NORMAL MENSTRUATION
5th-95th centile being 23
ssive
4. NORMAL MENSTRUATION
potent vaso
Thromboxane potent vasoconstrictor and platelet inhibitor.
site of synthesis.
6. ABNORMAl MENSTRUATION
intervals of more than 35 days.
l disorders:
s: malnutrition and
ith a
ome cycles are
the
vaginal and endometrial atrophy, vaginal, cervical and uterine cancers, urethral caruncle, cervical polyps,
uterine fibroids.
bleeding which can be confused with vaginal bleeding.
16. Vaginal bleeding Postcoital
penile bleeding: blood might come fr
n.
17. Vaginal bleeding Drugs Certain drugs and medications can cause vaginal bleeding.
contraceptives(starting or
seases), abdominal
(endometrial polyps,
ndometrium: proliferative or
time, blood sugar, renal and liver function tests based on suspected pathology,
related complications and abdominopelvic masses.
nfections
-reproductive age group
3. INC TREND.
with inc
incidence of pulmonary and extrapulmonary forms of tuberculosis including drug resistant forms.
4. SOURCE
intercourse with a partner suffering from tuberculous lesions of genitilia
5. MODE OF SPREAD
6. OBSTETRIC HISTORY
-bovine org
7. BACTERIOLOGY
ly a small no of cases
8. PATHOLOGY
9. FALLOPIAN TUBE
endosalphingitis
tubercular salphingitis
- frequent exacerbations
adhesions
11.
subacute,recurrent PID
Mucosa-
e to recurrent attacks by pyogenic organisms wrong diag - hyperplastic oedematous patternlate stage
urface
-attempt to separate adhesions
17. cervix
18. Vulva & vagina
-shallow,undermined edges
19. SYMPTOMS
20. INFERTILITY
- confirmed
15. OVARY
16. uterus
in uterine cavity- pyometra
-35-60%
Poor quality of ova may be responsible
-twenties-sec
- amenorrhoea
pain,nausea,vomitings,fever
30.
Histology-det
31.
genital lesion
Chestxray-healed/active pulmonary infection
-week preceeding menstruation
-
diagnostic
32.
Sensitivity-85-
lcer- mimic ca
-improper
cid
innoculation test-if positive-type the bcilli,report their drug sensitivity
-i
- 10 org in clinical specimens compared to 10,000 for smea positivity
Genital tb- always paucibacillary
d amplification,
-not rule out tb
34.
35.
reveal
cx,vagina,vulva
- lesion in
36.
diagnosis Laproscopy fluiddiscovered during diag lap for infertility
37. DIAGNOSIS The physician should Be conscious of entity
1.
Unexplained infertility/amenorrhoea 2. Recurr episodes of pelvic infections,not responding with usual
course of antibiotics 3. Presence of pelvic mass with nodules in the POD
38. DD Pelvic mass-
41. general
cute exacerbations
Ethambutol-prev treated/immunocompromised
43.
on phaseisoniazid,rifampicin
Positive-
pulation
nd bacteriological
ity rate
drug regimens(CDC)
2 or more agentsincluding
-5
46. DRUG Daily oral dose Nature Toxicity Comments Isoniazid 5mg/kg Max-300mg Bactericidal
Hepatitis,perip heral neuropathy Check LFT, Combine pyridoxine 50mg daily Rifampicin 10mg/kg Max600mg Bactericidal Hepatic dysfunction, Orange discolouration urine,febrile reaction avoid- ocp Monitor
liver enzymes Pyrizinamide 20-25mg/kg Max-2gm Bactericidal Hepatitis,huper uricaemia,GI
upset,arthralgia LFT, Active against intracellular dividing forms Ethambutol 15-20mg/kg Max-2.5gm
Bacteriostatic Visual disturbances,op tic neuritis,loss of visual activity Ophthalmosco pic prior to therapy
47. Itermittentdose shedule
Isoniazid-15mg/kg-3 times a week for 6 mnths
-30mg/kg-3 times a week6mnths
48.
30mg/kg
-15-aminosalicylic acid-
-15-
ionamide-15-15-20mg
-tubercular tx
iachr pelvic pain causing
deteriorating health status
50. CIAccidental discovery of tubercular tubo ovarian mass on laprotomy in young pt.-abdomen is closed after
taking tissue for biopsy
51. Precautions-
pyometra
be restored when tubal walls are damaged
53. PROGNOSIS
20-30%-
-success-
-ulcerated /hypertrophic
t cells,epitheloid
-hystrectomy
nfections of the female genital tract is causes by etiological agent such as Bacteria Fungus Parasite
Viruses
3. BACTERIA Chlamydia trachomatis Gardnerella vaginalis Acinomyces israelii Virus infection Herpes
simplx virus(HSV) Human papilloma virus(HPV) cytomegalovirusCMV ) Fungal Infection Candida albicans
Parasite infection Trichomonas vaginalis Infections of the female genital tract
4. BACTERIA
Chlamydia trachomatis
Chlamydia trachomatis is specialized
Gram Negative small bacteria an obligate extracellular pathogen
Chlamydia resembles viruses in being unable to reproduce outside of living cells.
