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Ten minutes

To explain about the carcinoma cervix with pregnancy.

Explaining INCIDENCE: The incidence of invasive carcinoma of the about the carcinoma cervix is about 1 in 2500 pregnancies. cervix with DIANGNOSIS: Asymptomatic cytologic screening of all pregnancy pregnant mothers is a routine during antenatal check up in the organised sector. Cases showing dyskaryotic smear are subjected to colposcopic directed biopsy. Symptomatic cases in cases of bleeding during pregnancy either in early months simualating threatened abortion or in the later months constituting APH, the cervix should be inspected through a speculum at the earliest opportunity. If suspicion arises, a biopsy from the site of lesion confirms the diagnosis. EFFECTS OF PREGNANCY ON CARCINOMA CERVIX The malignant process remains unaffected. There may be rapid spread following vaginal delivery and induced abortion. EFFECT OF CARCINOM ON PREGNANCY There is increased evidence of abortion, premature labour, secondary cervical dystocia, injury to the cervix and lower segment leasing to traumatic PPH, Lochiometra and Pyometra, uterine sepsis.

CARCINOMA CERVIX WITH PREGNANCY

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Explained about carcinoma cervix

TREATMENT 1. Carcinoma in situ : The pregnancy can be continued, follow up in pregnancy with repeat smear and colposcopy and re evaluation 6 weeks postpartum 2. Micro invasive : Cone biopsy and conservative management until delivery when the cone margins are negative . However postpartum evaluation is essential. 3. Invasive: To counsel the patient depending on the gestational age, tumour stage, metastatic evaluation and her desire for the baby. Radical hysterectomy Neoadjuvant chemotherapy before surgery or irradiation Chemotherapy and irradiation (external beam and brachytherapy) 10 mts Describe fibroid uterus with pregnancy INCIDENCE: the incidence of fibroid with pregnancy is Describing fibroid uterus about 1 in 1000. with pregnancy EFFECT ON PREGNANCY: 1. May be none 2. Pressure symptoms due to impaction such as bladder- retention of urine, rectum constipation 3. Abortion 4. Malpresentaions 5. Non engagement of the presenting part 6. Preterm labour and prematurity 7. Red degeration. EFFECTS ON LABOUR 1. May be unaffected 2. Uterine inertia 2

FIBROID UTERUS.

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Described fibroid with pregnancy

3. Dystocia due to cervical or broad ligament fibroid and fibroid not pulled up above the presenting part during the labour. 4. Obstructed labour 5. Post partum haemorrhage 6. Difficult caesarean section 7. Red degeneration EFFECTS ON PUERPERIUM 1. Subinvolution 2. Sepsis 3. Secondary PPH EFFECTS OF PREGNANCY ON FIBROID 1. Increase in size due to increased vascularity 2. Changes in position and shape 3. Changes in shape 4. Degenerative changes 5. Torsion of pedunculated subserous fibroid DIAGNOSIS Marked softening and alteration (flattening) make it difficult to differentiate from the pregnant uterus. In uncomplicated tumour, it is confused with ovarian tumour, retroverted gravid uterus, non- gravid half of a double uterus. In early months, fibroid is diagnosed but pregnancy is missed where as in later moths, pregnancy is diagnosed but the fibroid is missed. Sonography confirms the diagnosis with certainty. TREATMENT. The basic principle in the management of pregnancy complicated by a fibroid is not to do anything to the fibroid whenever possible. During pregnancy Uncomplicated- usual antenatal care followed. All cases are to be assessed at 38 weeks to formulate 3

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Tran spare ncy

the method of delivery. Impaction in early moths followed by retention of urine- if manual correction fails, laparotomy and myomectomy, is rarely indicated leaving behind the undisturbed pregnancy. Red degeneration- conservative management should be followed patient should be put on the bed. Ampicillin 500mg capsule trice daily for seven days is given. Analgesics and sedatives are frequently needed. The symptoms usually clears off within 10 days.. Place of elective caesarean section- 1) cervical or broad ligament fibroid. 2) associated complicating factors such as elderly primigravida or malpresentations. During labour Fibroid situated above the presenting part usually result in uneventfull vaginal delivery Fibroid situated below the presenting part spontaneous vaginal delivery may occur. If it fails, caesarean section is to be done. Myomectomy Discussing should be avoided duringing caesarean section. One should be alert for postpartum haemorrhage ovarian tumour and retained placenta. The fibroid usually reverts in pregnancy to a smaller size during puerperium. Discuss ovarian tumour in pregnancy

