynol-9, 12.5 %)
• Jelly — Koromex, Volpar paste
• Foam tablets— Aerosol foams, T or Contab, Sponge (Today)
c) Combination
• Combined use of mechanical and chemical methods
CONDOM (MALE)
❖ Condoms are made of polyurethane or latex
❖ It is the most widely practised method used by the male
❖ Protection against sexually transmitted disease (STD) is an additional
advantage
FEMALE CONDOM (FEMIDOM)
❖ It is a pouch made of polyurethane which lines the vagina and also the
external genitalia. It is 17 cm in length with one flexible polyurethane ring
at each end. Inner ring at the closed end is smaller compared to the outer
ring. Inner ring is inserted at the apex of the vagina and the outer ring
remains outside. It gives protection against STIs cytomegalovirus (CMV)
[HIV, hepatitis B virus (HBV)] and pelvic inflammatory disease
DIAPHRAGM
❖ It is an intravaginal device made of latex with flexible metal or spring ring at
the margin
❖ The device is introduced up to 3 hours before intercourse and is to be kept
for at least 6 hours after the last coital act.
❖ Ill fitting and accidental displacement during intercourse increase the
failure rate
VAGINAL CONTRACEPTIVES
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❖ Spermicides are available as vaginal foams, gels, creams, tablets, and
suppositories. Usually, they contain surfactants like nonoxynol–9, octoxynol
or benzalkonium chloride. The cream or jelly is introduced high in the
vagina with the help of the applicator soon before coitus
❖ Vaginal Contraceptive Sponge (Today) It is made of polyurethane
impregnated with 1 g of nonoxynol-9 as a spermicide Nonoxynol-9 acts as a
surfactant which either immobilizes or kills sperm. It releases spermicide
during coitus, absorbs ejaculate and blocks the entrance to the cervical
canal. The sponge should not be removed for 6 hours after intercourse. Its
failure rate (HWY) is about—parous women: 32–20, nulliparous 16-9.
208. Intrauterine contraceptive devices: classification, indications,
Contrindications, technique of insertion, mechanism of action, complications
and advantagees.
IUCD is an effective, reversible and long-term method of contraception, which
does not require replacement for a long period and does not interfere with sexual
activity. The device is commonly made of polyethylene which is impregnated with
barium sulphate to render it radiopaque so that the presence or absence of the
device in the pelvis can be easily detected by radiograph or ultrasound.
CLASSIFICATION
a) The device is classified as open, when it has got no circumscribed aperture
of more than 5 mm so that a loop of intestine or omentum cannot enter
and become strangulated if, accidentally, the device perforates through the
uterus into the peritoneal cavity. Lippes loop, Cu-T, Cu-7, Multiload and
Progestasert are examples of open devices.
b) If closed devices, like Grafenberg ring and Birnberg bow, accidentally enter
the abdominal cavity, they have the potential of causing strangulation of
the gut; and hence are obsolete.
c) The device may be nonmedicated as Lippes loop or medicated (bioactive)
by incorporating a metal copper, in devices like Cu T-200, Cu T-380A,
Multiload-250, Multiload-375
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d) Hormone containing IUDs either releasing progesterone (progestasert) or
levonorgestrel (LNGIUS) has also been introduced.
INDICATIONS of IUCD
• As a contraceptive
• Postcoital contraception (emergency contraception)
• Following intrauterine procedure such as adhesiolysis and septal resection
prevents development of Asherman syndrome (to be used after removing
the copper)
• Hormonal IUCD (Mirena) in menorrhagia and dysmen- orrhoea, and
hormonal replacement therapy in meno- pausal women
• In a woman on Tamoxifen for breast cancer, Mirena can be used to
counteract endometrial hyperplasia
Contraindications for Insertion of IUCD
(1) Presence of pelvic infection current or within 3 months; (2) Undiagnosed
genital tract bleeding; (3) Suspected pregnancy; (4) Distortion of the shape of the
uterine cavity as in fibroid or congenital uterine malformation; (5) Severe
dysmenorrhea; (6) Past history of ectopic pregnancy; (7) Within 6 weeks following
cesarean section; (8) Sexually transmitted infections (STIs): Current or within 3
months; (9) Trophoblastic disease; (10) Significant immunosuppression.
Additionally for Cu-T are: (11) Wilson disease, and (12) Copper allergy. For LNGIUS are: (13) Hepatic tumor or hepatocellular disease (active); (14) Current breast
cancer and (15) Severe arterial disease
TECHNIQUE OF INSERTION
(1) History-taking and examinations (general and pelvic) to exclude any
contraindication of insertion. (2) Patient is informed about the various problems,
the device is shown to her and consent is obtained. (3) The insertion is done in
the outpatient department, taking aseptic precautions without sedation or
anesthesia. To reduce cramping pain Ibuprofen [Nonsteroidal anti-inflammatory
drug (NSAID)] may be given (200–400 mg) 30 minutes before insertion. (4)
Placement of the device inside the inserter—the device is taken out from the
sealed packet
(1) The patient empties her bladder and is placed in lithotomy position. Uterine
size and position are ascertained by pelvic examination. (2) Posterior vaginal
speculum is introduced and the vagina and cervix are cleansed by antiseptic
273 | P a g e
lotion. (3) The anterior lip of the cervix is grasped by Allis forceps. A sound is
passed through the cervical canal to note the position of the uterus and the
length of the uterine cavity. The appropriate length of the inserter is adjusted
depending on the length of the uterine cavity. (4) The inserter with the device
placed inside is then introduced through the cervical canal right up to the fundus
and after positioning it by the guard, the inserter is withdrawn keeping the
plunger in position. Thus, the device is not pushed out of the tube but held in
place by the plunger while the inserter is withdrawn (withdrawal technique in
Figure 30.2). (5) The excess of the nylon thread beyond 2–3 cm from the external
os is cut. Then the Allis forceps and the posterior vaginal speculum are taken off.
No-touch’ insertion technique includes: (i) Loading the IUD in the inserter without
opening the sterile package. The loaded inserter is now taken out of the package
without touching the distal end. (ii) Not to touch the vaginal wall and the
speculum while introducing the loaded IUD inserter through the cervical canal
MECHANISM OF ACTION
Several mechanisms are responsible for the contraceptive effect of an IUCD.
• The presence of a foreign body in the uterine cavity renders the migration
of spermatozoa difficult.
• A foreign body within the uterus provokes uterine contractility through
prostaglandin release and in- creases the tubal peristalsis so that the
fertilized egg is propelled down the fallopian tube more rapidly than in
normal and it reaches the uterine cavity before the development of
chorionic villi and thus is unable to implant.
• The device in situ causes leucocytic infiltration in the endometrium. The
macrophages engulf the fertilized egg if it enters the endometrial tissue.