Normal habitat of Chlamydia trachomatis can be found n the human genitourinary tract.
Its occur in two forms:
-infective extracellular elementary body
-the intermediated reticulate bodies /particle
Pathogenesis
-urethritis
-vaginitis
-cervicitis
5. Microscopy and cytological features Show infected the metaplastic squamous cells and endocervical
cells frequently affected.Parabasal cells sometimes involved The important features significant is intra
cytolplasmic inclusion that also show faint eosinophilic coccoid bodies The inclition bodies also can be
detect microspically by immunofluorescence or Giemsa stained prepared. Other features is
showreactive changes of squamous and columnar cells and multinucleation
6.
Gardnerella vaginalis
Gardnerella vaginalis previously known as Haemophilus vaginalis
11.
Parasite infection
Trichomonas vaginalis
Trichomonas vaginalis is protozoan parasite that inhibit the vaginal in
women and the urethra in men and also in prostate sometimes.
T.V Transmitted with sexual intercourse from men to women and
also women to men.
In women,vaginal show foul smelling green yellow discharge
Vaginal pH also show alkaline
40-50% infected woman is asymptomatic
Cytological features of the TV parasite
Round oval and pear shape
Variable stained greenish-blue ,blue grey
Nucleus usually single and eccentrically occasionally binuclear ,
side by side lying
Occur single and irregular
Crowd epithelial cells(intermediated cells)
Motile identified by wet preparation of vaginal discharge
Staining with PAP
12. Cellular changes Abundant polymorph and cannonball cells. Squamous cells shift to the right in
maturation index Anucleated squamous cells and squamous cells smaller than usual (parakeratosis) A
background mucus may form a net like structure on the slide Perinuclear halos-clear zone around nuclei
Associated bacteria coccoid bacteria and leptophrix Nucler changes Enlargement of nucleus and
increase ratio of N/C Chromatin structure slightly granular and many small dark chromacentres
Nucleolus may be seen Binucletion and multiniclition may occur especially with endocervical cells
Nuclear degeneration nuclei loss (karyolysis)
13. Virus infection Herpes simplx viruse(HSV) Herpes simplx viruse(HSV) belong to the family
Herpesvirus. The viruses is Double Stranded DNA that have two types HSV 1 and HSV -2 Infection
caused by HSV 1 included gingivostomatitis (ulceration of the gums and lining of the mouth) in young
children. An important infection caused by HSV-2 is genital herpes. The virus is sexually transmitted and
can causes painful ulceration of he genital tract and uro genital organs .HSV -2 has been associated with
cancer of the cervix .
14. Cytological features The cytologic appearance of HSV infection is easily recognized,HSV show
cytologic canges where the cells are characteristic by large multiple nuclei that are molded together
(arrowed) and show marginatin of chromatin and generally empty nuclei.large intranuclear inclusion are
also commonly seen it is important to different such as cell from binucleated cell that are common
found in associated with HPV infection .cytologically appearance of degeneration and necrotic cells in
which ghost of the nuclei can just be recognized . this necrotic cellular appearance have to be different
from those that associated with carcinoma. microscopically can show enlargement squamous and
metaplastic type cells and also multinucleation .Internuclear moulding present on the cells and the
blurring and show smudge cells that lost of chromatin structure . the chromatin also show the
degeneration of chromatin form distinct nuclear border. in the primary infection ,nuclei show typical
ground glass, overlapping and molding nuclei and in the re-current infection a large eosinophilic
intranuclear inclusions.
15. Characteristic of Human Papilloma Virus (HPV) Human Papilloma Virus (HPV) is a very common virus
(germ) that causes abnormal cells or growth of tissue on the skin of the body. HPV can cause abnormal
tissue changes on the feet, hands, vocal cords, mouth and genital (sex) organs. Over 60 types of HPV
have been identified so far. Each type infects certain parts of the body. In gynecology, we are concerned
about the types of HPV that infect the female organs Human papilloma virus(HPV) is double stranded
DNA virus . HPV have 60 types the important type is Type 6,11,31,42,45 and this type of HPV only
produce a low risk lesions. Type 16,18,31,35,39 cause high risk lesions of ano genital ,laryngeal
esophageal and lung in the service may causes high grade lesions progress to malignancy .
