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THREATENED ABORTION

Threatened abortion occurs when products of conception tend to be expelled before 28 weeks of gestation, but the disturbance is minor enough that the fetus can continue to term.

Clinical Features of Threatened Abortion

Symptoms:

History of amenorrhea.
Painless vaginal bleeding.
Slight or no abdominal pain.
Patient may complain of backache and abdominal discomfort.

Examination (Signs):

General condition is good; on Vaginal examination, the OS is closed.
No uterine contractions.
Membranes remain intact.
Slight bleeding per vagina.
Signs of pregnancy.
The size of the uterus corresponds with the weeks of amenorrhea.
On abdominal palpation, the height of the fundus usually corresponds to the period of amenorrhea.

NB: No vaginal examinations must be done unless the bleeding is severe with clots.

Management of Threatened Abortion

Maternity:

Admit the patient and ensure complete bed rest.
Take personal and obstetrical histories, including the last normal menstrual period.
Monitor vital signs: temperature, pulse, respiration, and blood pressure.
Conduct a general examination to rule out anaemia, dehydration, and jaundice.
Investigations include, Blood smear for malaria parasites, Urine for urinalysis
Aseptic vulval scrubbing, provide a clean pad, and save used pads.
Administer Phenobarbital tablets 30mg – 60 mg 8 hourly.
Observe for 4-6 hours.
Paracetamol 1 g every 6-8 hours prn for 5 days.
Provide lubricants such as liquid paraffin (30 ml) to lubricate the faeces.
No enema is provided.
Change vulval scrubbing pads and examine used ones for blood loss.
Record the amount of blood loss, including clots and membranes.
Ensure daily bath and oral hygiene.
Pay special attention to the bladder; ensure regular urination and bowel movements.
If bleeding stops, avoid strenuous activity and abstain from sex for at least 14 days.
Follow up in 2 days in the ANC clinic.
If bleeding persists, refer to the hospital.

Hospital:

Admit the mother in the gynaecological ward for complete bed rest.
Take personal and obstetrical histories, including the last normal menstrual period.
Monitor vital signs: temperature, pulse, respiration, and blood pressure.
Conduct a general examination to rule out anaemia, dehydration, and jaundice.
Order investigations: blood for HB, grouping and cross-match, blood smear for malaria parasites, urine for urinalysis.
Reassure and calm the mother.
Conduct vaginal inspection, clean the vulva with normal saline, and apply a clean pad.
Encourage frequent urination to avoid urine retention.
Provide roughages to prevent constipation.
Ensure a highly nutritious diet.
Administer prescribed mild sedatives if the patient is restless and anxious.
Treat the identified cause of abortion (e.g., malaria).
Administer Phenobarbital tablets 30mg – 60 mg 8 hourly as prescribed.
Observe for 4-6 hours.
Paracetamol 1 g every 6-8 hours prn for 5 days as prescribed.
Provide lubricants such as liquid paraffin (30 ml) to lubricate the faeces.
No enema is provided.
Change vulval scrubbing pads and examine used ones for blood loss.
Record the amount of blood loss, including clots and membranes.
Ensure daily bath and oral hygiene.
Pay special attention to the bladder; ensure regular urination and bowel movements.
Maintain hygiene by changing soiled linen, carrying out bed baths, and ensuring oral hygiene.
Provide clean clothing to the patient.

Advice on discharge:

Continue bed rest at home.
Avoid sexual intercourse for 3-6 weeks.
Avoid heavy work such as lifting heavy things.
Report immediately if bleeding reoccurs.
Attend antenatal clinics.
Take only prescribed drugs.

Note: If threatened abortion is not attended to properly, it may lead to inevitable abortion.

INEVITABLE ABORTION

Inevitable abortion occurs when no measures can be taken to stop the abortion, leading to the cessation of pregnancy.

Causes of Inevitable Abortion

Maternal Infections: Infections such as syphilis, especially during the mid-trimester, can significantly increase the risk of inevitable abortion. Syphilis can lead to complications that affect the developing fetus and the health of the pregnancy, potentially resulting in unavoidable pregnancy loss.
Congenital Abnormalities: Fetal congenital abnormalities, which may arise due to genetic factors or environmental influences, can contribute to inevitable abortion. These abnormalities can impact the fetus’s viability and development, leading to pregnancy complications that cannot be averted.
History of Induced Abortion: A previous history of induced abortion can be a risk factor for inevitable abortion in subsequent pregnancies. The uterine scarring or damage resulting from a previous abortion procedure may increase the likelihood of pregnancy loss in future gestations.
Incompetent Cervix: Also known as cervical insufficiency, this condition involves the cervix opening too early during pregnancy, potentially leading to inevitable abortion. The weakened cervix is unable to support the growing fetus, resulting in premature dilation and pregnancy loss.
Uterine Anomalies: Structural abnormalities of the uterus, such as a septate or bicornuate uterus, can predispose women to inevitable abortion. These anomalies can interfere with the implantation and development of the fetus, increasing the risk of pregnancy loss.
Hormonal Imbalances: Fluctuations in hormone levels, particularly progesterone, can impact the maintenance of a healthy pregnancy. Hormonal imbalances may lead to inadequate support for the developing fetus, contributing to inevitable abortion.

Clinical Features of Inevitable Abortion

History of amenorrhea.
Lower abdominal pain and backache.
Heavy vaginal bleeding with clots.
Dilated cervix.
Painful uterine contractions.
Rupture of membranes, with liquor visible, especially after 16 weeks.
On speculum examination, membranes and other products of conception may protrude through the cervix or vagina.
Signs and symptoms of shock in the mother.
Palpable uterus may be smaller than expected.

NB: Inevitable abortion may be either complete or incomplete.

Management of Inevitable Abortion

In the Maternity Center:

Considered a gynaecological emergency requiring swift actions.
Admit the patient and provide reassurance.
Take a history, including presenting complaints.
Perform a physical examination, including vital signs and general examination.
Rule out signs of shock.
Examine to determine the level of the fundus and estimate gestation.
For pregnancies above 12 weeks, conduct a speculum examination to remove blood clots or visible products of conception.
If bleeding is heavy, administer ergometrine 0.5mg IM or oxytocin IV to induce uterine contractions and expel products of conception.
Administer pethidine injection 100 mg if Blood Pressure is 100/80 mm/Hg or more.
Keep the mother on IV fluids to prevent shock.
After complete expulsion of products of conception, check the uterus for adequate contraction.
Measure and record all blood loss and observations accurately.
Allow the mother to rest comfortably.
Assess if abortion is complete or incomplete and manage accordingly.

In the Hospital:

Admit the mother to a well-equipped gynaecological ward.
Take a complete history, focusing on the onset and amount of bleeding and any history of infection or disease.
Reassure the patient and relatives.
Conduct a brief general examination to assess the mother’s condition and rule out anaemia, dehydration, and shock.
Palpate the mother’s abdomen to estimate weeks of gestation.
Take baseline vital observations.
Clean the vulva, prepare for a vaginal examination, and apply a sterile pad.
Attempt to remove parts of the placenta or fetus visible through the cervical os or vagina.
Inform the doctor.
Carry out investigations as requested by the doctor.
Doctor’s treatment includes IV oxytocin for pregnancies 16 weeks and below; blood loss control with oxytocin/ergometrine injection; possible blood transfusion according to lab results; administration of intravenous fluids to prevent shock.
Prescribe analgesics to reduce pain, haematinics such as ferrous, and ensure good hygiene.
Provide a nutritious diet to the patient.

Prevention of Inevitable Abortion

Regular Antenatal Care: Attending antenatal clinics is crucial for the early identification and management of potential risk factors for inevitable abortion. Regular prenatal check-ups allow healthcare providers to monitor the pregnancy closely and address any emerging issues promptly.
Prompt Reporting of Symptoms: Early detection of symptoms such as bleeding is vital in preventing inevitable abortion. Individuals experiencing any signs of potential pregnancy complications, such as abnormal bleeding, should promptly report to maternity centres for thorough evaluation and appropriate intervention.
Timely Medical Consultation: Seeking prompt medical advice and treatment in the event of any concerning symptoms or risk factors can significantly contribute to preventing inevitable abortion. Timely intervention by healthcare professionals can help mitigate potential complications and support the continuation of a healthy pregnancy.
Lifestyle Modifications: Adopting a healthy lifestyle, including proper nutrition, regular exercise, and avoiding harmful substances such as alcohol and tobacco, can contribute to reducing the risk of inevitable abortion. Maintaining a healthy weight and managing pre-existing medical conditions can also play a role in preventing pregnancy loss.
Addressing Underlying Health Conditions: Managing pre-existing health conditions such as diabetes, hypertension, and thyroid disorders through appropriate medical care and lifestyle modifications can help minimize the risk of inevitable abortion.
Genetic Counselling: For individuals with a history of genetic abnormalities or recurrent pregnancy loss, genetic counselling can provide valuable insights and guidance on family planning, prenatal testing, and potential interventions to reduce the risk of inevitable abortion.

Complications of Inevitable Abortion

Hemorrhagic Shock: Excessive bleeding associated with inevitable abortion can lead to hemorrhagic shock, a life-threatening condition characterized by inadequate blood flow to vital organs. This can result in symptoms such as rapid heart rate, low blood pressure, and organ dysfunction.
Anaemia: Prolonged or heavy bleeding during inevitable abortion can cause anaemia, a condition characterized by a low red blood cell count. Anaemia can lead to fatigue, weakness, and shortness of breath, impacting the overall health and well-being of the individual.
Dehydration: Significant blood loss and prolonged bleeding can lead to dehydration, potentially resulting in electrolyte imbalances and compromised organ function. Dehydration can manifest as dizziness, dry mouth, decreased urine output, and in severe cases, may necessitate medical intervention.
Infection: Incomplete evacuation of the products of conception during inevitable abortion can increase the risk of uterine infection. This can lead to symptoms such as fever, pelvic pain, and abnormal vaginal discharge, requiring prompt medical attention to prevent complications.
Psychological Distress: Coping with the emotional impact of inevitable abortion can lead to psychological distress, including feelings of grief, guilt, and anxiety. Providing appropriate emotional support and counselling is essential to address the mental health implications of pregnancy loss.
Uterine Perforation: In rare cases, instrumentation or medical procedures during inevitable abortion can lead to uterine perforation, a serious complication that requires immediate medical evaluation and intervention.
Long-term Reproductive Health Implications: In some instances, inevitable abortion may be associated with long-term reproductive health implications, including scarring of the uterus, which can impact future pregnancies.