• Copper T elutes copper which brings about certain enzymatic and
metabolic changes in the endometrial tissue which are inimical to the
implantation of the fertilized ovum.
• Progestogen-carrying device causes alteration in the cervical mucus which
prevents penetration of sperm, in addition to its local action. It also causes
endometrial atrophy. It prevents ovulation in about 40%.
ADVANTAGES
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• Inexpensive: Cu-T distributed free of cost through government channel
• Simplicity in techniques of insertion and most cost effective of all methods
• Prolonged contraceptive protection after insertion (5–10 years) and
suitable for the rural population of developing countries
• Systemic side effects are nil. Suitable for hypertensives, breastfeeding
women and epileptics
• Reversibility to fertility is prompt after removal
DISADVANTAGES
• Require motivation
• Limitation in its use
• Adverse local reactions manifested by menstrual abnormalities, pelvic
inflammatory devices (PID), pelvic pain and heavy periods. Side effects
are less with third generation of intrauterine devices (IUDs)
• Risk of ectopic pregnancy
209. Hormonal contraceptive agents: combined oral pills. Their mechanism of
action, benefits, side effects, contraindications.
The combined oral steroidal contraceptives is the most effective reversible
method of contraception. In the combination pill, the commonly used progestins
are either levonorgestrel, or norethisterone, or desogestrel and the estrogens are
principally confined to either ethinylestradiol or mestranol (3-methyl ether of
ethinyl estradiol).
MECHANISM OF ACTION – The combined oral pill suppresses pituitary hormones,
FSH and LH peak and through this suppression prevents ovulation. At the same
time, progestogen causes atrophic changes in the endometrium and p t-events
nidation. Progestogen n also acts on the cervical mucus making it thick and
tenacious a impenetrable by sperms. OCP also increases the tubal motility, so the
fertilized egg reaches the uterine cavity) before the endometrium is receptive for
implantation
BENEFITS
a) Use of OCP results in regular cycles and average blood loss during
menstruation. It is helpful in women with menorrhagia and
polymenorrhoea. It also relieves dysmenorrhoea and premenstrual tension.
275 | P a g e
b) It prevents anaemia by reducing the menstrual blood loss.
c) It lowers the incidence of benign breast conditions such as fibrocystic
disease.
d) It reduces the incidence of functional ovarian cyst (50%).
e) Reduce incidence of malignancies. Both ovarian and endometrial
malignancies are less common among regu- lar users of OCP. The incidence
of ovarian malignancy is reduced by 40% and uterine malignancy by 50% if
taken for 1 year, this protective effect lasts as long as 10 years after
stoppage of use of OCPs. The incidence of PID is reduced, though it does
not reach the same low level as seen with the barrier method. This
protective effect is due to the thick cervical mucus caused by progestogen,
preventing the microorganisms entering into the uterine cavity.
f) Reduced incidence of ectopic pregnancy is due to suppression of ovulation
and reduction in PID.
g) It protects against rheumatoid arthritis.
h) Reduces the risk of anorectal cancer by 30%-40%.
i) It is useful in acne, Polycystic Ovarian Disease (PCOD) and endometriosis.
SIDE EFFECTS
• Intermenstrual spotting is common in the first 3 months. Amenorrhea
lasting more than 6 months requires investigations.
• Genital tract candidiasis. Oral pills are associated with monilial
(candidial) vaginitis.
• No documented association is seen with carcinoma of cervix; however,
dysplasia is more frequent.
• No adverse effect has been noted on uterine fibroids, and it is oestrogen
singly that increases their size.
• Breast. The combined pills should not be offered to a woman suffering
from cancer of the breast.
• Pituitary adenoma was attributed to the use of the pill but its exact role
in its development is not clear and doubtful.
• Breast milk amount in lactating woman who chooses to use OCPs is
reduced.
• Liver. Adenomas have been reported and though they are benign rarely
a rupture of a hepatoma can be fatal. Because the hormones are
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•
•
•
•
•
•
metabolized in the liver, chronic liver diseases and recent jaundice
contraindicate the use of pills. Gall bladder function may be adversely
affected.
Carbohydrate metabolism. Carbohydrate tolerance may be reduced.
Therefore, combined oral pills are contrain- dicated or given cautiously
to a diabetic woman.
Lipid metabolism. Oestrogen increases the high-density lipoprotein
(HDL) and lowers low-density lipoprotein (LDL).
Headache, migraine, depression, irritability, increased weight and
lethargy can occur due to progestogen.
Thromboembolic disorders. Pulmonary embolism and cerebral
thrombosis, both venous and arterial, are 7-10 times more frequent in
the pill users than in the nonusers in the first year of use.
Sickle cell anaemia patients can develop thrombosis and crisis.
A woman who wears contact lenses should be warned of oedema and
irritation of eyes (thrombosis of optic vessels) it is a relative
contraindication.
CONTRAINDICATIONS TO THE USE OF OCPS
a) Cardiac disease, hypertension, smoker older than 35
b) Diabetes.
c) History of thrombosis, myocardial infarction, sickle cell anaemia, severe
migraine.
d) Chronic liver diseases such as cholestatic jaundice of pregnancy, cirrhosis of
liver, adenoma, porphyrias.
e) Breast cancer, gall bladder disease.
f) Gross obesity.
g) Patient on enzyme-inducing drugs such as and antiepileptics except sodium
valproate. rifampicin,
h) 4-6 weeks prior to a planned surgery.
i) Lactating woman.
210. Hormonal contraceptive agents: POP (indications, contrindications, side
effects, advantages.
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POP is devoid of any estrogen compound. It contains very low dose of a progestin
in any one of the following form— levonorgestrel 75 µg, norethisterone 350 µg,
desogestrel 75 µg, lynestrenol 500 µg or norgestrel 30 µg. It has to be taken daily
from the first day of the cycle.
MECHANISM OF ACTION – It works mainly by making cervical mucus thick and
viscous, thereby prevents sperm penetration. Endometrium becomes atrophic, so
blastocyst implantation is also hindered. In about 2% of cases ovulation is
inhibited and 50 percent women ovulate normally.
ADVANTAGES – (1) Side effects attributed to estrogen in the combined pill are
totally eliminated (2) No adverse effect on lactation and hence can be suitably
prescribed in lactating women and as such it is often called ‘Lactation Pill’ (3) Easy
to take as there is no ‘On and Off’ regime (4) It may be prescribed in patient
having (medical disorders) hypertension, fibroid, diabetes, epilepsy, smoking, and
history of thromboembolism (5) Reduces the risk of PID and endometrial cancer.
DISADVANTAGES – (1) There may be acne, mastalgia, headache, breakthrough
bleeding, or at times amenorrhea in about 20–30% cases (2) All the side effects,
attributed to progestins may be evident (3) Simple cysts of the ovary may be
seen, but they do not require any surgery (4) Failure rate is about 0.5–2 per 100
women years of use. Failure is more in young compared to women over 40.