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OVARIAN TUMOR IN PREGNANCY

INCIDENCE: the incidence of ovarian tumour with pregnancy is about 2000. EFFECTS OF TUMOUR On pregnancy: There is increased chance of 1. Impaction leading to retention of urine 2. Mechanical distress in presence of large tumour 4

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3. Mal presentation 4. Non-engagement of head at term On labour: There is increased chance of obstructed labour if the tumour is impacted in the pelvis EFFECTS ON THE TUMOR: All the complications that occur in the non-pregnant state are likely to occur with increased frequency except malignancy. Torsion of the pedicle Intracystic haemorrhage is due to increased vascularity Rupture Infection DIAGNOSIS Patient may remain asymptomatic or presents with the symptoms of a) Retention of uterine due to impaction of the tumour b) Mechanical distress due to the large cyst c) Acute abdomen due to complications of tumour. Abdominal examination reveals the cystic swelling felt separated from the gravid the uterus. In later months of pregnancy confusion may arise. The patient is examined vaginally in head down Trendlenberg position to elicit the groove between the two swellings, eg. gravid uterus and the ovarian tumour (Hingorani sign). Ultrasonography is useful to have the details of pregnancy and the ovarian tumour. TREATMENT The principle is to remove the tumour as soon as the diagnosis is made. During pregnancy Uncomplicated the best time of elective 5

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operation is between 14-18th week, as the chance of abortion is less and access to the pedicle is easy. Beyond 36 weeks the operation is better to withheld till delivery and the tumour is removed in as early as puerperium as possible. Complicated the tumour should be removed irrespective of the period of gestation. Adequate pain relief should be offered for 48 hours following surgery. During labour If the tumour is well above the presenting part, a watchful expectancy hoping for vaginal delivery is followed. If the tumour is impacted in the pelvis causing obstruction , caesarean section should be done followed by removal of the tumour in the same sitting. During puerperium On occasion, the diagnosis made following delivery. The tumour should be removed as early in puerperium as possible. Following operation the specimen is sent for histological examination. Ten minutes Explain the retroverted gravid uterus in preganancy Retroverted gravid uterus either congenital or acquired is Explaining the considered as a normal variant of uterine position. retroverted Retroversion is either pre-existing or may be due to gravid uterus pregnancy. The incidence is about 10% during first trimester or pregnancy. MORBID ANATOMIC CHANGES IF LEFT UNCARED FOR Favourable: in the majority, spontaneous rectification occurs. As the uterus grows, the fundus rises spontaneously from the pelvis beyond 12 weeks. 6

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RETROVERTED GRAVID UTERUS

Thereafter, the pregnancy continues uneventfully. Unfavourable: In the minority, spontaneous rectification fails to occur between 12-16weeks. The developing uterus gradually fills up the pelvic cavity and becomes incarcerated. The probable causes of incarceration are a) Projected sacral promontory b) Uterine adhesions c) Pelvic tumour d) Idiopathic (majority) CHANGES FOLLOWING INCARCERATION: Changes in the uterus a) The cervix is pointed upwards and forwards and is placed even on the upper border of the symphysis pubis. b) Rarely, the uterus continues to grow at the expense of the anterior wall called anterior sacculation while the thick posterior wall lies in the sacral hallow. Changes in the urethra and bladder: Urethra Marked elongation along with the bladder base due to stretching of the anterior vaginal wall by the cervix. There is retention of urine. The causes of retention are: a) Mechanical compression of urethra by the cervix. b) Oedema on the bladder neck. Bladder changes: As a result of retention of the urine, the bladder gets distended and becomes an abdominal organ reaching even up to the umbilicus. If the retention is not relieved, the following may happen: a) The bladder walls become thickened due to edema b) Sever cystitis, pylonephritis with uraemia 7

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supervenes c) Intra peritoneal rupture may occur in grossly neglected cases resulting in infective peritonitis. EFFECT ON PREGNANCY 1. Abortion 2. If pregnancy continues with anterior sacculation, there is increased chance of a a) Malpresentaion b) Non-engagement of the head c) Preterm delivery and prematurity and d) Rupture of uterus during labour. TREATMENT Before incarceration 1. Periodic check up to 122 weeks until the uterus becomes an abdominal organ. 2. She is advised to empty the bladder frequently and to lie in prone position as far as possible After incarceration 1. To empty the bladder slowly by continuous drainage with a Foleys catheter 2. To put the patient in bed and advice her to lie on her face or in Sims position 3. Urine is sent for culture and sensitivity attest and urinary antiseptics ampicillin 500mg is given 8 hourly daily. With this simple regime uterus is expected to be corrected spontaneously within 48 hours. If spontaneous correction fails: Manual correction by pushing the uterus digitally through the posterior fornix while drawing the cervix posteriorly at the same time by Allis or ring forceps is effective. The procedure should be done after putting the patient in Sims or knee 8

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chest position. Anaesthesia may be required, on occasion. After correction, a Hodge-Smith pessary is to be inserted and to be kept up to 18 -20th week. In obstinate cases, when the above method fails due to adhesions, laprotomy may have to be done. Adhesiolysis is to be attempted failing which termination of pregnancy may be indicated. In diagnosed cases of anterior saccualation of the uterus, delivery by caesarean section is the method of choice.