THREATENED ABORTION Read More »

ABORTIONS

Abortion is defined as the expulsion of products of conception before 28 weeks of gestation.

Abortion is also defined as the termination of pregnancy prior to 28 weeks of gestation or delivery of a fetus weighing less than 500g.

It may be early or late abortion.

Early abortion is the termination of pregnancy before 12 weeks of gestation.
Late abortion is the termination of pregnancy between 12-24 weeks of gestation.

Causes of Abortion

Abortion can be categorized into

Fetal, Maternal, Uterine and Local causes.

Fetal Causes:

Malformation of the Zygote in Chromosomal Disorders: Abnormalities in the zygote’s chromosomal structure such as trisomy 21 (Down syndrome) or monosomy X (Turner syndrome) are examples of conditions that can result in fetal malformation and contribute to abortion.
Abnormal Implantation in the Uterus: Includes conditions like placenta previa, where the placenta attaches near the internal os, can impact normal fetal development and lead to complications that may result in abortion. Abnormal implantation can disrupt the supply of nutrients and oxygen to the fetus, affecting its growth and development.
Diseases of the Fertilized Ovum: Disorders affecting the fertilized ovum such as genetic or metabolic abnormalities, can compromise the viability of the embryo and contribute to spontaneous abortion. These diseases may interfere with the embryo’s ability to develop and thrive in the early stages of pregnancy.
Chromosome Abnormalities of the Fetus (30% – 40%): Genetic irregularities in the fetus including numerical and structural chromosomal abnormalities, are significant contributors to spontaneous abortion. These abnormalities can disrupt normal fetal development and increase the likelihood of pregnancy loss.

Maternal Causes:

Acute Illness with High Temperatures: Conditions like malaria, typhoid, rubella, etc., which can raise body temperatures.
Chronic Illnesses: Persistent conditions like anaemia, chronic nephritis, diabetes mellitus (DM), syphilis, etc.
Cervical Incompetence: Impaired cervical function leading to the inability to maintain a pregnancy.
Severe Malnutrition: Inadequate nutritional support impacting maternal health and fetal development.
Oxytocic Drugs: Medications that stimulate uterine contractions.
Hormonal Insufficiency: Such as insufficient production of progesterone before placental formation, affecting decidua development. Thyroid Deficiency and Hyperthyroidism also increase the risk.
Effects of Drugs Taken: Such as Cytotoxic Drugs which are toxic to cells, Radiation therapy, Overdose of malaria drugs, etc.
Uterine Abnormalities: Such as Retroverted Uterus, Divided Uterus (Bicornuate) or Fibroids (Submucosal): Noncancerous growths in the uterus affecting implantation.
Trauma: Severe Trauma on the Uterus informs of Impact injuries or falls or Insertion of Instruments or Foreign Bodies into the cervix, Operations Like Myomectomy.
Immunological Factors: Antibodies Crossing the Placenta in maternal blood attacking fetal erythrocytes (rhesus incompatibility).
Acute Emotional Disturbances like Severe Fright or Sudden Bereavement triggering contractions and potential abortions.

Predisposing Factors to Abortion

Unwanted Pregnancy:

Too early (adolescence): Teenage pregnancies are often unplanned and may result in abortion due to lack of resources, support, and education.
Too frequent: Pregnancies that occur too close together may strain a woman’s physical and emotional resources, increasing the risk of abortion.
Too late: Pregnancies that occur later in a woman’s reproductive life may carry increased health risks, leading some women to consider abortion.

Problem of Teenage Sexuality and Pregnancy:

Lack of sex education and access to contraception can contribute to high rates of teenage pregnancy and abortion.
Social and cultural factors may also influence teenage sexual behavior and the likelihood of unplanned pregnancy.

Low Preference Use of Family Planning:

Inconsistent or incorrect use of family planning methods can lead to contraceptive failure and unplanned pregnancy.
Lack of access to affordable and effective contraception can also contribute to unplanned pregnancy and abortion.

Sexual Coercion or Rape:

Unwanted pregnancy resulting from sexual coercion or rape may lead to abortion, as the woman may not have consented to the pregnancy.

Unstable Relationship:

Unstable or abusive relationships may contribute to unplanned pregnancy and abortion, as the woman may feel unsafe or unsupported in continuing the pregnancy.

Financial Constraints:

Financial difficulties may make it difficult for a woman to afford the costs of raising a child, leading her to consider abortion.

Need to Continue with Education or Job:

Some women may choose abortion in order to continue their education or maintain their job, as they may not have the resources or support to balance pregnancy and these other responsibilities.

Unfaithfulness:

In some cases, a woman may choose abortion if she discovers that her partner has been unfaithful, as she may not want to raise a child with someone she no longer trusts.

PREVENTION OF ABORTIONS.

Health educate the community about the dangers of unsafe abortion.
Talk about the importance of family planning to the community.
Provide family planning services to school girls.
The government should strengthen the rule governing unsafe abortion.
Good upbringing of children by the parents.
Strengthening youth friendly services at all health facilities.
Strengthening community based organization to teach the community on the dangers of unsafe abortion.

Types of Abortion

Abortions are broadly classified into spontaneous and induced types.

Spontaneous Abortion

Spontaneous abortion, also known as miscarriage, is the unintentional loss of a pregnancy before 20 weeks of gestation.

It is the most common type of pregnancy loss, occurring in about 10-20% of all pregnancies.

Types of Spontaneous Abortion:

Threatened Abortion: Bleeding occurs in early pregnancy without the opening of the cervix or evacuation of the products of conception (POC). Resolves on its own with no medical intervention.
Inevitable Abortion: The cervix is open and POC are visible indicating an unavoidable termination of pregnancy. The pregnancy will not continue and will proceed to incomplete or complete abortion.
Incomplete Abortion: POC are partially expelled.
Complete Abortion: POC are completely expelled.
Habitual Abortion: Three or more recurrent spontaneous abortions

Induced Abortion

Induced abortion is the intentional termination of a pregnancy before the fetus is viable outside the uterus. It is a legal medical procedure in many countries, but it is illegal in some countries.

Types of Induced Abortion:

Legal or Therapeutic Abortion: This type of abortion is performed to protect the life or health of the mother, or in cases of rape or incest.
Illegal or Criminal Abortion: This type of abortion is performed outside the law and is considered a crime in many countries. Poses serious health risks to the woman due to non-professional and unsafe procedures hence increased likelihood of Septic abortion.

General Nursing Interventions and Actions for Patients with Abortion

1. Helping Patient Through Anxiety and Providing Emotional Support

Assess and Encourage Expression of Feelings:

Assess the client’s anxiety and facilitate the expression of her emotions.
Recognize potential feelings of guilt in both the client and her partner.
Encourage grieving and acknowledge that the process may differ for each individual.

Consider Cultural Beliefs:

Assess the client’s and her partner’s cultural beliefs regarding abortion.
Establish a therapeutic relationship by demonstrating empathy and unconditional positive regard.
Provide compassionate care, acknowledging the significance of the pregnancy.

Provide Psychological Comfort:

Offer psychological and mental support to the client and her partner.
Utilize comfort measures such as breathing and relaxation techniques to reduce anxiety.
Explain procedures, stay with the client, and provide information for informed decision-making.

Support Person and Spiritual Guidance:

Facilitate the presence of a support person, especially during second-trimester procedures.
Explore spiritual support as a resource for coping.
Encourage questions, allowing the client to express fears and concerns.

2. Providing Pain Relief and Comfort:

Assess and Monitor Pain:

Evaluate the severity and location of discomfort, considering variations in pain perception.
Systematically monitor the client for verbal reports and objective cues of pain every two hours.

Educate About Expected Discomfort:

Explain the nature of expected discomfort associated with the termination process.
Provide information about the use of prescription or nonprescription analgesics.

Administer Analgesics and Comfort Measures:

Administer narcotic/non-narcotic analgesics, sedatives, and antiemetics as prescribed.
Offer comfort measures, including relaxation and breathing techniques.
Position the client for comfort and encourage position changes.

Assist with Pain Management Procedures:

Assist with the administration of paracervical block before surgical termination.
Support the client through pain management strategies during the termination process.

3. Promoting Maternal Safety and Preventing Injuries:

Assess and Monitor Methods Used:

Evaluate if the abortion is self-managed and assess for any additional methods used.
Monitor for excessive nausea and vomiting before and after elective termination.

Evaluate Discomfort and Vital Signs:

Assess for dyspnea, wheezing, or agitation, which may indicate complications.
Evaluate the level of discomfort, addressing abdominal pain and tenderness.
Stress the importance of returning for a follow-up examination.

Ensure Proper Procedures and Support:

Determine cervical status before the procedure and assist with the insertion of Laminaria tent or prostaglandin.
Administer RhoGAM to Rh-negative clients after termination.
Assist with additional treatment or procedures to control complications.

4. Preventing Hypovolemic Shock:

Monitor Vital Signs and Blood Loss:

Monitor vital signs, noting increased pulse rate and signs of shock.
Monitor and assess blood loss, counting and weighing peri pads.

Educate and Provide Emergency Contacts:

Educate the client on reporting signs of haemorrhage and adherence to prescribed medications.
Provide emergency contact information for immediate assistance.

Determine Cervical Status and Administer Medications:

Determine cervical status before the procedure and assist with the insertion of Laminaria tent or prostaglandin.
Administer antiemetic agents and draw blood specimens for blood typing and crossmatch.

Administer Oxygen and Intravenous Fluids:

Administer oxygen to increase oxygen tension and intravenous fluids as ordered.
Assist with surgical procedures to mitigate haemorrhage.

5. Preventing Infection:

Monitor and Assess for Signs of Infection:

Monitor for signs of infection, including fever, crampy abdominal pain, and tender uterus.
Regularly assess vital signs, particularly temperature.