16. Cytological features Cytological features of Human Papilloma Virus (HPV) can see microscopically
from the cellular changes.thimportant cellular changes that perform the characteristic of Human
Papilloma Virus (HPV) is Koilocytosis, Parakeratosis ,Binucletion and multinucletion ,Dyskeratosis ,and
Hyperkeratosis Koilocytosis Many cell show perinuclear clearing of the cytoplasm with a hard margins to
the vacuole(arrowed) . The borderline of nuclear also changes.that increase cytoplasmic ratio, smooth
muscle outline and fine evenly dispersed chromatin. The Squamous cells also show peripheral well
defined dense cytoplasmic and surrounding clear perinuclerahalos . It is commonly in the type of
superficial and intermediated cells .Cytoplasmic staining amphophilic
17. Parakeratosis Parakeratosis mean of when the cell become smaller than normal cells.or Minture
squamous cell singly or in groups.the type of cells to differ is smaller than parabasal cells.The nucleus
show pyknotic nucleus and cytoplasm may be keratinized Binucletion and multinucletion Binucletion
and multinucletion always seen in mature squamous ,metaplastic cells and in parakeratotic cells. The
chromatin structure due to nuclear smudge and pyknotic. The Nuclear also enlargement and dysplastic
changes Dyskeratosis Enlargement of nucleus with chromatin clearing and incomplete nuclear envelope
and a result of degeneration superimposed changes.Cytoplasm also become darker Hyperkeratosis
Hyperkeratosis show anucleated squamous due to karyolysis.karyolysis is cytoplasm when nucleus are
disappear.(not have nucleus).Also show yellow and orange cytoplasm.
18. CytomegalovirusCMV) belongs to the family Herpesvirus Disease caused by CMV can occurs
conginental neonatal and childhood thatcan causes infection in epithelial tissue of salivary gland
,bronchus alveolar,renal tubes and endoservic . During pregnancy lead to conginental disease ,mental
diagnosed ,deafness and multiple other birth defectsRarely diagnosed with cervical-vaginal smear.
Cytological features CytomegalovirusCMV) microscopically characteristic by eosinophilic intranuclear
inclusion with single nuclei.CMV differ from HPV because multinucletion not occur. To confirm CMV case
must diagnosed by immunocytochemical method CytomegalovirusCMV
19. Normal flora of female genital tract is lactobacillus spp. Account for 95% of vaginal microorganism,
lactobacillus acidophilus. Maintain vaginal pH 3.8-4.2 from the production of lactic acid. Lactobacillus
also suppress the growth of gram negative and gram positive facultative and obligate anaerobes via the
production of hydrogen peroxide. The organism make up Normal flora of female genital tract is
corynebacterium, streptoccus,peptostreptococci and bacteroids. Infections in the female genital tract
are extermly common in clinical and cytophatology practice and include complication of
pregnancy,inflammation,tumor and hormonally.other high risk factor is IUCd user,oral
contraceptive,and via sexually. The main symptom of infections in the female genital tract is
diching,pruritus,dysuria and dysparaeunia . CONCLUSION
20. From the TBS (the Bethesda system) Infections of the female genital tract is categories of benign
cellular changes. The main focus of cervical/vaginal cytology traditionally been the detection of cervical
cancer precursor. However, various benign processes can also be recognized morphologically, and
diagnosis of these entities can make an important contribution to patient care. The Infections of the
female genital is causes by etiological agent such as Bacteria ,Fungus,viruses and parasite .
Definition
vaginal canal or a
graduallydescends of the uterus in the axis of the vagina takingthe vaginal wall with it.
3.
4. Usually, prolapse is rated by degrees:
-degree prolapse: the cervix part of
-degree prolapse
-degrees prolapse: the
uterus protrudes through the introitus.
Introduction
Up to half of the normal female population will develope uterovaginal prolapse during their lifetime.
Twenty percent of these women will be symptomatic and need treatment .
As the population of the world continues to increase in age, the prevalence of pelvic floor dysfunction is
likely to increase.
3. : Structure and function of the pelvic floor
The pelvic floor functions to support the pelvic and abdominal viscera and help maintain control of their
contents.
It has two major components which are interdependent:
the muscle and facia.
4. Muscle:
Levator ani muscles consist of pubococcygeus , coccygeus and ileococcygeus muscles on each side which
together form a muscular floor to the pelvis.
The striated muscle of levator ani is under voluntary control but is a unique striated muscle in having a
resting tone.
5. Muscle:
Contraction of the muscles results in a forward elevation of the pelvic floor which is important in their
role in continence.
This forward elevation helps to increase the angulation between bladder and urethra anteriorly and
rectum and anal canal posteriorly . Increase in this angulation is one of the fundamental mechanisms
which aid continence
6. Muscle:
When the intra-abdominal pressure rises levator ani muscles contract and provide additional support
and outlet resistance to the bladder and rectum.
This reflex response to intra-abdominal pressure rises also requires an intact innervation.
Damage to the pelvic floor muscle innervation is likely to impair the pelvic floor muscle responses.
7. Fascia:
Fascia envelopes levator ani, attaches it to bone at its origin and holds the two muscles together in the
midline.
The urethra, vagina and rectum perforate this midline fascia.
Thus, the pelvic viscera are supported both by the levator ani muscle below and the fascial attachments
which are condensed in some areas and are often referred to as ligaments the uterosacral, cardinal
and round ligaments being examples.
8. Fascia:
any factor that influences the strength or integrity of pelvic floor fascia will influence the function of the
pelvic floor.
These factors may be congenital (such as hyperelasticity of the collagenous component of fascia ) or
environmental , such as stretching or tearing of fascia during childbirth or heavy lifting.
9. Pathophysiology of pelvic floor dysfunction Muscle
The striated muscle of the pelvic floor, undergoes a gradual denervation with age .