Women using drugs that induce liver microsomal enzymes to alter a metabolism
(mentioned above) should avoid this method of contraception.
CONTRAINDICATIONS – (i) Pregnancy, (ii) unexplained vaginal bleeding, (iii) recent
breast cancer, (iv) arterial disease and (v) thromboembolic disease
211. Hormonal contraceptive agents: depot injections (drugs, dosage, route of
administration, indications, advantagcs and disadvantages).
• Depot Injections of Progesterone. Although not very popular in India depot
injections of progesterone (Depot medroxyprogesterone acetate, DMPA;
norethisterone enanthate NET-EN) are two commonly used intramuscular
injections of progesterone.
• In fact, in more than 125 countries these are available in the Family Planning
Pro- grams. Ease of administration, repeating action at 2-3 monthly intervals
and high efficacy have made this mode of administration of contraceptives
very popular.
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• To overcome the inconvenience of daily compliance, depot injections of
progestogens have been developed.
• DMPA is given in a microcrystalline aqueous suspension and NET-EN in a castor
oil solution, both by deep intramuscular injec- tion (subcutaneous preparation
of DMPA is also available in 104 mg).
• Menstrual irregularity though common 18 accepted by puerperal woman as
physiological. The injection should be started within a month of delivery in a
non- lactating woman and during the third month in a lactating woman
because ovulation is delayed up to at least 10 weeks in lactating mothers.
Pregnancy rate is 0.4 per 100 woman- years for DMPA and 0.6 per 100
woman-years for NET-EN.
• The injection should be administered within 7 days of menstruation with a
grace period of 2 weeks for DMPA and 1 week for NET-EN for a repeat
injection. Action lasts 12-14 weeks of the first injection for DMPA and 8-9
weeks for NET-EN.
Advantages
• Injections are easy to administer and there is no worry over 'missing pill'.
They are long-acting and reversible.
• The compliance is good and the woman remains under regular medical
supervision.
• The side effects on lipid and carbohydrate metabolism are avoided. DMPA
is least androgenic.
• It is suited to lactating women.
• The incidence of PID, ectopic pregnancy and functional ovarian cysts is low,
so also endometrial cancer.
• Avoids oestrogenic side effects.
• Can be given to a woman with sickle cell anaemia.
• Return of fertility is slightly delayed in DMPA group com- pared to NET, but
80% conceive within a year (5 months for DMPA and 3-4 months for NETEN).
• Independent of coitus.
• They turn out to be more cost-effective for mass usages.
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Disadvantages
• Once administered, the side effects, if any, need to be toler- ated until the
progestogenic effect of the injection is over.
• Menstrual irregularities are common in the form of amenorrhoea or
irregular bleeding. Amenorrhoea is reported in 20%-50% users of DMPA at
the end of 1 year and are more common with DMPA than NET. Heavy and
irregular bleeding is reported in 1%-2% users and is more common with the
use of NET.
• Do not prevent STD and HIV.
• There is a delay in return of fertility but 80% are expected to conceive by
end of 1 year. With DMPA, ovula- tion returns in 5 months, and with NET
within 3 months of the last injection.
• The side effects in the form of weight gain, depression. bloated feeling and
mastalgia can occur with injectable progestogen.
• Prolonged DMPA use, by virtue of antioestrogenic action, may reduce bone
density mass and induce osteopenia.
• Contraindicated in breast cancer.
• It does increase LDL but does not adversely affect the blood pressure.
• It may decrease libido, cause dry vagina.
Because of risk of osteopenia, this contraceptive is contraindicated in adolescents,
and should not be used for more than 2 years in others. Lately, subcutaneous
injections are under development to enable self-administration by the woman.
Once-a-Month Injections. Once-a-month intramuscular injections of combined
oestrogen and progestogen are available in some countries. These are as follows:
• MESIGYNA - (1/2 mL containing NET 50 ing with oestra- diol valerate 5 mg) is
given by deep intramuscular injec- tion once a month with 3 days. The low
failure rate of 0.4% at the end of 1 year is encouraging.
• CYCLOFEM AND LUNELLE - 1/2 mL contains 25 mg DMPA and oestradiol
cypionate 5 mg. The failure rate is 0.2% at the end of 1 year. The menstrual
irregularity is less than with progestogen-alone injections.
• MARVELON - Desogestrel 150 mcg with EE 30 mcg.
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• FEMOVAN - Gestodene 75 mcg with EE, 30 mcg.
• ANAFERTIN - Dihydroxyprogesterone acetophenide 75 mg + estradiol
enanthate 5 mg.
212. Hormonal contraceptive agents: subdermal implants (drugs, route of
administration, contraindications, advantages and disadvantages).
Implants are inserted subcutaneously over the anterior abdominal wall using local
anesthesia. 17 β-estradiol implants 25 mg, 50 mg or 100 mg are available and can
be kept for 6 months. This method is suitable in patients after hysterectomy.
Implants maintain physiological E2 to E1 ratio.
In the quest to find alternative routes of giving hormonal contraceptives,
subdermal implants were discovered. With this method, the progestogens are
delivered into general circulation with a slow and sustained release manner with
lesser side effects. There are two types of subdermal implants, biodegradable and
nondegradable. Once im- planted they release drug slowly over a period of 1-5
years depending upon the implant.
• The subdermal implant has no nuisance value of continuous compliance
which often adversely affects motivation. Besides, being nonoral it avoids
hepatic first-pass effect and thus, reduces systemic side effects.
• Norplant I. Norplant I was the first subdermal implant introduced for
contraception containing six silastic capsules, it has now been withdrawn
from the market and replaced by a single rod implant.
• Norplant II (Jadelle) was the second implant system introduced for
contraception. It consisted of two rods each containing 70 mg LNG with a
daily release of 50 provides contraception for 3-5 years. mcg and The
implants suppress ovulation in 50% of the cycles but the main mechanism
of action is suppression of endometrium.
INSERTION OF IMPLANTS.
• The implants are inserted on the first day of the menstrual cycle or within 5
days of abortion, and 3 weeks after the delivery. The woman needs to use
barrier contraception or abstain in the first 7 days after insertion.
• It takes 5-10 minutes to insert under local anaesthesia. It is best inserted on
the medial aspect of the upper arm. The capsules are nonbiodegradable, so
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they need removal at the end of its use or earlier, if side effects are
intolerable.
• The insertion and removal is made easier using a single rod system called
Implanon (40 x 2 mm), which contains 68 mg etonogestrel and does not
require an incision to insert. It releases 30 mcg of the hormone daily and is
effective for 3 years. There has been no failure to date. It prevents
ovulation and is reversible within 1 month of removal.
• With the use of Implanon, amenorrhoea is common at the end of 1 year.