Perform Hand Hygiene and Educate on Perineal Hygiene:

Practice hand hygiene before and after each care activity.
Educate the client on proper perineal hygiene to prevent the spread of bacteria.

Encourage Universal STD Screening:

Educate the client about the importance of universal STD screening for sexually active women.
Instruct the client to report any signs or symptoms of infection promptly.

PREMENSTRUAL SYNDROME

Premenstrual syndrome is a group of symptoms both physical and psychological that occur before menstruation.

Symptoms can range from mild to severe and occur during the luteal phase (begin 7-14 days before the onset of menses) and disappear after the onset of menses.

Majority of women experience premenstrual syndrome but it is considered severe if it impairs work, relationships or usual activities.

Causes of Premenstrual Syndrome

The cause of premenstrual syndrome remains unknown/unclear although changes in the hormonal level, Vitamin B6 and calcium deficiency have been suspected.

Signs and symptoms of Premenstrual Syndrome

Premenstrual syndrome presents with both physical and psychological symptoms as outlined below.

Psychological Symptoms: These are emotional and mental aspects affected by PMS, including irritability, depression, tension, anxiety, fatigue, and difficulties in concentration.

Irritability: Feelings of annoyance, impatience, and mood disturbances.
Depression: Persistent feelings of sadness, hopelessness, and despair.
Tension: Increased stress levels and heightened emotional response.
Anxiety: Experiencing nervousness, unease, or a sense of impending doom.
Fatigue: A general feeling of tiredness, weakness, and lack of energy.
Inability to Concentrate: Difficulty focusing, poor attention, and mental fog.

Physical Symptoms: Physical manifestations of PMS, such as abdominal bloating, perceived weight gain, breast swelling, acne, headache, and migraines.

Abdominal Bloating: Swelling or feeling of fullness in the abdominal area.
Feeling of Weight Gain: Perceived increase in body weight, often due to fluid retention.
Swelling of Breasts: Breast tenderness and enlargement due to hormonal changes.
Acne: Skin breakouts and increased oiliness.
Headache: Pain or discomfort in the head.
Migraine: Severe headaches often accompanied by other symptoms like nausea and sensitivity to light.

Management of Premenstrual Syndrome (PMS)

A woman is considered to have PMS if her symptoms interfere with the activities of daily living.

Non-pharmacological Strategies

Diet:

Increase intake of vitamin B6, carbohydrates, fruits, and vegetables, such as legumes and cereals.
Avoid consumption of caffeine.
Refrain from smoking and limit alcohol intake.
Reduce overall salt intake.
Educate patients about the benefits of a diet rich in omega-3 fatty acids and low in saturated fats.
Encourage the consumption of fruits and vegetables.

Physical Exercises:

Engage in regular physical activities, including aerobic exercises and walking.
Encourage exercises to relieve bloating, irritability, and insomnia.

Education and Counseling:

Provide education about the causes, treatment, and prevention of PMS.
Offer counselling to address emotional aspects and coping mechanisms.

Stress Management:

Implement relaxation techniques and mental imagery to manage stress.

General Measures:

Educate the patient about premenstrual syndrome.
Encourage regular exercises to relieve bloating, irritability, and insomnia.
Advise a diet rich in carbohydrates, calcium, omega-3 fatty acids, and low in saturated fats.
Avoid caffeine to reduce breast tenderness and irritability.
Reduce the consumption of sugar, alcohol, and salt.
Restrict salt intake to decrease abdominal bloating and fluid retention.
Encourage the consumption of fruits and vegetables.
Advise patients who smoke to quit.

Pharmacological Strategies

Combined Oral Contraceptives (COCs): Use hormonal contraceptives to regulate hormonal fluctuations.

Antidepressants:

Consider selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (20 mg once daily) or paroxetine (20 mg once daily) if PMS presents with depression and anxiety symptoms.
Start SSRIs at the time of ovulation and stop on the first day of menses.
Monitor for side effects such as insomnia, fatigue, and loss of libido.

Diuretics:

Recommend diuretics, such as furosemide (20-40 mg), for patients with weight gain.
Spironolactone (50-100 mg daily for 7 days) may help reduce fluid retention.

Vitamins:

Consider Vitamin B6 (50-100 mg once daily) and calcium (600 mg twice daily) to reduce physical symptoms.

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DYSFUNCTIONAL UTERINE BLEEDING

Dysfunctional uterine bleeding (DUB) refers to abnormal uterine bleeding that occurs in the absence of organic causes or underlying medical conditions.

It is characterized by irregular, prolonged, or heavy menstrual bleeding. Dysfunctional uterine bleeding also refers to abnormal bleeding resulting from hormonal changes rather than from trauma, inflammation, pregnancy or a tumour.

Associated Causes of Dysfunctional Uterine Bleeding

Although there is no apparent structural or organic cause, the term “dysfunctional” means that the bleeding originates from a dysfunction within the normal hormonal regulation of the menstrual cycle rather than a specific anatomical abnormality.

While these are not direct causes of DUB, they can influence or worsen the condition.

Hormonal Dysfunction: Hormonal imbalances, particularly disruptions in oestrogen and progesterone levels, can interfere with the normal menstrual cycle. These imbalances may result from various factors, including stress, medical conditions, or natural hormonal fluctuations.
Benign and Malignant Tumours: The presence of benign growths (such as uterine fibroids) or malignant tumours (like uterine or cervical cancer) can lead to abnormal bleeding patterns. Tumours affect the uterine structure, impacting the regularity of menstrual cycles.
Use of Some Contraceptives: Certain contraceptives, especially those containing hormones, can influence menstrual patterns. Changes in contraceptive methods or formulations may contribute to dysfunctional bleeding in susceptible individuals.
Coagulation Disorders: Conditions affecting blood clotting, such as thrombocytopenia or leukaemia, can lead to dysfunctional bleeding. Impaired coagulation mechanisms may result in irregular and excessive menstrual flow.
Systemic Diseases – Ovarian Failure: Ovarian failure, characterized by the loss of normal ovarian function, can disrupt hormonal balance and menstrual regularity. Systemic diseases impacting ovarian function contribute to dysfunctional bleeding.
Various Factors Influencing Hormonal Balance:
Immature hypothalamus
Changes in exercise patterns
Impaired follicular stimulation
Malnutrition
Emotional viability/crises
Temporary oestrogen withdrawal at ovulation
Radiation and chemotherapy
Lifestyle changes

Types of Dysfunctional Uterine Bleeding (DUB):

DUB may present in any of the following ways:

Menorrhagia: Menorrhagia involves prolonged or excessive bleeding during regular menstruation.
Metrorrhagia: Metrorrhagia refers to vaginal bleeding occurring between regular menstrual periods.
Oligomenorrhea: Oligomenorrhea is characterized by a significantly reduced menstrual flow, often accompanied by irregular cycles.
Polymenorrhea: Polymenorrhea manifests as frequent menstruation, occurring at intervals of less than three weeks.
Menometrorrhagia: Menometrorrhagia involves excessive bleeding both during the usual menstrual time and at irregular intervals.

Signs and Symptoms of Dysfunctional Uterine Bleeding

Irregular menstrual cycles: Menstrual periods may occur more frequently or infrequently than usual.
Prolonged bleeding: Menstrual bleeding may last longer than the typical duration.
Heavy menstrual bleeding: Excessive or abnormally heavy bleeding during menstrual periods.
Intermenstrual bleeding: Bleeding that occurs between menstrual cycles.
Fatigue or tiredness due to excessive blood loss.
Anaemia symptoms: Weakness, lightheadedness, shortness of breath, or pale skin.

NOTE : A diagnosis of dysfunctional uterine bleeding is made only when all other possibilities of causes of bleeding have been excluded.

Investigations

Dysfunctional uterine bleeding is diagnosed based on patient history and physical examination and laboratory investigations.

Complete blood count (CBC): Helps to detect anaemia
HCG test: It is recommended to rule out pregnancy
Thyroid stimulating hormone (TSH): Elevated levels of TSH may be due to hypothyroidism
Measurement of prolactin levels: Helps to rule out pituitary adenoma
Pelvic ultrasound: Helps to rule out ovarian or uterine causes

MANAGEMENT OF D.U.B

Treatment depends on various factors like age, condition of the uterine lining and the woman’s plans regarding pregnancy.
When the uterine lining is thickened but contains normal cells, heavy bleeding may be treated with a high dose of oral contraceptive oestrogen and progestin(COC) or oestrogen alone usually intravenously, then followed by a progestin given by mouth. Bleeding generally stops within 12-24 hours and then low doses of oral contraceptives may be given in the usual manner for at least 3 months. Women who have lighter bleeding may be given low doses from the start.
If a woman has contraindications to oestrogen-containing drugs, progestin only pills may be given by mouth for 10-14 days each month.
Other medications include;

Class of Drug	Example	Remarks
NSAIDs	Mefenamic acid 500mg	Reduces menstrual blood loss by lowering endometrial prostaglandin concentration.
	Ibuprofen 400-800mg	Should be taken before and during menstruation.
Antifibrinolytics	Tranexamic acid 1g twice daily	Helps prevent blood loss during menstruation.
Hormonal Contraceptives	Combined Oral Contraceptives or IUDs	Controls chronic bleeding by suppressing the endometrium.
Progesterone Therapy	Norethisterone 5mg bd from day 5-26 of menstrual cycle	Helps stop acute bleeding.

Total hysterectomy is indicated if the woman is over 35 years, uterine lining thickened and contains abnormal cells and she does not want to become pregnant.
D&C may be used if response or hormonal therapy proves ineffective.
If a woman wants to become pregnant, clomiphene drugs may be given orally to induce ovulation.

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POLYMENORRHOEA/ EPIMENORRHOEA

Polymenorrhea, also known as epimenorrhoea, is a medical condition characterized by frequent menstrual periods that occur more frequently than the normal menstrual cycle.

Polymenorrhoea also refers to menstruation periods that occur at shorter intervals than usual (14-21 days), but they are frequent and regular.