This denervation will result in a gradual weakening of the muscle over time .
Pelvic floor muscle denervation is increased by vaginal delivery , particularly if the active second stage of
labour is prolonged .
Caesarean section may offer some protection from this injury.
10. Pathophysiology of pelvic floor dysfunction Muscle
The site of pelvic floor muscle denervation during childbirth is unclear. It has been proposed that
stretching of the pudendal nerve at the ischial spine results in nerve injury .
In neurological diseases like multiple sclerosis , pelvic floor muscle may behave unpredictably ranging
from inappropriate relaxation causing incontinence to spasm resulting in voiding dysfunction.
11. factors have a significant influence on pelvic floor support: .
1.CONGENITAL.
2.AGE
3.CHILDBIRTH INJURY.
4.ENDOCRINE .
12. : 1.CONGENITAL
Congenital differences in collagen behaviour are clinically evident in women who have increased joint
elasticity.
Women with hyperextensible joints will develope uterovaginal prolapse at an earlier age. Such women
often excel at sports requiring increased joint elasticity (such as gymnastics) and they develop fewer
striae gravidarum during pregnancy because of increased skin elasticity.
13. : 2.AGE
The fascia of the pelvic floor will provide weaker support with advancing years.
Gynaecologists repairing the pelvic floor often recognize that the tissues used for building a repair are of
poor quality and are poorly vascularized.
The repair after surgery will heal with less strength and more slowly. The recurrence of prolapse seen
after surgery in one out of three cases must in some part be due to a deterioration of fascial strength
with age.
14. : 3.CHILDBIRTH INJURY
Most women recognize that their pelvic floor is different after vaginal delivery.
regaining the tone and shape of their anterior abdominal wall is also often a difficult challenge.
These changes are due to a combination of muscle and fascial changes. whether pelvic floor fascia
stretches or tears during pregnancy and childbirth.
15. : 4.ENDOCRINE
The menstrual cycle, pregnancy and the menopause are the most significant endocrine events which
may influence pelvic floor fascia.
Women often declare that prolapsed symptoms are worse around the time of menstruation.
This is thought to be secondary to higher progesterone levels increasing fascial elasticity.
16. : 4.ENDOCRINE
women examined at the time of menstruation will have a higher stage of prolapse than at other times of
the cycle.
During pregnancy, prolapse symptoms will be more evident in the first trimester but diminish as the
pregnant uterus enlarges out of the pelvis.
18. Symptoms:
Prolapse classically produces a sensation of fullness in the vagina or a visible or palpable lump at the
introitus.
Low backache is a common symptom but is also commonly experienced by women who do not have
prolapse .
Vaginal atrophy , if present, will exacerbate many prolapse symptoms and should be treated as a first
priority with topical oestrogens unless clinically contraindicated .
Some couples find that the loss of tone in the vagina leads to sexual dissatisfaction for both parties.
23. Classification:
1 Dislocation of the urethra the urethra is displaced
downwards and backwards off the pubis. It may be also dilated becoming an urethrocoele.
2 Cystocoele hernia of the bladder trigone .
3 Uterine prolapse descent of the uterus and cervix.
24. Classification :
4 Enterocoele or pouch of Douglas herniaa prolapse of the upper part of the posterior vaginal wall.
The hernia contains the peritoneum of the pouch of Douglas often with a loop of bowel.
5 Rectocoele a prolapse of the lower part of the posterior vaginal wall due to weakness of the
levatores ani; the rectum bulges into the vagina.
Proctography can give some insight into factors which may be contributing to difficulty with defaecation
and may help avoid unnecessary, unhelpful vaginal operations .
31. Treatment: of genital prolapse:
CONSERVATIVE:
Some women elect for non-surgical treatment of their prolapse either because:
1 the prognosis offered for treatment is not sufficiently attractive
2 they are unfit for surgery
3 they wish to delay surgical treatment for other reasons.
Space occupying pessaries such as the shelf pessary preclude normal sexual relations and are therefore
unsuitable for sexually active women.
The shelf pessary may be particularly helpful for uterine or vaginal vault prolapse .
Careful examination, at least every 6 months is advisable and topical oestrogens may reduce the risk of
ulceration and erosion.
The Kelly operation became the treatment of choice for anterior prolapsed partly because of the
simplicity of the procedure .
39. Complications :
1.5% developed stress incontinence and 5% detrusor overactivity postoperatively.
2.Long-standing voiding problems occurred in less than 1%.
3.Post-operative pyrexia developed in 10%
The use of support materials in primary repairs would certainly not appear to be justified.
40. Posterior vaginal wall prolapsed :
The classical posterior vaginal repair involves not only plication of the fascia underlying the vaginal skin
but also a central plication of the fascia overlying the pubococcygeus muscle even including the muscle
itself.
cervical canal, which communicates the uterine cavity with the vagina. It extends downwards and
backwards from the isthamus, protrudes through the anterior wall of vagina which divides the cervix
into supravaginal and vaginal parts.