Acne is reduced and it has no effect on bone density.
ADVANTAGES
• They are long-acting with sustained effect-compliance is good.
• Coital-independent with no 'nuisance of daily oral or frequent injections.
• Pregnancy rate varies between 0.2 and 1.3 per 100 woman- years. The
failure rate is higher in obese women weighing more than 70 kg.
• Systemic side effects are few and the first-pass effect on the liver avoided.
• Return of fertility is prompt (within 4-12 weeks).
• Can be used by lactating mothers and women older than 40 years.
DISADVANTAGES
• Breakthrough bleeding, irregular cycles, amenorrhoea occur as seen with
other progesterone only contraceptives.
• Other side effects of progestogens are seen.
• Ectopic pregnancy is reported in 1.3%.
• Local infection at the site of insertion may occur.
• Requires insertion and removal with nonbiodegradable implants; however,
it is a minor surgical procedure.
• The implants are expensive.
• Infertility may be seen in a few cases after the removal of implant.
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213. Hormonal contraceptive agents: silastie vaginal rings (mechanism of action,
advantages and disadvantages).
• Another route which has been tested and found suitable for delivery of
hormonal contraceptive is in the form of contra- ceptive vaginal rings.
• In an attempt to reduce the side effects of systemic hormonal contraception
and the surgical method of insertion of implants, silastic vaginal rings carrying
progestogens in different doses have been tried.
• The ring is 50-75 mm in diameter and 5-9 mm thick.
• The ring currently available contains LNG released at a rate of 20 mcg of
hormone daily.
• The ring needs a change after 3 months.
• Another ring which contains both oestrogen and progesterone is available in
the market by the name of NuvaRing containing 11.7 mg etonogestrel and 2.7
mg ethinvloestradiol.
• NuvaRing is effective for 1 month.
• Advantage of NuvaRing is that incidence of breakthrough bleeding and
spotting is less compared to vaginal ring containing only progesterone. Failure
rate is 13 per 100 woman-vears.
Recently, a lot of research is going on in this field, some progestin-containing rings
(3-keto desogestrel 10 mg) have been left in for 5 months at a time. The
pregnancy rate with this is reported to be woman-years (WHO, 1985). A ring
releasing 30 meg LE with either 120 mcg desogestrel or 650 meg norethister one
is under trial. per 100
Other rings are as follows:
a) NuvaRing - 120 meg etnogestrel + 15 mcg EE, daily release can be removed
during intercourse but not for more than 3 hours at a time
b) Nestorone 150 mcg progesterone +15 meg EE, effect tive for 1 year: failure
rate is 1.2 per 100 womanseats.
ADVANTAGES
• Self insertion and removal good compliance.
• Other advantages of progestogen contraceptives.
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• Quick reversibilis.
DISADVANTAGES
• Expensive. Rs 700 per ring per cycle
• Local irritation is felt by few vaginitis
• Expulsion can occur especially in woman with vaginal prolapse.
• Systemic side effects of progestogens have been noted in some women,
214. Hormonal contraccptive agents: skin patches (route of administration,
mcchanism of action, side effects, contraindications).
• Hormonal Patch (Ortho-Evra). Another route of hormonal contraceptives
which has been tested in clinical practice is a skin patch impregnated in
hormone. A Ortho Evra Hormonal patch releases 6.00 mg norelgestromin
(NGMN) and 0.75 mg EE. A patch lasts 7 days. Three patches are required in
each cycle followed by 1-week patch-free inter- val. The patch should be
applied within 5 days of menses over the buttocks or abdomen but not over
the breasts.
• The failure rate is 1-2.8 per 100 woman-years. Compliance of 90% is reported.
The breakthrough bleeding (18%). skin reaction (20%) and breast discomfort
are the side effects. The other symptoms are headache, nausea and mastalgia.
The site of patch should be changed often and is contraindicated in obese
women.
• Although found popular among women in rich countries, its popularity is low
in India. Because of sweating, excessive heat the patch may get displaced
decreasing its effectiveness.
215. Postcoital contraception.
EMERGENCY CONTRACEPTION (EC) – Hormones, IUD, Antiprogesterone and
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Others
Indications of emergency contraception: Unprotected intercourse, condom
rupture, missed pill, delay in taking POP for more than 3 hours, sexual assault or
rape and first time intercourse, as known to be always unplanned. Risk of
pregnancy following a single act of unprotected coitus around the time of
ovulation is 8%
HORMONES
• Morning-after pill: This is not true contraception, but has rightly been called
interception, preventing conception in case of accidental unprotected
exposure around the time of ovulation. Drugs commonly used are
levonorgestrel ethinyl estradiol 2.5 mg. The drug is taken orally twice daily for
5 days, beginning soon after the exposure but not later than 72 hours.
• Levonorgestrel (E. Pills) 0.75 mg, two doses given at 12 hours interval, is very
successful and without any side effects. The two tablets (1.50 mg) can be taken
as a single dose also. The first dose should be taken within 72 hours (Fig.
30.11) may be taken upto 120 hours.
• No fetal adverse effects has been observed when there is failure of emergency
contraception. However, induced abortion should be offered to the patient, if
the method fails.
• Other - Levonorgestrel (POP), Copper IUDs (gold standard), Ulipristal acetate
(SPRM), Ethinyl estradiol 50 μg + Norgestrel 0.25 mg (COC), Mifepristone RU
486 (PA)
MODE OF ACTION: The exact mechanism of action remains unclear. The following
are the possibilities:
• Ovulation is either prevented or delayed when the drug is taken in the
beginning of the cycle.
• Fertilization is interfered.
• Implantation is prevented (except E. Pills) as the endometrium is rendered
unfavorable.
• Interferes with the function of corpus luteum or may cause luteolysis.
DRAWBACKS: Nausea and vomiting are much more intense with estrogen use.
Antiemetic (meclizine) should be prescribed
COPPER IUD
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• Introduction of a copper IUD within a maximum period of 5 days can prevent
conception following accidental unprotected exposure. This prevents
implantation. Failure rate is about 0–1%. It is the gold standard method to be
offered to all women for EC.
• ADVANTAGE: It can be kept in place for 10 years if desired as a regular method
of contraception. Postcoital contraception is only employed as an emergency
measure and is not effective if used as a regular method of contraception.
Combined hormonal regimen (Yuzpe method) is equally effective. Two tablets
of Ovral (0.25 mg levonorgestrel and 50 µg ethinyl estradiol) should be taken
as early as possible after coitus (< 72 hours) and two more tablets are to be
taken 12 hours later. Oral antiemetic (10 mg metoclopramide) may be taken 1
hour before each dose to reduce the problem of nausea and vomiting.
ANTIPROGESTERONE
• Antiprogesterone (RU 486-Mifepristone) binds competitively to progesterone
receptors and nullifies the effect of endogenous progesterone.