Causes of Polymenorrhea/Epimenorrhoea:

Hormonal imbalances: Fluctuations in oestrogen and progesterone levels can disrupt the normal menstrual cycle and result in more frequent periods.
Thyroid disorders: Overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism) can affect hormone production and menstrual regularity.
Polycystic ovary syndrome (PCOS): This condition is characterized by hormonal imbalances, enlarged ovaries with cysts, and irregular menstrual cycles.
Uterine abnormalities: Conditions such as uterine fibroids, polyps, or adenomyosis can cause abnormal bleeding and frequent periods.
Stress and lifestyle factors: Chronic stress, excessive exercise, drastic weight changes, and poor nutrition can disrupt the hormonal balance and contribute to polymenorrhea.

Signs and Symptoms of Polymenorrhea/Epimenorrhoea:

Menstrual Cycles Shorter than 21 Days: Defined by the duration between the onset of one period and the beginning of the next, with cycles constantly falling below the normal 21-days.
Frequent Menstrual Periods: Menstrual bleeding occurring every two weeks or at intervals of less than 14 days, indicating increased frequency compared to the standard monthly cycle.
Altered Bleeding Patterns: Variations in blood flow, with episodes of lighter or heavier bleeding than what is considered for the individual.
Increased Menstrual Discomfort: Discomfort or pain associated with menstruation, more than the discomfort experienced during a regular menstrual cycle.
Fatigue or Tiredness: Resulting from more frequent blood loss due to polymenorrhea, leading to a decrease in energy levels and an increased sense of tiredness.
Emotional and Psychological Impact: Potential emotional consequences, including anxiety or mood swings, from the physical and hormonal changes associated with more frequent menstrual cycles.

Investigations for Polymenorrhea/Epimenorrhoea:

Medical history and physical examination: A thorough evaluation of the menstrual patterns, symptoms, and any underlying medical conditions is conducted. A pelvic examination may be performed to assess the reproductive organs.
Hormone level assessment: Blood tests may be done to measure hormone levels, including oestrogen, progesterone, thyroid hormones, and other relevant hormones.
Pelvic ultrasound: This imaging test can provide visual information about the ovaries, uterus, and any structural abnormalities.
Endometrial biopsy: A sample of the uterine lining may be obtained and examined to rule out any abnormalities or cancer.

Medical and Nursing Management of Polymenorrhea/Epimenorrhoea:

Hormonal therapy: Depending on the underlying cause, hormonal medications, such as oral contraceptives or hormone-regulating medications, may be prescribed to regulate the menstrual cycle and reduce the frequency of periods.
Treatment of underlying conditions: If polymenorrhea is caused by conditions such as PCOS or uterine abnormalities, appropriate treatment strategies will be implemented to address the specific cause. Carry out dilatation and curettage (D&C) to remove retained products if its the cause.
Lifestyle modifications: Stress reduction techniques, maintaining a balanced diet, regular exercise, and adequate sleep can help regulate hormonal balance and promote overall well-being.
Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene, symptom management, and lifestyle modifications.
Monitoring and follow-up: Monitoring patients’ response to treatment, assessing the effectiveness of interventions, and ensuring appropriate follow-up care should be put into considerations.

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METRORRHAGIA/INTERMENSTRUAL BLEEDING

Metrorrhagia, now commonly called Intermenstrual bleeding is vaginal bleeding that occurs at irregular intervals not associated with the menstrual cycle.

Metrorrhagia is a medical term used to describe irregular or abnormal uterine bleeding that occurs between menstrual periods.

It is characterized by light spotting that occurs outside of one’s period patterns and does not need sanitary protection.

This is a symptom of some underlying pathology which may be organic or functional.

Causes of Metrorrhagia

Fibroid Uterus: Presence of uterine fibroids, noncancerous growths that can cause irregular and abnormal bleeding.
Adenomyosis: A disorder involving the glands that secrete cervical mucus and fluids, contributing to abnormal uterine bleeding.
Pelvic Endometriosis: Presence of endometrial tissue outside the uterine lining, leading to premenstrual pain and dysmenorrhea.
Chronic Tubo-Ovarian Mass: Persistent mass involving the fallopian tubes and ovaries, contributing to irregular uterine bleeding.
Retroverted Uterus (Due to Congestion): Uterus tilted backward, causing congestion and contributing to metrorrhagia.
Uterine Polyp: Presence of a polyp with a rich blood supply, making it prone to easy bleeding.
Cervical Erosions: Presence of wounds on the cervix with increased blood supply, leading to bleeding.
Cancer of the Cervix or Endometrial Cancer: Malignant growths in the cervix or endometrium causing abnormal bleeding.
Chronic Threatened Abortion or Incomplete Abortion: Prolonged or incomplete abortion affecting uterine function and causing irregular bleeding.
Retained Pieces of Placenta: Residual placental fragments interfering with uterine contraction, preventing proper closure of blood vessels after childbirth.
Mole Pregnancy: Abnormal uterine mass growing post-fertilization, characterized by an excess of blood capillaries leading to bleeding.
Ovulation Bleeding: Bleeding associated with the process of ovulation.
Short Cycles like Polymenorrhea: Menstrual cycles shorter than the average duration, contributing to irregular and frequent uterine bleeding.
Infections: Having lower abdominal or pelvic infections such as vaginitis can lead to metrorrhagia.

Signs and symptoms of Metrorrhagia

Bleeding Between Menstrual Periods: Presence of abnormal bleeding episodes occurring between regular menstrual cycles.
Irregular Menstrual Cycles: Variations in the normal pattern of menstrual cycles, including changes in cycle length or timing.
Heavier or Lighter Bleeding Than Usual During Menstrual Periods: Experiencing unusually heavy or light menstrual flow compared to the individual’s typical pattern.
Prolonged Bleeding That Lasts Longer Than Normal: Extended duration of menstrual bleeding beyond the usual timeframe.
Pelvic Pain or Discomfort: Presence of pain or discomfort in the pelvic region, often associated with abnormal bleeding.
Fatigue or Tiredness Due to Blood Loss: Feeling tired or fatigued as a result of significant blood loss during irregular bleeding episodes.
Anaemia Symptoms: Manifestations of anaemia, including: Shortness of Breath, Dizziness, Weakness.

Investigations of Metrorrhagia

Assessment:

Thorough medical history and physical examination.
Detailed history about menstrual cycles, associated symptoms, and relevant medical conditions.
Pelvic examination to assess the condition of reproductive organs.

Diagnostic Tests:

Hormone Level Assessment: Blood tests to evaluate hormone levels, including oestrogen, progesterone, and thyroid hormones. This helps identify hormonal imbalances that may contribute to metrorrhagia.
Transvaginal Ultrasound: Imaging test for visualizing the uterus and ovaries, detecting structural abnormalities or conditions such as fibroids.
Endometrial Biopsy: Collection of a sample from the uterine lining for microscopic evaluation. This procedure helps identify abnormalities, including signs of cancer.
Hysteroscopy: Procedure involving the insertion of a thin, lighted tube into the uterus to visualize the uterine cavity. It aids in detecting abnormalities or issues affecting the uterine lining.
Digital and Speculum Examination: Examination techniques to visualize the cervix for any signs of abnormality.
Pelvic Scan: Imaging scan focused on visualizing pelvic organs, assisting in ruling out any abnormalities.
Urine Test: Urine samples to check for pregnancy, infection, or STDs.
Pap Smear: To rule out cancer.

Management of Metrorrhagia

The best management to investigate and treat the cause.

Aims of Management:

Alleviate Symptoms.
Determine and address the root causes of metrorrhagia.
Prevent Complications

Medical and Nursing Management of Metrorrhagia:

Assessment: Medical History and Physical Examination: Gather detailed information on menstrual cycles, symptoms, and relevant medical conditions. Conduct a pelvic examination to assess reproductive organs.
Hormonal therapy: Depending on the underlying cause, hormonal medications, such as birth control pills or progestin therapy, may be prescribed to regulate the menstrual cycle and reduce abnormal bleeding.
Nonsteroidal anti-inflammatory drugs (NSAIDs): These medications can help manage pain and reduce bleeding during episodes of metrorrhagia.
Treatment of underlying conditions: If metrorrhagia is caused by conditions such as fibroids, polyps, or infections, appropriate treatment strategies will be implemented to address the specific cause.
Surgical interventions: In some cases, surgical procedures may be necessary to remove uterine abnormalities or address the underlying cause of metrorrhagia.
Supportive care: Nursing management focuses on providing emotional support, educating patients about menstrual hygiene and symptom management, and promoting overall well-being.
Rest: Rest is advised during the bleeding phase. Assurance and sympathetic handling are helpful particularly in adolescents. Anaemia should be corrected energetically by diet, hematinics, and even by blood transfusion.
Monitoring and follow-up: Monitor patients’ response to treatment, assess the effectiveness of interventions, and ensure appropriate follow-up care.

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MENORRHAGIA

Menorrhagia is a condition characterized by abnormally heavy or prolonged menstrual bleeding.

Menorrhagia can be heavy or prolonged menstrual bleeding or both.

Causes of Menorrhagia

Hormonal imbalances: Fluctuations in oestrogen and progesterone, two key hormones in the menstrual cycle, can disrupt the normal regulation of the menstrual cycle. Irregularities in these hormones may lead to excessive and prolonged menstrual bleeding.
Uterine fibroids: Uterine fibroids are noncancerous growths in the uterus. Depending on their size and location, they can interfere with the normal contraction and relaxation of the uterine muscles, resulting in heavy menstrual bleeding.
Adenomyosis: Adenomyosis occurs when the inner lining of the uterus (endometrium) grows into the muscular wall of the uterus. This condition can lead to an enlarged uterus and heavy menstrual bleeding.
Polyps: Uterine polyps are small, benign growths on the lining of the uterus. These growths can cause irregularities in the menstrual cycle, leading to heavy and prolonged bleeding.
Endometrial hyperplasia: Endometrial hyperplasia is the abnormal thickening of the uterine lining. This condition can result in an increase of the surface area leading to heavy and prolonged menstrual bleeding.
Inherited bleeding disorders: Conditions like von Willebrand’s disease, which are inherited, affect blood clotting. Women with such disorders may experience excessive bleeding during menstruation.
PID (Pelvic Inflammatory Disease): PID is an infection of the female reproductive organs. Inflammation and infection can disrupt the normal functioning of the uterus and surrounding structures, leading to heavy menstrual bleeding.
Cancers (cervix and endometrium): Cancerous growths in the cervix or endometrium can lead to irregular and heavy menstrual bleeding. The abnormal growth of cancerous cells interferes with the normal shedding of the uterine lining.
Ovarian tumours: Tumours in the ovaries can disrupt hormonal balance. Changes in hormone levels may affect the regularity of the menstrual cycle, resulting in heavy bleeding.
Nutritional factors: Deficiencies or imbalances in certain nutrients can impact overall health, including menstrual health.
Psychogenic factors (e.g., stress): Psychological stress can influence hormonal balance and the menstrual cycle. Chronic stress may contribute to irregularities in menstrual bleeding, including excessive and prolonged periods.
Family inheritance: A family history of certain conditions, especially those related to blood clotting or hormonal imbalances, may increase the likelihood of menorrhagia.
Intrauterine Device (IUD): The use of intrauterine devices for contraception may lead to increased menstrual bleeding in some cases. The presence of the IUD can cause changes in menstrual flow.
Clotting disorders: Conditions that affect blood clotting, such as certain disorders like Thrombocytopenia, DIC, DVT, or medications like warfarin, heparin, can result in heavy menstrual bleeding. Proper blood clotting is essential for the normal cessation of menstrual flow.
Functional tumours of ovaries: Tumours in the ovaries that are hormonally active can disrupt the balance of reproductive hormones. This disruption may lead to irregular menstrual cycles and heavy bleeding.