9. Structure of the cervix: Serous coat: from the peritoneum which covers the posterior surface of
supravaginal part. Muscular coat: disposed smooth muscle. Some parts produced from collagenous
and elastic fibrous tissue. Mucous membrane: by columnar epithelium and stratified squamous
epithelium.
10. Ligaments of cervix Laterally by a pair of Mackenrodts ligaments. Posteriorly by a pair of
uterosacral ligaments. These ligaments have unstriped muscles and leashes of blood vessels and
lymphatics. On each side, the lymphatic drainage into external iliac, obturator lymph nodes, internal
iliac groups and sacral groups.
11. PERINEAL TEAR
12. Anatomy and Physiology A. Pelvic floor: Pelvic floor is a muscular diaphragm that separates the
pelvic cavity above from the perineal space below. It is formed by the levator ani and coccygeus
muscles, and is covered by parietal fascia. The levator ani muscles on either side arise from posterior
surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine.
13. The levators sweep from the lateral pelvic wall downwards and medially to fuse with the opposite
side in the midline and form a pubo-coccygeal raphe. Fibres of Levators are inserted from before
backwards and fuse with muscle fibres of urethra, the vaginal walls, perineal body, anal canal,
anococcygeal body and the lateral borders of coccyx. Functions: To support the pelvic viscera. To
maintain effective intra-abdominal pressure. To facilitate anterior rotation and downward and forward
propulsion of the presenting part during parturition. Serves as a support and voluntary sphicter of
urethra, vagina and anal canal.
14. B. Urogenital diaphragm: The urogenital diaphragm is external to pelvic diaphragm and includes the
triangular area between the ischial tuberosities and the symphysis. It is made up of deep transverse
perineal muscles, sphincter urethrae and internal and external fascial coverings.
15. C. Perineum: Perineum is a diamond-shaped space that lies below the pelvic floor. it is bounded by:
ischi
16. This area is divided into two triangles by transverse muscles of perineum and base of urogenital
diaphragm: Anteriorly- Urogenital triangle. Posteriorly- Anal triangle Most of the support of
perineum is provided by pelvic and urogenital diaphragms.
17. Perineal Body: The median raphe of levator ani between the anus and vagina, is reinforced by the
central tendon of the perineum. Bulbocavernosus, superficial transverse perineal and external anal
sphincter muscles also converge on the central tendon. These muscles contribute to perineal body,
which provides much support to perineum.
18. PERINEAL TEAR Gross injury is due to MISMANAGED 2ND STAGE OF LABOUR More common in
PRIMIGRAVIDA than MULTIGRAVIDA . Due to extension of episiotomy, posteriory it involves the anal
sphincter from back & obliquely upwards into the lateral vaginal wall ETIOLOGY: - OVER STRETCHING OF
PERINIUM - RAPID STRETCHING OF PERINIUM - INELASTIC PERINIUM
19. Causes and Predisposing Factors: Obstetric injuries:
babies Non-obstetric injuries: rape, molestation, fall, accidental injuries like RTA, bull horn injuries etc.
20. Degrees of Perineal tear:
degree- trauma involves the anal
sphincter.
- extends into the rectal lumen, through the rectal mucosa. A rare type of
tear is central tear of the perineum when the head penetrates first through the posterior vaginal wall,
then through the perineal body and appears through the skin of the perineum. It usually occurs in
patients with contracted outlet.
21. THIRD DEGREE PERINEAL TEAR FOURTH-DEGREE PERINEAL TEAR
22. First & second degree tears :Spontaneous tears originate near the midline of the perineum, but
when they are traced upwards they are invariably found to extend into one / other posteriolateral
vaginal sulcus.
helpful to catch the upper edge of
care must be taken to unite the lateral vaginal walls to the
loose posterior tongue.
meatus. Later, pt. is unable to void urine because of muscle spasm consequent on the bruising around
the urethra & bladder neck.
23. Third degree tears:
anal canal is closed by interrupted or continuous catgut sutures (No.0) placed so that the suture avoids
the bowel mucosa. Disadvantage appearance of small rectovaginal fistula at the upper end of the
wound.
24. Symptomatology: Immediate: Bleeding Traumatic PPH - hemorrhagic shock. Perineal
Pain Perineal hematoma Urinary retention due to painful perineum Urinary incontinence Anorectal
dysfunctions like fecal incontinence Delayed: 1. 2. 3. 4. 5. 6. Infected perineum- perineal abscess
Uterovaginal prolapse Urinary incontinence (stress and urinary fistula) Fecal incontinence ( rectovaginal
fistula) Dyspareunia Feeling of slack vagina during coitus Bleeding Disruption of anatomical
continuity
25. PREVENTION - LIBERAL USE OF EPISIOTOMY - PROPER CONDUCT OF LABOUR DURING 2ND STAGE PERINEAL SUPPORT DURING 2ND STAGE
26. Repair of perineal tear : First degree: Sometime doesnt require suturing or can use one or two
interrupted suture. Second degree: The vaginal mucosa is to be sutured first. The first suture is placed
at or just above the apex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures
with chromic catgut no. Ofrom above downwards till the fourchette is reached. The sutures should
include the deeper tissues to obliterate the dead space.