• Dose: A single dose of 100 mg is to be taken within 17 days of intercourse.
Implantation is prevented due to its anti-progesterone effect. Pregnancy rate
is 0–0.6%.
• Ulipristal acetate as an EC is superior to levonorgestrel. It is a progesterone
receptor modulator. A single dose 30 mg, to be taken orally as soon as possible
or within 120 hours of coitus. It acts by suppressing follicular and endometrial
growth. It delays ovulation and inhibits implantation. It should not be
prescribed in women with severe hepatic dysfunction nor with severe asthma
216. Surgical male and female sterilization.
VASECTOMY
Vasectomy consists of dividing the vas deferens and disrupting the passage of
sperms. It is done through a small incision in the scrotum, under local anesthesia.
The sterility is not immediate. The sperms are stored in the reproductive tract for
up to 3 months. The couple must therefore abstain from intercourse during this
period or use some other methods of contraception such as condoms.
Approximately, 20 ejaculates clear the semen of all sperms. Two semen analysis
reports must confirm the absence of sperms before the man can be declared
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sterile. No-scalpel technique has been now adopted. One single incision is made
with a special forceps and skin stitch is not required. Clips and plugs can be
applied over the vas instead of cutting. Vasectomy is cheaper than tubectomy
Reversible inhibition of sperm under guidance (RISUG) has been experimented by
All India Institute of Medical Sciences and Indian Institute of Technology in India.
A polymer gel is injected into the vas. Reversibility is possible by flushing the vas
with sodium bicarbonate. This technique is under trial.
COMPLICATIONS
• Local pain, skin discolouration, bleeding, haematoma formation (1%-2%).
• Infection (1%), trauma to the testicular artery causing gangrene, rare.
• Antibody formation and autoimmune disease (10%). Failure rate of 0.15 per
100 woman-years at the end of 1 year.
• Granuloma formation in 0.1%-3% cases. Spontaneous recanalization.
• Formation of spermatocele.
• Decreased libido or impotency are mainly psychological in origin and occur
in men who were not properly motivated.
• Does not prevent HIV, STD.
ADVANTAGES
• It is an outpatient procedure.
• Local anaesthesia is adequate.
• It is a minor surgical procedure and the man can resume duty after rest of 1
or 2 days.
• Libido not affected. No evidence of prostate cancer.
REVERSIBLE INHIBITION OF SPERM UNDER GUIDANCE (RISUG)
NEWER TECHNIQUES
New nonsclerotic occlusive copolymer of styrene maleic anhydride (SMA) - lowers
pH of semen and alters sperm transportation and morphological changes in the
sperms. This copolymer is injected in the lumen of vas deferens under ultrasound
guidance with the help of a fine hypoder- mic needle. Its action begins
immediately and action can be reversed subsequently by injection of another
copolymer which neutralizes its action.
Chemical sclerosing agents such as 90% ethanol, 3.6% formaldehyde, silver
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nitrate, hydrogen peroxide, acetic acid can eliminate the need of surgery, are
effective and easily administered. However, the consequence of intravascular
injection and excessive destruction of the vas by even a slight increase of
instillation can be disastrous and the procedure is irreversible.
Occlusive plugs and intravasal devices are still in the experimental stage.
PLUGS
A device called 'SHUG' consists of two flexible silicon plugs connected by a nylon
thread which lies outside the vas. This thread prevents migration of plugs and
allows easy removal through a small incision.
Contraindications to vasectomy are as follows:
• Local skin infection
• Varicocele, hernia
• Undescended testis
FEMALE STERILIZATION (TUBECTOMY, TUBAL STERILIZATION)
Tubal ligation can be done at any time convenient to the patient. Postpartum
sterilization is done within the first week of delivery when the patient is already
hospitalized. Interval sterilization is done when the woman is not pregnant or any
time after 6 weeks of delivery. Tubec- tomy can also be combined with caesarean
section.
INDICATIONS
Apart from multiparity and the need of permanent method of family planning,
sterilization may be advisable in women with medical diseases. Indications are as
follows:
• Multiparity
• Three caesarean deliveries
• Medical diseases making a subsequent pregnancy high risk.
• Psychiatric problems
• Breast cancer
• Eugenic - repeat fetal malformations, haemophilia, Rh incompatibility,
Wilson disease. Tay-Sachs disease and Marfan syndrome.
The interval surgery should preferably be done soon after menses to avoid the
potential risk of pregnancy in the postovulatory period.
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CONTRAINDICATIONS
• Woman younger than 25 years (as directed by the Government of India).
• Parity less than two children (as per the Government rule).
• Local infection.
METHODS OF STERILIZATION
1. Laparotomy - sterilization is performed during caesarean section and during
gynecological surgery.
• Pomeroy method
• Madlener method
• Irving method
• Aldridge method
• Cornual resection
• Uchida method
• Fimbriectomy
2. Mini-laparotomy - The operation is performed through a small incision less
than 2.5 cm in length. Because of its simplicity and ease of doing operation this
procedure is advocated for routine sterilization especially in a smaller set up.
• Pomeroy
• Madlener
• Aldridge
• Uchida
• Fimbriectomy
3. Vaginal route – Vaginal tubal ligation is not popular because of higher
morbidity and because of relatively more difficulty in performing the
procedure. The pouch of Douglas is opened after placing patient in a lithotomy
position, the fallopian tube is hooked out with finger or Babcock and
tubectomy performed. It is associated with risk of pelvic infection, higher
failure rate and it is more difficult to perform. It is mainly combined with the
Manchester repair operation for prolapse of uterus.
4. Laparoscopy – Silastic ring, bipolar cautery, Filshie – This technique has
become the most commonly used technique of tubal sterilization.
Laparoscopic sterilization is carried out under local or general anesthesia. A
small sub umbilical incision is made and pneumoperitoneum created by
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inserting a Veress needle and introducing CO2. CO2 is safer than air and
nitrous oxide which can cause air embolism and accidental ex- plosion,
respectively. With the patient in the head low position, the trocar and cannula
are inserted through the incision and an operating laparoscope introduced
after removing the trocar Each fallopian tube is picked up near the isthmic end
(2-3 cm away) and it clipped/banded (silastic bands) (Filshie, Hulka band,
silastic ring) or cauterization of a segment of the tube done with a bipolar
cautery. The gas is allowed to escape at the end of the procedure and the
instruments are removed. A subcuticular skin stitch completes the operation.
The failure rate with this technique is 0.6 per 100 woman-years.
5. Hysteroscopy – Chemical agents, Essure clip. – In this technique during
hysteroscopy either a chemical agent or some plug is introduced in the cornual
of the fallopian tube. The technique of using sclerosing agents and quinacrine
has been abandoned because of high failure rate, and other complications
such as uterine perforation, burn injury and infection.