Signs and symptoms of Menorrhagia

Prolonged Menstrual Bleeding: Menstrual bleeding lasting longer than seven days. Menstrual periods last around five to seven days, and bleeding beyond this timeframe may indicate menorrhagia.
Heavy Menstrual Flow: Soaking through one or more sanitary pads every hour for several consecutive hours, indicating a heavy flow. This level of bleeding is considered excessive and can impact quality of life.
Passing Large Blood Clots: Experiencing the passage of large blood clots during menstruation. The presence of large blood clots can be a sign of menorrhagia, often causing discomfort and contributing to heavy bleeding.
Fatigue and Tiredness: Feeling fatigued and tired due to excessive blood loss during menstruation, which can lead to anaemia. Menorrhagia can result in the loss of a significant amount of blood, leading to fatigue, weakness, and decreased energy levels.
Shortness of Breath or Rapid Heart Rate: Experiencing shortness of breath or a rapid heart rate caused by anaemia resulting from excessive blood loss. Anaemia, a common consequence of menorrhagia, can lead to symptoms such as shortness of breath and an increased heart rate due to decreased oxygen-carrying capacity in the blood.
Lightheadedness or Dizziness: Feeling lightheaded or dizzy, which can be a symptom of anaemia or excessive blood loss. These symptoms may occur as a result of reduced blood volume and oxygen supply to the body due to heavy menstrual bleeding.
Disruption of Daily Activities: Menstrual periods that significantly disrupt daily activities due to the severity of symptoms and discomfort. Menorrhagia can lead to the inability to engage in regular activities, impacting work, social life, and overall well-being.
Iron Deficiency: Developing symptoms of iron deficiency, such as pale skin, brittle nails, and cravings for non-nutritive substances like ice or dirt, due to chronic blood loss associated with menorrhagia.
Sleep Disturbances: Experiencing sleep disturbances, such as waking up due to the need to change sanitary products during the night, leading to disrupted sleep patterns and fatigue.

Diagnosis and Investigations of Menorrhagia

Complete Medical History and Physical Examination: Conduct a thorough review of the patient’s medical history and perform a physical examination to gather information about symptoms & menstrual patterns.
Blood Tests: Blood tests will be conducted to assess blood count, iron levels, and hormonal imbalances. These tests can help identify anaemia, iron deficiency, and hormonal irregularities that may contribute to menorrhagia.
Transvaginal Ultrasound: A transvaginal ultrasound will be performed to evaluate the structure of the uterus and detect any abnormalities, such as fibroids, polyps, or other structural issues that could be causing or contributing to menorrhagia. This imaging technique helps in visualizing the internal reproductive organs and identifying potential sources of abnormal bleeding.
Endometrial Biopsy: An endometrial biopsy involves the collection and examination of a sample of the uterine lining to check for abnormalities, such as hyperplasia or cancer.
Hysteroscopy: Hysteroscopy is a minimally invasive procedure that involves the insertion of a thin, lighted tube into the uterus to directly visualize the uterine cavity. This allows to identify and evaluate abnormalities within the uterus, such as polyps, fibroids, or other structural issues contributing to menorrhagia.
Coagulation Tests: Bleeding time, prothrombin time, and clotting time tests may be conducted to assess for coagulopathy and platelet availability. Abnormal results in these tests can indicate potential bleeding disorders or coagulation abnormalities that may contribute to heavy menstrual bleeding.
Full Haemoglobin Levels and Hormone Analysis: To rule out hormonal imbalances and to identify any underlying endocrine disorders that could be contributing to menorrhagia. This includes evaluating levels of oestrogen, progesterone, thyroid hormones, etc.
Pelvic MRI: In some cases, a pelvic MRI may be recommended to provide detailed imaging of the pelvic organs, helping to identify structural abnormalities, such as adenomyosis or other conditions that may be contributing to menorrhagia.
Coagulation Factor Testing: Testing for specific coagulation factors, such as von Willebrand factor and other clotting factors, may be performed to assess for inherited bleeding disorders that could be a contributing factor to menorrhagia.

Management of Menorrhagia

The best management is to investigate and treat the cause.

Aims of Management

Identify and Address Underlying Causes.
Alleviate Symptoms and Improve Quality of Life.
Preserve Fertility and Reproductive Health

Medical Management of Menorrhagia:

Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help reduce pain and bleeding. Hormonal contraceptives, such as birth control pills or hormonal intrauterine devices (IUDs), can regulate menstrual cycles and decrease bleeding.
Iron supplementation: If anaemia is present due to excessive bleeding, iron supplements may be recommended to restore iron levels.
Endometrial ablation: A minimally invasive procedure that destroys the lining of the uterus to reduce menstrual bleeding.
Uterine artery embolization: A procedure in which small particles are injected into the blood vessels supplying the uterus to reduce blood flow and control bleeding.

Other drugs;

Treatment Approach	Examples	Mechanism
NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)	Ibuprofen, Naproxen	Inhibits prostaglandin synthesis, reducing menstrual bleeding
Tranexamic Acid	Tranexamic acid	Antifibrinolytic action prevents the breakdown of blood clots, reducing excessive bleeding
Hormonal Therapy	– Oral Contraceptives (Birth Control Pills) – Progesterone Therapy – Hormonal IUDs	Regulates hormonal fluctuations, stabilizes endometrial lining, and reduces menstrual bleeding
GnRH Agonists (Gonadotropin-Releasing Hormone)	Leuprolide, Goserelin	Suppresses ovarian function, inducing a state similar to menopause, temporarily reducing menstrual bleeding
Desmopressin (DDAVP)	Desmopressin	Enhances blood clotting, used in women with bleeding disorders
Antifibrinolytic Medications	Aminocaproic acid, Tranexamic acid	Prevents the breakdown of blood clots, reducing bleeding
Iron Supplements	Iron supplements	Treats or prevents iron-deficiency anemia caused by chronic heavy bleeding
Selective Progesterone Receptor Modulators (SPRMs)	Ulipristal acetate	Affects the endometrium, reducing menstrual bleeding

Nursing Management

Assessment:

Detailed History:

Menstrual history, including onset, duration, and flow characteristics.
Obstetric history, noting any pregnancies, deliveries, and miscarriages.
Current medications, including contraceptives.
Family history of bleeding disorders or gynaecological issues.

Physical Examination:

Vital signs, including blood pressure and heart rate.
Pelvic examination to assess the reproductive organs and identify abnormalities.
Blood tests to check for anaemia, clotting disorders, and hormonal imbalances.

Education:

Patient Education: Educate the patient about menorrhagia, its causes, and potential complications.
Medication Management: Provide information on prescribed medications, their purpose, and proper usage. Emphasize the importance of adherence to medication schedules.
Home Care: Advise on the use of over-the-counter pain relievers for discomfort. Educate on the use of heat therapy to alleviate pain.
Signs of Complications: Instruct the patient on signs of excessive bleeding or other complications. Encourage immediate reporting of any concerning symptoms.

Symptom Management:

Pain Relief: Administer prescribed pain medications. Assist with the application of heat therapy for pain relief.
Monitoring and Assessing Bleeding: Regularly assess and document the amount and characteristics of menstrual bleeding. Monitor for signs of anaemia.
Supportive Measures: Provide emotional support, addressing any anxiety or concerns. Encourage the patient to rest and maintain a balanced diet.

Collaboration with Healthcare Team:

Communication: Maintain open communication with the healthcare team regarding the patient’s condition.
Follow-Up: Coordinate follow-up appointments for ongoing evaluation and adjustments to the treatment plan.

Patient Advocacy:

Ensuring Informed Decision-Making: Support the patient in making informed decisions about treatment options.
Advocating for Patient Needs: Advocate for the patient’s needs, including pain management and emotional support.

Documentation:

Accurate Records: Maintain accurate and detailed records of the patient’s symptoms, interventions, and responses to treatment.
Communication with Healthcare Team: Ensure clear documentation for effective communication within the healthcare team.

Continuous Evaluation:

Response to Treatment: Continuously evaluate the patient’s response to medications and other interventions.
Adjustment of Care Plan: Collaborate with the healthcare team to adjust the care plan based on the patient’s progress.

Nursing diagnosis

Ineffective tissue perfusion related to excessive bleeding evidenced by pallor.

Nursing interventions

Assess the patient’s vital signs. To obtain baseline data.
Lift the foot of the bed. To allow blood flow to vital centres of the body like the brain, kidneys, lungs, heart and liver.
Administer intravenous fluids. To maintain the circulatory volume of fluids.
Administer vitamin k as prescribed to reduce bleeding. Vitamin k activates coagulation factors.
Administer whole blood as prescribed. To maintain circulatory volume of blood.

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DYSMENORRHOEA

Dysmenorrhea is a medical term used to describe painful menstrual cramps that occur just before or during menstruation (the monthly shedding of the uterine lining).