27. A continuous suturing may cause shortening of the posterior vaginal wall. Complete perineal tear:
The rectal and anal mucosa is sutured from above downwards by interrupted sutures. Muscle walls
including the pararectal fascia are then sutured by interrupted sutures. The torn ends of the sphincter
ani externus are sutured with figure of eight stitch by another interrupted suture. Perineal skin by
interrupted suture
28. AFTER CARE: LOW RESIDUE DIET STOOL SOFTNER SEITZ BATH BD ORAL ANTIBIOTICS:
ANAEROBIC ANALGESICS
29. Complications if left untreated: Infection Hemorrhagic Shock Cosmetic disadvantage 3rd and
4th degree tears if left untreated may lead to fecal incontinence.
30. Episiotomy It is an incision on the perineum & the posterior vaginal wall during the second stage of
labor It should be performed just before the crowning of head in second stage of labour. It is
commonly performed for spontaneous vaginal delivery , about 2/3rd of primigravida , 1/3rd of the
multiparous
31. Objective: To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus
spontaneous or manipulative. To minimize over stretching & rupture of the perineal muscles & fascia
To reduce the stress & strain on the fetal head. Indications: In elastic or rigid perineum. Anticipating
perineal tear big baby, face to pubis delivery, breech delivery, shoulder dystocia. Operative delivery:
forceps delivery, ventouse delivery. Previous perineal surgery: pelvic floor repair, perineal
reconstructive surgery.
32. Types
are encountered & repair is very simple. Disadvantage: extension of incision includes the anal sphincter
or canal itself.
considerable difficulty may be encountered in securing an accurate realignment of the divided
structures.
33.
rting at the midpoint of the fourchette or posterior commissure. It has
the advantage to the damage to the sphincter.
in the midline until a point is reached 2-3 cm from the anterior margin of the anus.
34. DR ASHRAF ATIA DEWIDAR MD MRCOG
35. Median Merits : -the muscles are not cut - blood loss is least. - repair is easy. - postoperative comfort
is maximum. - healing is superior. - Wound disruption is rare. - Dypareunia is rare. Mediolateral - relative
safety from rectal involvement from extension. - if necessary, the incision can be extended.
36. Demerits : - Extension, if occurs involves rectum. -Apposition of the tissues is not so good. -Blood
loss is little more. - Not suitable in - Relative increased manipulative delivery or in incidence of wound
abnormal presentation or disruption. position. - Dyspareunia is more
37. Advantages Maternal Reduction in the duration of second stage. Reduction of trauma to the pelvic
floor muscles. Fetal it minimizes intracranial injuries.
38. The structures involved during mediolateral episiotomy are :
perineal branches of pudendal vessels and nerves.
39. Timing of the repair of episiotomy
blood loss from the
implantation site because it prevents the development of extensive retroplacement bleeding.
manual removal must be performed
40. Post operative care: Clean wound with clean water after each urination and defaecation. Keep
area dry Apply clean pads Analgesics if needed Peri-care and peri-light Suture removal on 7th 10th post op day if silk is applied. F/U after 6 wks if no complication
41. Complication Immediate: 1. Extension of the incision: involves rectum, mainly in median episiotomy
or occipito posterior. 2. Vulval haematoma. 3. Infection. 4. Wound dehiscence: infection is the primary
cause of wound disruption. 5. Injury to anal sphincter. 6. Rectovaginal fistula.
42. Cont-d Remote: Dyspareunia due to narrow introitus. Chance of perineal lacerations. Scar
endometriosis.
43. Prevention of perineal tear: Well support of the perineum at the time of delivery of head
Delivery by early extension is to be avoided Spontaneously forcible delivery is to be avoided To
deliver the head in between contraction To perform timely epsiotomy To take care during delivery of
shoulder
44. Periurethral Tears Vaginal tears can also occur at the region around the urethra - the opening
through which urine comes out. These are then called ' Periurethral tears'. The problem with these type
of tears is that there may be profuse bleeding from even a small tear since the region has a large blood
supply.
45. Causes The commonest cause for a periurethral tear is a sudden extension of the fetal head at the
time of delivery. Normally, the fetal head is in a position of flexion with the chin touching the chest. At
the time of delivery, after crowning occurs, the head is born by extension. A gradual extension will not
put much presure on the anterior or upper part of the vagina. But a sudden extension will cause a
sudden pressure on upper vaginal area resulting in a periurethral tear.
46. How to prevent It is important for the doctor or midwife to press gently on the fetal head at the
time of delivery and guide it to a slow and gradual extension at the time of birth.
47. Treatment Periurethral tears need to be stitched carefully under proper light. If not repaired well
or if it is not diagnosed after the delivery, it can bleed continuously for quite some time and cause many
other problems It is advisable for the woman to use cold packs on the site of the tear for at laeast 7-10
days to hasten healing. Using anti-inflammatory painkillers like Ibuprofen aslo helps. Thankfully, during
the course of a pregnancy the body is primed to heal quickly. The immune system is more efficient than
usual and therefore wounds will heal within a few weeks after childbirth
48. Complications if not treated Continuous Bleeding Infections in the tear Severe pain and
inflammation Urine Retention due to inability of the woman to pass urine through the inflamed urethra
49. Vaginal lacerations
nvolves middle or upper third of the vagina but not associated with
derlying tissues and give rise to
Blood dyscrasis.