217. Contraception for adolescents.
In India, many girls get married at an early age and become mothers. They need
counselling regarding spacing and delaying the birth of the next child. Unmarried
adolescents are exposed to the risk of unwanted pregnancy and unsafe abortion,
as well as the possibility of acquiring AIDS and sexually transmitted infections.
Family planning and contraception become impor tant health care issues amongst
adolescents. Although sex education will provide benefit, many will require
contraceptive guidance and provision of a suitable contraception.
BARRIER METHOD
• It is the best method in young girls. Apart from providing contraceptive
method, it can prevent transmission of infections from one partner to the
other.
• If the man refuses to use condoms, a married woman can use Today
sponge with spermicidal cream. A recently married woman may find barrier
method cumbersome in the initial stages.
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• The adolescent should receive informed knowledge on 'unsafe period'
when ovulation occurs, and be provided with emergency contraception
such as LNG, two tablets. This is because periodic abstinence is difficult
amongst the young couples.
IUCD
• While IUCD may not be a suitable contraceptive device in the unmarried
and recently married nulliparous women, it is a long-term coitalindependent method suited to young parous women, provided no
contraindi- cation exists for its use. It is one of the best methods for spacing
childbirth. Progesterone copper device is recommended if the woman has
heavy periods with dysmenorrhoea.
HORMONAL CONTRACEPTIVES
• COC pills can be safely prescribed to adolescents. One must remember the
possibility of breast cancer at a later date if the young nulliparous woman
younger than 24 years of age takes COC for more than 4 years.
• POPs are not preferred over COC, because of the irregu- lar bleeding,
amenorrhoea, a higher failure rate and osteo- penia.
• Three-monthly injections or implants, skin patches and vaginal rings may be
acceptable to young married adolescents, and side effects tolerated.
Occasional failure may be backed up with MTP facilities.
• Sterilization should not be offered to young couples. The Government of
India has passed a law that the surgical procedure should not be performed
in a woman younger than 25 years with two or less children and the child
less than 2 years old. youngest
• MTP and emergency contraception should form the backup procedures in
these girls.
218. Lactational amenorrhoea.
Regular breastfeeding with at least one feed at night is shown to prevent
pregnancy for initial 6 months after delivery, with a failure rate of only 0.5%-1.5%.
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This occurs due to prolactin preventing LH surge and ovulation. There- after, the
protective effect wears off. Apart from the beneficial effects of lactation on the
newborn, it is advocated as the natural method of family planning in the first 6
months after childbirth. Beyond 6 months of breastfeeding, prolactin level falls
and ovulation can occur. It is the frequency rather than the duration of feed that
decides an ovulation in a nursing mother.
Prolonged and sustained breastfeeding offers a natural protection of pregnancy.
This is more effective in women who are amenorrheic than those who are
menstruating. The risk of pregnancy to a woman who is fully breastfeeding and
amenorrheic is less than 2% in the first 6 months. Otherwise, the failure rate is
high (1–10%). Thus during breastfeeding, additional contraceptive support should
be given by condom, IUCD or injectable steroids where available to provide
complete contraception. When the women is full breastfeeding, a contraceptive
method should be used in the 3rd postpartum month and with partial or no
breastfeeding, she should use it in the 3rd postpartum week. Fertility awareness
based methods are: (1) Natural contraception (rhythm method, coitus
interruptus, and LAM) (2) Barrier method (condoms, diaphragm, and spermicides)
219. Contraception for women over the age of 35 years.
CONTRACEPTION FOR WOMEN OLDER THAN 35 YEARS
Women older than 35 years constitute 20% of the contra- ceptive users, and
selection of the proper contraception is an essential component of family
planning counselling. A woman after the age of 35 years may become obese,
hypertensive and diabetic. She is likely to suffer AUB. The choice depends upon
the suitability, contraindication and side effects.
STERILIZATION
• When considering a permanent method of sterilization, one should weigh the
risk of surgical procedure against the number of years a woman needs
contraceptive protection. In a woman nearer the menopause with a fewer
years of fertility, surgical procedure may not be a wise proposition, and
temporary methods will be cost-effective as well as safe, with emergency
contraception and MTP as a back-up method.
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LOW-DOSE COC PILLS
• They are safe, if the woman is thin, nonsmoker without any medical disease up
to the age of 15 years.
• Although POPs may be safer than COC, its adverse effect on bone density and
occurrence of osteoporosis must be borne in mind if given over a prolonged
period. Besides, they cause irregular bleeding, and the risk of breast cancer
increases.
• IUCD may be suitable and effective. If the woman suffers from menorrhagia,
Mirena may be inserted and is effective for 5 years.
• Desogestrel and gestodene cause thromboembolism and are contraindicated
in elderly women.
220. Contraception for woman with medical disease.
• The risk of pregnancy should be weighed against the risk of any
contraception in a woman with medical disorder. While prescribing a family
planning method, due consideration and counselling related to side effects
is necessary.
• If the risk is negligible, sterilization provides the perma- nent method to
prevent a pregnancy. Vasectomy would be ideal, with no risk to the
woman.
• IUCD is carefully considered in cardiac and diabetic women, because of the
possibility of pelvic infection.
• COC is contraindicated in a hypertensive, cardiac and diabetic women, as
well as a woman with breast cancer, liver disease and previous
thromboembolism. An epileptic woman and a woman on antitubercular
drugs such as rifa- mycin may face a higher failure rate due to interaction
with rifamycin and antiepileptic drugs except sodium val- proate.
• Similarly POP is contraindicated in liver diseases, vascular disorders and
breast cancer. It is safe in sickle cell anaemia.
• Emergency contraception (LNT tablets) is safe in a woman with medical
disorders.
• Contraception for a Woman with Psychiatric Disorder.
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• If a woman is considered unfit to bear children, and permanent method
considered, a written opinion regarding psychiatric problem should be
obtained. The written consent should be obtained from the husband or
guardian. as the psychiatric patient may not be mentally aware of the
nature of sterilization.
• Emergency contraception is no bar to a woman with a medical disorder, as
only two tablets are given in 24 hours.
221. Medical termination of pregnancy in India and in Russia.
The MTP Act permits the wilful termination of pregnancy before the age of fetal
viability (20 weeks' gestation) for well-defined indications. It has to be performed
by recognized medical practitioners in a recognized place approved by the
competent authority under the Act.
INCIDENCE
It has been estimated that the total number of abortions performed globally is
approximately 46 million annually; of these, 26 million take place in countries
where abortions are legalized. In India, 6.7 million MTPs take place annu- ally.
However, exact incidence remains unknown. In women undergoing MTP, 40%
pregnancies are unplanned and 25% are unwanted. Despite the law, 40%-50% of
abortions are unsafe terminations of pregnancy done by unqualified persons
under unhygienic conditions.