Dysmenorrhea refers to painful menstrual periods.

Nearly 50% of all women have some degree of pain associated with their periods. About 10% are unable to perform their normal activities because of this pain.

Dysmenorrhoea can occur at any age, though uncommon in the first 6 months after the onset of menses and relatively uncommon in the years prior to menopause. The most common ages for this problem to occur are in the late teens and early twenties.

Types of dysmenorrhoea

Primary dysmenorrhoea.

Primary dysmenorrhea refers to painful menstruation that starts a few years after puberty and usually no exact cause can be identified.

Cause

The exact cause of primary dysmenorrhea is not fully understood, but it is believed to be related to the release of certain chemicals called prostaglandins in the uterus at the time of menstrual period. The prostaglandin causes contractions of the muscle wall of the uterus, which are called menstrual cramps.

Secondary dysmenorrhoea

Secondary dysmenorrhoea is the type of menstrual pain with a known organic cause.

Secondary dysmenorrhea means pelvic pain caused by a disorder or disease.

Common Causes of Secondary Dysmenorrhoea

Uterine Fibroids: Noncancerous growths in the uterus.
Endometriosis: The presence of endometrial tissue outside the uterus.
Adenomyosis: The occurrence of endometrial tissue within the muscular walls of the uterus.
Chronic Pelvic Inflammatory Disease (PID): Long-term inflammation of the female reproductive organs.
Endometrial Polyps: Abnormal tissue growth on the inner lining of the uterus.
Leiomyomata: Benign tumors of the uterine muscle.
Intrauterine Device (IUD) Use: Complications related to the use of contraceptive devices placed in the uterus.

Signs and Symptoms of Dysmenorrhoea

Women with dysmenorrhea tend to begin experiencing symptoms approximately 12 hours before the onset of menses. Common presenting symptoms of dysmenorrhoea include:

Cramping pain in the lower abdomen: Lower abdominal pain (LAP) is a hallmark symptom, usually occurring 3-4 days or even a week before menstruation. The intensity of the pain, ranging from mild to colicky or crampy, extending to the back, thighs and legs, may either improve or exacerbate with the onset of menstruation.
Bilateral Lower Quadrant Pain: The pain associated with secondary dysmenorrhea often extends to both lower abdominal quadrants.
Backache: Patients may experience lower back pain.
Menorrhagia: Characterized by excessive menstrual bleeding.
Painful Coitus (Dyspareunia): Discomfort or pain during sexual intercourse.
Infertility: Difficulty conceiving or achieving pregnancy.
Nausea: Some individuals may experience feelings of nausea.
Headache: Headaches are a common symptom associated with dysmenorrhea.
Vomiting: In severe cases, dysmenorrhea can lead to vomiting.
Fatigue: Fatigue is a general feeling of tiredness or lack of energy that may accompany dysmenorrhea.
Dizziness: Some individuals may experience dizziness or lightheadedness.
Constipation or Diarrhoea: Dysmenorrhea can be associated with bowel changes, including diarrhoea or constipation.
Fainting: In severe cases, dysmenorrhea may lead to fainting.
Fever: Although less common, some individuals may experience a mild fever during dysmenorrhea.

Predisposing factors

Narrow Cervical Os (Stenosis): During menstruation, the uterus contracts to shed its lining. If the cervical os is narrow, it can result in increased tension during these contractions, leading to pain.
Reduced Blood Supply to the Endometrium (Ischaemia): Inadequate blood supply to the endometrium can contribute to the development of primary dysmenorrhea.
Hormonal Imbalance: Fluctuations in hormone levels, particularly prostaglandins, can lead to increased uterine contractions and inflammation, resulting in pain.
Retroverted Uterus: A retroverted uterus, where the uterus is tilted backward, can cause increased tension and discomfort during menstruation.
Psychological or Social Stress: Emotional stress, fear, or anxiety can exacerbate the perception of pain during menstruation.

Diagnosis

History taking: It is through history taking, asking about the nature of pain, duration and when it occurs. This is often confirmatory.
Physical examination: It is also through physical examination to rule out pelvic tumours, endometriosis which is often absent.

Management of Dysmenorrhoea

Aims of Management

Alleviating pain and discomfort associated with menstruation.
Identifying and addressing any underlying causes or contributing factors.
Minimizing the impact of dysmenorrhoea on daily activities and quality of life.

History taking

Take a detailed gynaecological history, including age, parity, first day of the last menstrual period, age of menses onset, length and regularity of cycles, and duration of flow.
Take a pain history to include severity, duration, character, location, radiation, and the relationship of pain to menarche, menses, coitus, bowel movements, voiding, and any other associated symptoms.
Document previous known or suspected pelvic problems.
Review past obstetric history, including first-trimester losses.
Review the past history for other organ system problems that can present with pelvic pain.
Review pelvic infection history, with special attention to recent or past STIs, including the history of STIs among current or former partners.
Review contraceptive history with special attention to past or present IUD use and oral contraception. Document any changes in symptoms with particular contraceptive use.
Review surgical history, including surgical procedures involving the cervix, Caesarean delivery, gynaecological procedures, and other abdominal procedures.

General observation

TPR/BP and careful examination of the reproductive system, including a complete gynecologic examination with cervical testing (abdominal, vaginal, and rectal examination), laparoscopy, and blood tests for progesterone and oestrogen.

Primary dysmenorrhea treatment

Begin treatment 2 days before menstruation begins and continue until 2 days after the period has stopped.
Avoid additive drugs since this treatment is for a long period.
Contraceptive drugs like COCs may be given to suppress ovulation and relieve pain. Usually given for 4-6 months, and many get permanent relief after this treatment has been stopped.
Dilation and Curettage (D&C) may be of help to remove necrotic tissue of the endometrium, but usually not encouraged since it increases the risk of infections.
Cervical stenosis can be treated by surgical widening of the canal.
Effective counselling is important since pain is usually psychological to avoid drug dependence and abuse.
Natural processes like childbirth or ageing can contribute to the reduction of pain as uterine muscles relax.
Severe dysmenorrhea may require prescription prostaglandin inhibitors (non-steroidal anti-inflammatory drugs – NSAIDs). Over-the-counter prostaglandin inhibitors: Aspirin 600 mg Q.I.D, Ibuprofen 400 mg Q.I.D.
Psychotherapy, i.e., explanation and assurance.
Well-balanced diet.
Rest and regular aerobic exercises.
Encourage her to empty bowel during menses.

Drugs used in the management of symptoms of primary dysmenorrhoea either inhibit prostaglandin production or inhibit ovulation.

Class of Drug	Example	Remarks
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)	Mefenamic acid 500mg 8 hourly. Ibuprofen 400mg 8 hourly. Diclofenac- 50mg 8 hourly. Indomethacin 50mg 8 hourly.	NSAIDs should be taken one day before onset of symptoms and continue for 2-3 days. All the listed NSAIDs should not be given to patients with active peptic ulcer disease.
Combined Oral Contraceptives (COCs)	Pilplan plus, Microgynon	COCs suppress ovulation leading to a decrease in the production of progesterone concentration, which is needed in the production of prostaglandin. They are recommended for cases that have failed to respond to NSAIDs. COCs should be given for at least 3 months (3 cycles).
Depot Progestogens	Depo provera, Injecta plan	Depot progesterone acts by suppressing ovulation and thus relieving dysmenorrhoea.

Secondary dysmenorrhea treatment

Management is according to the cause of dysmenorrhea.
For cases of causes of secondary dysmenorrhea, surgical measures (e.g Dilatation and curettage and presacral neurectomy, hysterectomy, etc.) can be the best strategy (treatment is determined by the cause).

Lifestyle and Complementary Management:

Encourage enough rest, sleep, exercises, hygiene, and a good diet.
Explore alternative therapies such as hypnotherapy and acupuncture.

Nursing Management

Nursing Diagnosis: Acute pain related to increased uterine contractility evidenced by verbalization of the girl or woman.

Nursing Interventions:

Warm the abdomen to cause vasodilation and reduce spasmodic contractions.
Massage the painful abdominal area to reduce pain through therapeutic touch.
Perform light exercises to improve blood flow to the uterus and enhance muscle tone.
Implement relaxation techniques to reduce pressure and induce relaxation.
Administer analgesics as prescribed to block nociceptive receptors.

Nursing Diagnosis: Ineffective individual coping related to emotional stress evidenced by the patient’s verbalization.

Nursing Interventions:

Assess the patient’s understanding of the condition, as anxiety is influenced by knowledge.
Provide opportunities for the patient to discuss and identify coping mechanisms.
Ensure the patient gets periods of sleep or rest to promote relaxation.

Nursing Diagnosis: Risk for imbalanced nutrition less than body requirements related to nausea and vomiting.

Nursing Interventions:

Provide the patient with periods of sleep or rest for overall relaxation.
Encourage small, frequent feeds that are easily tolerated.
Administer antiemetic drugs like promethazine to block emetic centres.

Nursing Concerns

Assess the severity and characteristics of pain, including location, intensity, and duration.
Monitor vital signs and assess for signs of complications.
Evaluate menstrual patterns, duration, and heaviness of bleeding.
Assess the impact on the patient’s quality of life, emotional well-being, and daily activities.

Nursing Interventions

Provide pain management through prescribed medications.
Apply heat therapy and educate the patient on proper techniques.
Teach relaxation techniques, deep breathing exercises, and guided imagery.
Encourage rest in a comfortable position during painful episodes.
Educate the patient about the condition, its management, and treatment options.
Collaborate with the healthcare team for appropriate management.
Offer emotional support, acknowledging the patient’s pain and distress.

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AMENORRHOEA

Amenorrhoea refers to absence of menstruation which occurs in females during their reproductive age.

Types of Amenorrhoea

1. Primary amenorrhoea.

Primary amenorrhoea is failure to menstruate by the age of 16 in the presence of normal secondary sexual development.

The absence of menses by age 14 in the absence of normal secondary sexual characteristics.

Causes of Primary Amenorrhoea

1. Excessive Weight Loss: Reduction in body weight due to factors like restrictive diets or eating disorders which can lead to Disruption of hormonal balance crucial for menstruation.

2. Excessive Exercise or Stress: Intense physical activity or chronic stress may disrupt the normal hormonal fluctuations necessary for the menstrual cycle.