GENITAL PROLAPSE
Pregnancy is not uncommon in first degree uterine prolapse with cystocele and rectocele. Pregnancy, is however, unlikely when the cervix remains outside the introitus and continuation of pregnancy in 3rd degree prolapse is an extremely rare event. The incidence of prolapse is about 1 in 250 pregnancies. EFFECT ON PROLAPSE: There is aggravation of the morbid anatomical changes in prolapse Marked hypertrophy and oedema of the cervix. First degree becomes second degree. Cystocele and rectocele become pronounced. There is aggravation of stress incontinence. These are marked during early pregnancy and the effect are due to the weight of the uterus and increased vascularity. Vaginal discharge may be copious and decubitus ulcer may develop when the cervix remains outside the introtious There is chance of incarceration, if the uterus fails to rise above the pelvis by 16th week of 9 Described genital prolapse in pregnancy Describing genital prolapse in pregnancy

Describe genital prolapse in pregnancy

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pregnancy. EFFECTS: On pregnancy: There is increased chance of 1. Abortion 2. Discomfort due to increased aliments 3. Premature rupture of the membranes 4. Chorioamnionitis. During labour: There is increased chance of 1. Early rupture of membranes 2. Cervical dystocia 3. Prolonged labour due to non dilatation of cervix and obstruction due to sagging cystocele and rectocele. 4. Operative interference. During puerperium: 1. Sub involution 2. Uterine sepsis TREATMENT During pregnancy: The symptoms are mostly pronounced in early pregnancy. If the cervix is outside the introitus The cervix is to be replaced inside the vagina and is kept in position by a ring pessary. The pessary is to be kept until 18-20th week of pregnancy when the body of the uterus will be sufficiently enlarged to sit on the brim of the pelvis. The pelvic floor is too much lax- the patient is to lie in bed with the foot end raised by about 20 cm. to relieve oedema and congestion of the prolapsed mass, it should be covered by gauze soaked with glycerine and acriflavine. The treatment is continued until 18-20th week of pregnancy till the prolapsed mass is reduced in size and replaced inside the vagina. Thereafter, the patient is allowed to walk about. 10

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Ten minutes

-If reposition is not possible and there is incarceration, termination of pregnancy may be indicated. -If the cervix remains outside the introitus even in the later months, it is preferable to admit the patient at 36th week. DURING LABOUR: The patient should be in bed, not only to prevent early rupture of the membranes but also to facilitate replacement of the prolapsed cervix inside the vagina. Intra vaginal plugging soaked with glycerine and acriflavine not only helps in reduction of cervical oedema but also facilitates its dilatation. Prophylactic antibiotic, in cases of premature rupture of the membranes or when the cervix remains outside, should be administered. Manual stretching of the cervix or pushing up the cystocele or rectocele pastthe presenting part during uterine contractions facilitates progressive descent of the head. If the head is deeply engaged with the cervix remaining oedematous, thick or undilatedcaesarean section is a safe procedure. PUERPERIUM The patient should lie flat on the bed. If the mass remains outside, it should be covered with guaze soaked in glycerine and acriflavine. If sub involution is evident, a ring pessary may be put in until involution is completed. Prophylactic antibiotic is administered. BIBLIOGRAPHY

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1. Dutta D.C, Text Book of Obstetrics, 6th edition,

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2006, New Central Book Agency (P) Ltd, Calcutta, Page 307-313 2. Fraser M. Diane ,Cooper A. Margaret, Myles Textbook For Midwives, 15th edition, 2009, Published by Churchill Livingstone Elsevier, London, Page 347-356 3. www.pubmed.com
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Stated the minor disorders of newborn and its management

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Explained the level of newborn care.

State the minor disorders of newborn and its management

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Chalk board Stating the minor disorders of newborn and its management.

Discussed regarding the maintenance of reports and records Listens attentively Describe the levels of newborn care

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Describing the levels of newborn care.

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Ten minutes

Discuss the maintenance of records and reports of newborn

Discussing regarding maintaining reports and records.

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Contributing their views

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