GROUNDS FOR PERFORMING MTP
The MTP Act has permitted termination of pregnancy for following indications:
222. Grounds for perfornming MTP.
MEDICAL GROUNDS
When the continuation of pregnancy is likely to (i) endan- ger the life of the
pregnant women or (ii) cause grievous injury to her physical and/or mental
health, as in cases of severe hypertension, cardiac disease, diabetes, psychiatric
illnesses, genital and breast cancer.
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EUGENIC GROUNDS
When ultrasound shows a malformed embryo or fetus or there is a substantial
risk of the child being born with serious physical or mental abnormalities. For
example, hereditary disorders, congenital malformation in previous offspring with
a high risk of recurrence in subsequent child- birth/Rh-isoimmunization,
teratogenic drugs and maternal rubella posing risk of anomalies in the fetus.
Chorion villus biopsy, cordocentesis and sonographic evaluation of the fetus have
contributed significantly in identifying the fetuses at risk.
HUMANITARIAN GROUNDS
In cases when the pregnancy is caused by rape or incest.
SOCIAL GROUNDS
When: (i) in the actual or reasonably foreseeable future, her [environment (social
or economic) might lead to risk of injury to her mental or physical health. (ii)
pregnancy resulting from failure of contraceptive device or method.
The written consent of the patient on a specially prescribed form is necessary
before undertaking the procedure. The written consent of the legal guardian must
be obtained in case the woman is younger than 18 years or she is mentally ill,
even if she is older than 18 years.
223. The persons who can perform the MTP and the place for performing 222
MTP.
WHO CAN PERFORM MTP?
Only doctors who have been registered and authorized by the District Health
Authorities for the purpose of carrying out MTP can carry out MTP. Generally for
carrying out the first-trimester MTP, opinion and signature of one doctor is
sufficient. However, for the termination of pregnancy between 12 and 20 weeks,
opinion of two certified doctors is must.
THE PLACE FOR PERFORMING MTP
The Act stipulates that MTP can be performed only at: (i) a hospital established
and maintained by the government, (ii) a place recognized and approved by the
government, under this Act.
• Abortion services are provided under this Act at these centres under strict
confidentiality.
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• The identity of the person is treated as a statutory personal matter.
• Ultrasonic scanning plays an important role in confirm- ing uterine
pregnancy, estimating gestational age, detect- ing malformed embryo and
sometimes in performing MTP under ultrasonic guidance.
224. Indications of the MTP act. Methods of MTP.
Indications of MTP are as follows:
• Maternal medical disorders
• Fetal conditions
• Rape, incest
• Failure of contraceptives
• Social grounds
METHODS OF MTP
There are different methods adopted for termination of the first- and secondtrimester pregnancies.
Methods of the first-trimester MTP
• Menstrual regulation
• Dilatation and suction evacuation
• Cervical softening before dilatation and suction evacuation
• Medical methods
Methods of the second-trimester MTP
• Prostaglandins given vaginally, intraamniotic, extra amniotic or
intramuscular
• Surgical evacuation
• Extraovular instillation of drugs such as ethacridine lactate
• Extrauterine methods
The above methods are used singly or in combination. The oxytocic drugs
stimulate myometrial activity and shorten the induction-abortion interval in the
second trimester. Similarly, the use of prostaglandins (gel, supposi- tory) a few
hours before the procedure helps to attain a gradual softening and atraumatic
dilatation of the cervix, facilitating further dilatation and evacuation procedures.
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225. First trimester MTP: surgical methods, medical methods
⎯ 6-8 weeks pregnancy – Medical abortion, menstrual regulation
⎯ 8-12 weeks pregnancy – Suction evacuation, medical methods
⎯ 12-14 weeks pregnancy – Extra amniotic drugs, intramuscular prostaglandins,
vaginal misoprostol
SURGICAL METHODS
Menstrual Regulation
Menstrual regulation consists of aspiration of the contents of the uterine cavity
by means of a disposable plastic cannula (Karman's cannula). It has an attached
plastic 50 mL syringe capable of creating a vacuum of 65 cm Hg. It has a simple
thumb-operated pressure control valve and a piston-locking handle. It is
independent of electricity, is por table and washable. It is effective when carried
out on preg nancy within 12 days of the last menstrual period (LMP). A
paracervical local anaesthetic block or preoperative sedative alone usually suffices
but sometimes in an apprehensive pa tient, general anaesthesia may be
necessary. The occasional complications encountered include failure to evacuate
leading to continuation of pregnancy incomplete evacuation, haemorrhage,
cervical laceration, perforation, infection and anaesthetic complications. If
pregnancy was not confirmed by ultrasound, an ectopic pregnancy may be
missed.
A failure to evacuate is due to following reasons:
1. Too early a pregnancy.
2. Ectopic pregnancy.
3. Uterus bicornuate, aspiration being carried out in a non- pregnant horn.
Rh anti-D globulin 50 mcg im, should be given to an Rh-negative nonimmunized
woman with pregnancy less than 12 weeks.
Medical Abortion
Of late termination of early pregnancy (less than 19-63-days) is being carried out
with the use of mifepristone (RU (86) and misoprostol. This method avoids need
for a surgical method such as menstrual regulation. In India termination of
pregnancy up to 49 days has been permitted for the use of a medical method. In a
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confirmed pregnancy the woman is initially given a tablet of mifepristone contain
ing 200 mg of drug, followed by vaginal administration of 800 mcg of misoprostol.
In most cases, abortion is successful within few hours after administration of
misoprostol. Most women experience continuation of bleeding for a period of 714 days. A repeat ultrasound after 14 days is carried out to check for any retained
products or possible continuation of pregnancy. Some patients may require
suction evacuation for heavy bleeding after medical abortion. Prophylactic
antibiotics are given for a period of 48 hours to 5 days.
TERMINATION OF PREGNANCY BETWEEN
8 AND 12 WEEKS
VACUUM EVACUATION (SUCTION EVACUATION)
Vacuum evacuation is the most efficient method of terminating pregnancy up to
12 weeks of gestation. It has gained rapid acceptance worldwide. The operation
can be generally undertaken under local anaesthetic, paracervical block, coupled
with some sedation if necessary. Apprehensive patients may need general
anaesthesia. The procedure involves examination of the patient in the operation
theatre observing full aseptic precautions. The gestation size and the position of
the uterus are carefully assessed. After administering a paracervical block, the
cervix is held with an Allis vulsellum forceps and dilated by means of Hegar's or
some other metal dilators until adequate dilation is achieved te permit in
reduction of the suction cannula of the appropriate size (diameter corresponding
to the weeks of gestation) into the uterine cavity (Fig. 20.2). When the procedure
is completed, a grating sensation is felt all around the uterine cavity, no further
tissue is aspirated and the internal os begins se gr the Karman cannula which may
also reveal a blood-stained froth.