3. Physiological Delay: Family History: A delay in menstruation initiation, reported through family history, may contribute to a genetically influenced delay in onset.

4. Imperforate Hymen: The hymen, a thin membrane at the vaginal opening, is imperforate, obstructing menstrual blood outflow, hence retention of menstrual blood in the vagina.

5. Eating Disorders: Conditions like anorexia nervosa or bulimia may lead to nutritional deficiencies impacting reproductive hormones.

6. Thyroid Dysfunction: Disorders affecting the thyroid gland can disrupt the hormonal balance necessary for regular menstrual cycles.

7. Genetic Factors: Certain genetic syndromes or chromosomal abnormalities can impact reproductive development, delaying the onset of menstruation.

8. Chronic Illnesses: Long-term illnesses affecting various body systems can interfere with the hormonal balance required for menstruation.

9. Anatomical Abnormalities: Structural abnormalities in the reproductive organs such as Uterine or Ovarian Issues may hinder the normal menstrual process.

10. Hormonal Imbalances: Abnormalities in hormones like FSH (Follicle Stimulating Hormone) or LH (Luteinizing Hormone) crucial for puberty and menstruation.

11. Tumors or Growths: Non-cancerous growths or tumors affecting the ovaries or pituitary gland can disrupt hormonal balancing.

12. Medication Side Effects: Prolonged use or abrupt discontinuation of certain medications, such as hormonal contraceptives, may impact menstrual patterns.

13. Celiac Disease: Celiac disease, affecting nutrient absorption, may lead to disruptions in hormonal balance affecting menstruation.

2. Secondary amenorrhoea.

Secondary amenorrhoea may be defined as absence of menstruation for 6 months in women with established menstrual cycles.

Pregnancy should be ruled out in a patient who presents with secondary amenorrhoea.

Causes of Amenorrhoea

Normal physiology:

Pregnancy: During pregnancy, high levels of estrogen and progesterone maintain the endometrium, leading to amenorrhea.
Lactation: After delivery, prolactin is secreted in large quantities, partially suppressing LH production and preventing ovulation, resulting in amenorrhea.

Abnormal physiology:

Functional hypothalamic amenorrhea: Lower levels of FSH and LH due to hypothalamic dysfunction can lead to secondary amenorrhea. This condition may exclude organic diseases and exhibit abnormal GnRH secretion, low/normal LH concentrations, absent follicular development, and anovulation.
Premature Ovarian Failure: Accelerated atresia and dysfunction of follicular maturation can cause premature ovarian failure, leading to secondary amenorrhea.
Birth control pills: Hormonal birth control can affect menstrual cycles and cause secondary amenorrhea.
Malnutrition: Inadequate nutrition can disrupt hormone levels and lead to secondary amenorrhea.
Psychogenic factors: Emotional stress and psychological factors can impact hormonal balance, potentially causing secondary amenorrhea.
Infections (e.g., PID): Infections like pelvic inflammatory disease can disrupt normal reproductive function, leading to secondary amenorrhea.
Polycystic ovarian syndrome: PCOS can cause hormonal imbalances, leading to irregular menstrual cycles and potential secondary amenorrhea.
Emergency contraceptive pills: These pills can affect hormone levels and disrupt the menstrual cycle, potentially leading to secondary amenorrhea.
Diabetes mellitus: Poorly controlled diabetes can impact hormone levels and lead to secondary amenorrhea.
Resistant ovarian syndrome: This condition can lead to hormonal imbalances and disrupt the menstrual cycle, potentially causing secondary amenorrhea.
Radiation: Full doses of radiation can disrupt normal ovarian function, leading to secondary amenorrhea.
Drugs: Certain medications, especially hormonal contraceptives, can impact hormone levels and cause secondary amenorrhea.
Head injury: Traumatic head injuries can disrupt normal hormonal regulation, potentially leading to secondary amenorrhea.
Debilitating diseases: Conditions such as tuberculosis (TB), HIV/AIDS, and diabetes mellitus can disrupt normal hormonal balance, potentially leading to secondary amenorrhea.
Tumors of the pituitary gland, hypothalamus, ovaries, and uterus: Tumors in these reproductive and endocrine organs can disrupt normal hormonal function, leading to secondary amenorrhea.
Early onset of menopause: Premature menopause can cause secondary amenorrhea.
Idiopathic: In some cases, the cause of secondary amenorrhea may be unknown or unidentifiable.

Diagnosis and Investigation

Amenorrhoea is diagnosed by taking a proper history (history of change in weight, presence of stress, questions about excessive weight, presence of excessive body or facial hair)and physical examination.

The laboratory investigations are carried out to help identify the cause of amenorrhea and to rule out other causes.

Laboratory Investigations

Investigation	Remarks
Luteinizing hormone (LH)	LH is slightly elevated in the case of polycystic ovary syndrome.
Follicle stimulating hormone (FSH)	FSH is usually very high in the case of premature menopause.
Total testosterone levels	Testosterone level is slightly raised in polycystic ovary syndrome.
Thyroid stimulating hormone (TSH)	Helps to rule out hypothyroidism as a cause of amenorrhea.
Measurement of prolactin levels	High levels of prolactin are associated with hyperprolactinemia.
HCG test	It is used to rule out pregnancy.

Signs and Symptoms of Amenorrhoea

Cessation of Menses: The cessation of menstrual cycles is a primary and defining symptom of amenorrhea. It can be either primary (absence of menstruation by the age of 16) or secondary (absence of menstruation for three consecutive cycles in a woman who previously had regular periods).
Complaints of Infertility: Many women with amenorrhea may experience difficulties in conceiving (infertility). The absence of regular menstrual cycles can indicate underlying hormonal imbalances or reproductive system disorders, affecting the ability to conceive.
Vaginal Dryness and Decreased Libido: Hormonal imbalances associated with amenorrhea, such as low oestrogen levels, can lead to changes in vaginal moisture and lubrication, resulting in vaginal dryness. Additionally, decreased oestrogen levels may contribute to a reduced libido or interest in sexual activity.
Recent Excessive Weight Loss or Weight Gain: Amenorrhea can be linked to changes in body weight. Sudden and significant weight loss, as seen in eating disorders or excessive exercise, can disrupt the hormonal balance, leading to amenorrhea. Conversely, rapid weight gain, especially in conditions like polycystic ovary syndrome (PCOS), can also impact menstrual regularity.
Presence of Acne and Hirsutism: Hormonal disorders such as PCOS, characterized by elevated androgen levels, may present with symptoms like acne (skin condition) and hirsutism (excessive hair growth, especially in male-pattern areas). These symptoms can be indicative of hormonal disturbances contributing to amenorrhea.
Galactorrhea (Breast Milk Discharge): In some cases, elevated prolactin levels, a hormone responsible for milk production, can lead to galactorrhea (spontaneous discharge of milk from the breasts), which may accompany amenorrhea.
Pelvic Pain or Headaches: Certain underlying conditions causing amenorrhea, such as pituitary tumors or ovarian cysts, may present with symptoms like pelvic pain or headaches.
Mood Changes and Fatigue: Hormonal imbalances associated with amenorrhea can influence mood, leading to mood swings or changes. Fatigue may also be experienced due to disruptions in hormonal regulation.

Management of Amenorrhoea

This will depend on the cause. It may be medical, surgical, or psychological.

Nursing Management:

Assessment: Conducting a comprehensive evaluation of the woman’s medical and menstrual history, as well as performing a physical examination to identify the underlying cause of amenorrhea.
Emotional Support: Offering empathetic and non-judgmental support to address any emotional distress associated with the condition.
Education: Providing information on menstrual health, reproductive anatomy and physiology, and the potential causes and treatment options for amenorrhea.
Lifestyle Modifications: Encouraging women to adopt a healthy lifestyle, including regular exercise, balanced nutrition, stress reduction, and sufficient sleep, as these factors can contribute to hormonal balance regulation.
Contraception Counselling: Discussing contraceptive methods and family planning options to prevent unintended pregnancies.

Medical Management:
Medical management of amenorrhea encompasses treating the root cause identified through investigations done. Various medical management options include:

Hormone Therapy: If hormonal imbalance, such as polycystic ovary syndrome or hypothalamic dysfunction, is determined as the cause of amenorrhea, hormone therapy may be prescribed to regulate hormone levels and restore menstruation.
Medications: Certain medications like progestins or combined oral contraceptives may be prescribed to induce menstruation or regulate the menstrual cycle.
Treatment of Underlying Conditions: If amenorrhea is a result of an underlying medical condition, such as a thyroid disorder or a pituitary tumour, appropriate medical treatment will be initiated to address the specific condition.
Hyperprolactinemia is treated by administration of bromocriptine 2.5mg 2-3 times daily which reduces prolactin levels which results into resuming of menstruation. Bromocriptine is an ergot alkaloid which directly opposes prolactin secretion. Radiotherapy is reserved for those patients who fail to respond to medical therapy.
Amenorrhoea due to polycystic ovary syndrome (PCO) Recommend Metformin 500mg 3 times daily which reduces insulin resistance.

Surgical Management:
Surgical management is rarely required for the treatment of amenorrhea. However, in certain cases, surgery may be necessary to address structural abnormalities or correct anatomical issues contributing to the condition. For example:

Hysteroscopic Surgery: This minimally invasive procedure involves the insertion of a thin, illuminated tube called a hysteroscope through the vagina and cervix to visualize and treat abnormalities within the uterus, such as polyps or adhesions.
Imperforate hymen is treated by incision and drainage. Very large amount of blood may be released, and if the septum is particularly thick, some form of plastic operation may be required.
Surgical Intervention: In some instances, surgical intervention may be essential to correct structural abnormalities in the reproductive organs or to remove tumours or cysts that are interfering with normal menstruation.

Psychological Management:
Psychological management plays a crucial role in providing support for women with amenorrhea, as it significantly impacts their emotional well-being. It involves:

Counselling: Offering psychological counselling or referring women to mental health professionals who can assist them in coping with the emotional distress associated with amenorrhea.
Support Groups: Suggesting participation in support groups or facilitating connections with other women who have faced similar challenges to foster a sense of community and validation.
Body Image and Self-esteem: Addressing concerns related to body image and promoting a positive self-image by emphasizing that amenorrhea does not define femininity or a woman’s worth.