59. Cont-d 2. Local:
losure.
bodies tissue reaction and inflammation, necrosis
60. UTERINE RUPTURE
61. spontaneous or traumatic rupture of the uterus ie., the actual separation of the uterine
myometrium/ previous uterine scar, with rupture of membranes and extrusion of the fetus or fetal parts
into the peritoneal cavity. Dehiscence - partial separation of the old uterine scar; - the fetus usually
stays inside uterus and the bleeding is minimal when dehiscence occurs
62. Rupture uterus
63. CAUSES: IATROGENIC: INJUDICIOUS USE OF OXYTOCIN, FORCIBLE ECV/ IPV, FALL OR BLOW OVER
THE ABDOMEN, , FORCEPS or BREECH EXTRACTION TYPES: INCOMPLETE RUPTURE: PERITONIUM
REMAINS INTACT COMPLETE RUPTURE: SCAR IN UPPER SEGMENTINVOLVES PERITONIUM
64. RISK FACTORS: Women who have had previous surgery on the uterus (upper muscular portion)
Having more than five full-term pregnancies Having an overdistended uterus (as with twins or other
multiples) Abnormal positions of the baby such as transverse lie. Use of Pitocin (oxytocin) and other
labor-induced medications (prostaglandin) Rupture of the scar from a previous CS
are present. Provide information to the support person and inform him or her about fetal outcome, the
extent of the surgery and the womans safety. Let the pt express her emotion without feeing
threatened.
82. FGM Female Genital Mutilation compromises all procedures involving partial or total removal of
the external female genitalia or other injury to the female genital organs for non medical reasons (WHO,
UNICEF, UNFPA, 1997)..
83. Procedures *Type III- Also known as Infibulation. *Type IV- All other harmful procedures to the
female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and
cauterization.
84. Health Risks health benefits. damages healthy genital tissue and interferes with a womans natural
bodily functions.
85. Health Risks Immediate Complications Severe pain Shock Hemorrhage Tetanus Sepsis
(bacterial infection) Urine retention Open sores
86. Cont-d Long Term Consequences Bladder and urinary tract infections Cysts Infertility
Need for later surgeries Childbirth complications Newborn deaths Decreased sexual pleasure
87. International Organizations
the uterus and ovaries are present and the presence and location of kidneys. MRI shows a more
detailed picture of the reproductive tract and kidneys.
5. Treatment Most young women are treated in their late teens or early 20s. Others may wait until they
are older and sexually active. Treatment is not urgent, but it is usually necessary before sexual
intercourse. Self dilation: some patients can create a vagina without surgery using self dialation. In this
treatment, the patient presses a small rod (dialator) against the skin or the small vagina for 15 to 20
minutes per day. This is often done after bathing, when skin is more pliable. Progressively larger dilators
are used to expand the vagina. Several month may be required to obtain the desired result.
6. Cont.. Surgery (vaginoplasty): Surgery (vaginopalsty) is used to create a functional vagina. These
treatments are usually delayed until the patient possesses the maturity to handle follow up dilation.
Skin graft(McIndoe procedure)- The McIndoe procedure) is the most commonly performed vaginal
plasty. The procedure uses the skin graft from the buttock(which leaves only a disfigurement). The
surgeon makes an incision where the vagina would normally developed and inserts the graft to create a
vagina. A mold is placed in the newly formed vagina for seven days.
7. Cont Counseling: it is often useful for a patient to speak with a counselor about her condition.
After treatment patient can have a normal sex life. Although it is not common some patients have
normal uterus and can bear children. Typically, vaginal absence patients have undersized uterus and
cannot become pregnant. However, if their ovaries are healthy, which is often the case, affected woman
can have children by INF of their own eggs with the pregnancy carried by a surrogate mother.
8. Uterine Malformation A uterine malformation is a type of female genital malformation resulting
from an abnormal development of the Mllerian duct(s) during embryogenesis. Symptoms range from
amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the
nature of the defect.
9. Prevalence The prevalence of uterine malformation is estimated to be 6.7% in the general
population, slightly higher (7.3%) in the infertility population, and significantly higher in a population of
women with a history of recurrent miscarriages (16%).
10. Types of uterine malformation Class I: hypoplasia/agenesis (absent uterus). Combined agenisis of
the Uterus, cervix and upper portion of vagina. The condition is also called Mayer-Rokitansky-KusterHauser syndrome. The patient with MRKH syndrome will have primary amenorrhea. Patients have no
reproductive potential aside from medical intervention in the form of invirto fertilization of harvested
ova and implantation in a host uterus.
11. Class II: Unicornuate uterus (a one-sided uterus). Only one side of the Mllerian duct forms. The
uterus has a typical "penis shape" on imaging systems. Unicornuate Uterus If a woman has a
Unicornuate uterus, she will have a single uterine cavity with a cervix and one fallopian tube coming off
of the uterus. In this malformation, the uterus only forms half-way. The other side of the uterus may
have a rudimentary horn. An ultrasound can be used to find a Unicornuate uterine malformation.