Vacuum aspiration as a method of MTP has a very low failure rate (<15%).
Complications such as incomplete evacuation, infection, uterine perforation and
excessive bleeding occur in less than 2% of cases. The mortality is less than 2 per
100,000 procedures, Nonimmunized Rh-negative mothers must receive 100 mcg
of anti-D immunoglob after undergoing MTT Failure to end pregnancy is due very
early pregnancy, unrecognized ectopic pregnancy pregnancy in a rudimentary
hom. Preoperative ultrasound is useful in preventing these complications.
MEDICAL METHODS
Prostaglandins and RU 486 have been extensively used as medical methods of
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MTP in early pregnancy. Acting singl they are not as effective as when used in
combination. The medical method avoids hospitalization ne the prolonged
observation, occasional need of surgical temination (fail ure) and the cost of the
drugs are some of the disadvantages.
Prostaglandins
Prostaglandin Injections (Prostin, Carboprost-prostaglandin Fod 250 mcg given im,
every 3 hours up to a maximum of 10 doses has been found to be effective in
initiating the process of abortion. It has not been popular in the first trimester
because of an unacceptably high incidence of incomplete abortion (20% )
requiring surgical intervention to complete the procedure, and the high rate of
smpleasant side effects such as nausea, vomiting, diarrhoea, cramping abdominal
pain, brunchospasm and mild fever at times
Mifepristone (Mifeges! - RU486)
First invented in France, in 1980, RU 186 stands for Roussel Urlaf 186 (boratory
number It is a synthetic steroid, a derivative of 19-nortestosterone. with
antiprogestogenic effect. It also has antiglucocorticoid and weak antiandrogenic
action. By competing with progester- one receptors, it reduces the endometrial
glandular activity accelerais degenerative changes and increases stromal action,
thereby causing sloughing of endometrium. It thus prevents ut disturbs
implantation of the fertilized ovum through luteolysis, It also causes uterine
contractions, softens and slightly dilates the cervix.
The protocol is as follows:
• Witten consent for MTP is required.
• Blood group Rh. Hb, urine albumin
• Ultrasound is done to confirm uterine pregnancy and duration, and exclude
ectopic pregnancy
Day 1: 200 mg of mifepristone given as a single dose the woman is observed for
half an hour and then allowed to go home. Ann-D globulin given to an Rhnegative woman
Day 3: 800 mcg of oral misoprostol (prostaglandin) administered unless abortion
has occurred. Sublingual or vaginal misoprostol is also used but a stronger action
of a sublingual route can cause uterine rupe in a scarred uterus, Puhe and BP are
observed for 2 hours, if all is well patient is allowed to go home.
Nowadays, misoprostol (PGE) vaginal tablet of 400 mcg is inserted instead of oral
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tablet.
Day 14: Follow-up to confirm abortion has occurred; if not, surgical MTP is done.
The bleeding usually starts within few hours of taking mifepristone, and abortion
occurs in about a week
CONTRAINDICATIONS
• IUCD in situ- IUCD should be removed before medical termination to avoid
the risk of perforation.
• Suspected ectopic pregnancy - ultrasound should be done before
termination.
• Hypertension, anaemia, glaucoma, cardiovascular disease, smoker,
asthmatic.
• A woman on anticoagulant (coagulopathy) and glucocortscoid therapy.
Allergy, porphyria, seizures (adrenal failure).
• Previous uterine scar scar rupture can occur with misoprostol
• Fibroid uterus.
• Lactating woman - Since the drugs are secreted in the milk, leading to
diarrhoea in infants. Lactation may be stopped temporarily.
• Gestation period should not exceed 63 days (preferably 49 days).
ADVANTAGES
• Easily stored in room temperature Shelf life: 3 years
• Cheap
• Easy administration
Not contraindicated in patients with asthma.
COMPLICATIONS
• Adrenal failure
• Headache, malise, skin rash, fever, nausea vomiting, danboe
• Failure to abort. 1%
• Misoprostol causes Möbius syndrome in the fes (congenital facial palsy,
limb defects, bladder extrophy. hydrocephalus). Therefore, termination of
pregnancy is strongly recommended if medical termination fails.
• It takes longer time for termination compared to Surgical termination and
longer follow-up of 2 weeks is necessary.
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• Surgery is required in case of failure or is incomplete. In case the woman
starts bleeding profusely emergency surge cal evacuation is required.
Therefore, emergency surgical backup is a must for medical termination of
pregnancy
• The subsequent menstruation may be de Lived by 10-14 days
• Sublingual misoprostol is as effective as vaginal pessary, but side effects are
more severe than with oral tablets and vaginal pessaries.
• If vomiting occurs soon after oral misoprostol, repeat the dose. Vaginal
pessary is safe. Alternative protocols used are as follows:
• 200 mg of oral mifepristone followed by 800 meg vaginal misoprostol on
the third day.
• 200 mg mifepristone and 1 mg tablet of prostaglandin E, analogue,
gemeprost vaginally –
pregnancy failure is reported in 0.2% -2.3% cases.
• Methotrexate 50 mg intramuscular or oral followed 5-7 days later by 800
mcg vaginal misoprostol (repeat misoprostol 24 hours later, if required).
• Epostane - A progesterone-blocking agent is adminis- tered in doses of 200
mcg every 6 hours for 7 days.
Misoprostol alone for termination of pregnancy between 8 and 12 weeks:
• For termination of pregnancies between 8 and 12 weeks, misoprostol alone
has been used extensively. Several dosages regime have been employed
with a variable success rate. In most cases induction-abortion interval may
last 24 hours or longer with a risk of incomplete abortion or excessive
bleeding.
MEDICAL VERSUS SURGICAL METHODS FOR TERMINATION OF EARLY PREGNANCY
• While choosing between medical and surgical methods for termination of
early pregnancy, there is not much difference in terms of safety and
efficacy of two methods. However, surgical method has inherent risk of
complications such as perforation of uterus, infection and excessive
bleeding during the procedure.
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226. Late sequels of MTP
Late sequelae of MTP include following:
• Pelvic Inflammatory Disease (PIB) - chronic pelvic pain. • Infertility caused
by tubal infection and blockage.
• Incompetent os following trauma to the cervix; this may lead to preterm
births and recurrent mid-trimester abortions.
• Adherent placenta in the subsequent pregnancy, • Asherman syndrome.
• Ectopic pregnancy as a result of PID.
• Cervical ectopic pregnancy caused by trauma.
• Intrauterine Growth Restriction (IUGR).
• Rh-isoimmunization if anti-D has not been administered after the MTP to
nonimmunized Rh-negative mothers.
• Psychological problems, if MTP was done without proper counselling, and
there is a feeling of regret, especially if infertility follows the procedure.
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