Further diagnostic test used to confirm this diagnosis are; hysteroscopy, ultrasound, and laparoscopy.
Excision of rudimentari horn by Surgical procedure.
12. Cont. Unfortunately, a woman with this malformation can have much risk if she becomes
pregnant. There is a great risk of pregnancy loss and preterm labor. Also, there is a chance of the woman
having an ectopic pregnancy. The common miscarriages due to this malformation are caused by
abnormalities in the blood supply of the uterus. The reason that there is a great risk for preterm labor is
due to space restrictions in the Unicornuate uterus. Furthermore, for the woman with the rudimentary
horn, she will have greater risks associated with pregnancy. This horn will cause a lot of space restriction
which could result in ectopic pregnancy. This is the reason that most doctors recommend surgery to
remove the rudimentary horn.
13. Class III: Uterus Didelphys: A woman with a didelphic uterus has a duplication of the uterus and a
duplication of the cervix. In this malformation, there are two uterine cavities and two cervixes
accompanying each cavity. It is not recommended that a woman have surgery to connect the two
uteruses together. Women with this malformation may be asymptomatic. The malformation is normally
found with a pelvic examination. There are two common complaints of women that have a didelphic
uterus. There are complaints of dysmenorrheal (uterine pain during menstruation) and complaints of
dyspareunia (painful sexual intercourse).
14. Cont Class IV: The bicornuate (heart-shaped) uterus has a marked indentation and is separated
into two different cavities. This malformation is a result from the uterus forming improperly in the
womans early prenatal development. The way that a woman can confirm that she has a bicornuate
uterus is by having an ultrasound or by the use of laparoscopy. The primary risk with having a bicornuate
uterus is preterm labor and cervical insufficiency. The cervical insufficiency could cause the woman to
have a miscarriage during the second trimester of pregnancy. The good news is that there is a chance
that the baby can still survive. Furthermore, in some cases, a woman with this type of uterine
malformation can carry the baby to full term with no complications. It just varies from person to person.
15. Class V: Septated uterus (uterine septum or partition). A woman with a septate uterine
malformation will have the problem from which the septum separates the uterine cavity into two
separate cavities. The septum will arise at the top of the uterine cavity and then extend down to the
cervix and the vagina. It is normally recommended that a woman with this malformation have a simple
out patient surgical removal of the septum. There is a risk of miscarriage associated with a septate
uterine malformation. Furthermore, there is a chance of preterm labor. Doctors can normally find a
septate uterine malformation with the use of an ultrasound. However, to confirm the diagnosis, the
woman will need to have a hysteroscopy performed.
16. Class VI(arcuate uterus):The arcuate uterus has a depression at the fundus. A woman with an
arcuate uterus can carry a baby to full term pregnancy. However, this condition is associated with a
higher risk for miscarriage and premature births. The best way for a woman to find if she has this
malformation is through transvaginal ultrasonography, hysterosalpingography, MRI, or hysteroscopy. In
most cases, the woman will not have any reproductive problems. For those that do have reproductive
tribulations, there is the option to have a hysteroscopic resection performed.
17. Cont. Class VI: DES uterus. Several women were treated with diethylstilbestrol(DES), an estrogen
anolouge prescribed to prevent miscarriage from 1945-1971. The drug was withdrawn once its
teratogenic effects on the reproductive tracts of male and female foetus were understood. The uterine
anomaly is seen in the female as many as 15% of women exposed to DES during pregnancy. Female
fetuses who are affected have a variety of abnormal findings that include uterine hypoplasia and a Tshaped uterine cavity. Patients with uterine abnormalities may have associated renal abnormalities
including unilateral renal agenesis.
18. Diagnosis Physical examination TAS and TVS Hysterosalpingography(HSG) MRI and CT scan
19. Clinical features Gynaecological impact
occur in bicornuate uterus.
20. Obstetrical impact
ty
21. Management During pregnancy When the diagnosis of uterine malformation is made at the
beginning of pregnancy, the treatment can be only preventive(setting at rest, sonographic monitoring of
the fetal growth and the cervical competence). Cervical cerclage should be proposed only in the case of
proved cervical incompetence observed in 1/3 to of uterine malformations. Abdominal mertoplasty
could be done either by excising the septum or by incising the septum. The success rate of abdominal
metroplasy in terms of live birth is 5-75%. Nowadays hysteroscopy metroplasty is done for this
condition.
22. Abnormalities of the fallopian tube The fallopian tubes may be unduly elongated, may have
accessory ostia or diverticula. Rarely, the tube may be absent on one side. These conditions may lower
the fertility or favour ectopic pregnancy.
23. Abnormalities of Ovaries The congenital anomaly of the ovaries includes congenital absence of ovary
and developmental overian cyst. Accessory ovary (division of original ovary into two) also comes under
this condition. Rarely, supernumerary ovaries may be found in the broad ligaments.