NB; Management of gynaecology conditions can be in the maternity centre and hospital. In the maternity centre investigations and operations may not be done from that place.

The maternity centre can manage some cases e.g. pregnancy, stress, lactational causes of amenorrhoea however the diagnosis of some causes of amenorrhoea that involves investigations are referred to the hospital.

AMENORRHOEA Read More »

HISTORY, PHYSICAL EXAMINATION AND INVESTIGATIONS IN GYNAECOLOGY

History taking:

Proper history taking is key in determining the proper diagnosis and a guide to the required examination and investigations. The history from the patient should be taken from a private room.

During history taking, which should always start with the patient’s demographics, the following specific information should be captured.

Personal history: This refers to the biographic data of the patient.(NAATRENREM )

N Name
A Age
A Address
T Tribe
R Religion
E Education
N Next of kin
R Relationship with the next of kin
O Occupation
M Marital status.

Presenting complaints: The patient should be asked to state her problems. In chronological order. It is important that you first listen to the patient. The patient should describe fully the nature of her problems to enable you to come to a conclusion using the acronym “DOPAPRA.”

D Duration
O Onset
P Progression
A Aggravation
R Relieving
A Association.

NOTE: If the complaint is a disorder of menstruation, take full menstrual history. If about abnormal vaginal discharge, ask about colour, odour, and relationship with menstrual periods.

History of abnormal vaginal discharge: Vaginal discharge may be normal or abnormal. Normal vaginal discharge is usually off-white and is neither associated with vaginal itching nor presence of a foul smell.

Abnormal vaginal discharge is usually associated with change in quantity, colour, vaginal irritation, smell and sometimes abdominal pain. Conditions commonly associated with abnormal vaginal discharge include trichomoniasis, bacterial vaginosis and vaginal candidiasis.

Cervical cancer may also present with abnormal vaginal discharge especially in the advanced stage of the disease when there is secondary infection.

When taking history, capture the following information:

Amount of discharge
Duration of discharge
Ask about the presence of smell of the discharge
Colour change
Relationship of the discharge with menstruation cycle
Associated lower abdominal pain.

If the presenting complaint is pain, as in abdominal pain, follow the acronym “SOCRRATES.”

S	Site	Where is the pain? Or the maximal site of the pain.
O	Onset	When did the pain start, and was it sudden or gradual? Include also whether it is progressive or regressive.
C	Character	What is the pain like? An ache? Stabbing?
R	Radiation	Does the pain radiate anywhere?
A	Associations	Any other signs or symptoms associated with the pain?
T	Time course	Does the pain follow any pattern?
E	Exacerbating / relieving factors	Does anything change the pain?
S	Severity	How bad is the pain?

Menstrual History:

Age of onset of the first period (menarche).
Regularity of the cycle.
Duration of the period.
Length of the cycle.
Amount of bleeding—Excess is indicated by the passage of clots or the number of pads used.
First day of the last menstrual period (LMP).

The menstrual history can be represented as 13/4/28, indicating that the onset of the period was at the age of 13, bleeding lasts for 4 days, and occurs every 28 days.

Past Gynaecology History: Has she ever had any gynaecological conditions like fibroids, rectal vaginal fistula, vesico-vaginal fistula, perineal tears, and abortions, etc.? Any operations on the cervix or dilation and curettage.

Past Medical History: Relevant medical disorders—systemic, metabolic, or endocrine (diabetes, hypertension, hepatitis) should be enquired. Their presence requires care during operative procedures. Next pertinent point is the interrogation about sexually transmitted diseases.

Find out any chronic conditions that the patient may be suffering from like chronic lung disease and cardiovascular diseases. Find out if the patient is on any medication, hospitalization, and for what reason.

Past Surgical History: This includes general, obstetrical, or gynaecological surgery. The nature of the operation, anaesthetic procedures, bleeding, or clotting complications if any, postoperative convalescence are to be enquired. Any histopathological report or relevant investigation related to the previous surgery is most often helpful.

Past Obstetric History: This entails the number of pregnancies, abortions, type of delivery, history of trauma, prolonged labour, etc., and menstrual cycle i.e. menarche, regularity, duration, and length of cycles, volume of blood loss, etc.

Family History: It is of occasional value. Malignancy of the breast, colon, ovary, or endometrium is often related. Tubercular affection of any family member can give a clue in the diagnosis of pelvic tuberculosis.

Past Social History: Look out for marital status, lifestyle, smoking, alcohol, occupation, etc.

Contraceptive History: Find out which method she uses, any side effects so far experienced, and if not using any, this information is important to rule out the possibility of pregnancy and also to determine whether the present complaint is not a result of the method of conception.

Cervical Cancer Screening: If the woman is over 35 years of age, ask whether she has ever been screened for cervical cancer.

Sexual History: This should be included if appropriate to presenting complaints. Most patients feel embarrassed to talk about their sexual behaviours. Capture information on pain during sexual intercourse or difficulty with coitus. Pain during sexual intercourse (dyspareunia) may be superficial, that is the woman feels pain during the entrance of the penis.

Superficial dyspareunia may be associated with lack of vaginal lubrication or vaginismus. Deep dyspareunia may be due to a scar, endometriosis or a mass.

EXAMINATION

After history taking, gynaecological examination is performed to confirm the presence/absence of pathology based on the history obtained.

Before gynaecological examination is carried out, the following should be done:

Explain to the patient the need for the examination and its nature.
Obtain an informed verbal consent.
The male examiner should be accompanied by a chaperone (female who can either be a nurse, fellow clinician or attendant)
The examination should be done in a private room respecting the patient’s privacy at all times.
The patient should be covered at all times and only relevant parts of her anatomy exposed.
Ensure that there is good lighting in the examination room.
Instruct the patient to void before the examination.
Ensure all the relevant supplies, sundries and equipment is available before beginning the examination.

Note: After the gynaecological examination, explain in a simple language and with the help of learning aids such as drawings or models the findings of the examination.

Physical Examination

The examination includes:

General and systemic examination (General Examination)
Gynaecological examination.

Breast examination
Abdominal examination
Pelvic examination

General Examination

1. Body Composition:

Built: Assessment of body weight and distribution.
Significance: Endocrinopathy can manifest as obesity or thinness, impacting menstrual patterns.

2. Nutritional Status:

Nutrition: Evaluation of dietary habits.
Significance: Nutritional factors may influence reproductive health, emphasizing the importance of a balanced diet.

3. Growth and Development:

Stature: Monitoring overall height and development of secondary sex characteristics.
Significance: Growth abnormalities may indicate hormonal imbalances affecting gynaecological health.

4. Systemic Indicators:

Pallor: Examination for paleness, suggesting potential anaemia.
Jaundice: Inspection for yellowing of the skin or eyes.
Edema of Legs: Assessment for abnormal fluid retention.
Significance: Anaemia or liver dysfunction can impact gynaecological well-being.

5. Oral Health:

Teeth, Gums, and Tonsils: Inspection for signs of infection or septic foci.
Significance: Oral health can contribute to overall systemic health, influencing gynaecological conditions.

6. Neck Examination:

Thyroid Gland and Lymph Nodes: Palpation, focusing on left supraclavicular glands.
Significance: Thyroid disorders or lymphatic abnormalities may have implications for gynaecological health.

7. Cardiovascular and Respiratory Assessment:

Cardiovascular System: Evaluation for any abnormalities.
Respiratory System: Inspection for respiratory issues.
Significance: Any cardiovascular or respiratory irregularities can impact surgical procedures if intervention is required.

8. Vital Signs Monitoring:

Pulse: Measurement of heart rate.
Temperature: Assessment of body temperature.
Respirations: Monitoring breathing rate.
Blood Pressure: Evaluation of systemic blood pressure.
Significance: Vital signs provide insights into overall health and may influence gynaecological management.

Gynaecology Examination

A gynaecological examination is done to assess the overall health of the female reproductive system.

During the exam, the gynaecologist will look at the external and internal reproductive organs, as well as at the breasts, to determine whether there are any problems or conditions present.

Breast examination

This should be a routine, especially in women above the age of 30, to detect any breast pathology, the most important being carcinoma.

This is carried out before pelvic examination to try to allay the woman’s anxiety.

It can be performed while she is sitting on either a chair or an examination coach. Inspect for size, shape, and any other obvious abnormalities. Then the breasts are palpated each at a time to rule out any abnormal lumps and discharges.

It also gives an opportunity to teach the mother self-breast examination.

Examination of the breasts

Inspection with the arms at her sides.
Inspection with the arms raised above the head.
Inspection with hands at the waist (with contracted pectoral muscle).
Palpation of the axillary nodes.
Palpation of the supraclavicular nodes.
Palpation of the outer half of the breast (a pillow is placed under the patient’s shoulder).

Abdominal examination

Abdominal examination is done when the patient is lying supine with a pillow for headrest.

The arms should be by the sides and the bladder must be emptied. The only exception to the procedure is the presence of a history suggestive of stress incontinence. If history suggests chronic retention of urine, catheterization should be done, taking aseptic precautions, using a sterile simple rubber catheter.

The physician usually prefers to stand on the right side.

Actual steps of abdominal examination

INSPECTION:

Abdominal examination assesses for:

Shape of the abdomen
Abdominal distension or masses
Movement with respiration
Presence of scars due to surgery or trauma
Distended veins and presence or absence of striae
Distribution of the pubic hair
Swelling or bulging inguinal orifices (with or without cough impulse)

PALPATION

Palpation for tenderness, spleen, liver, kidneys, and for masses. Palpate the abdomen in all the nine regions; right hypochondria (RH), epigastrium (E), Left Hypochondria (LH), Right Lumbar (RL), Umbilical (U), Left Lumbar (LL), Right Iliac (RI), Pubic/Hypogastric (P) and Left Iliac.

Palpation should be done with the flat of the hand gently rather than the tips of the fingers.
If a mass is felt in the lower abdomen, its location, size above the symphysis pubis, consistency, feel, surface, mobility from side to side and from above to down, and margins are to be noted.

PERCUSSION

Percussion is done to assess for presence or absence of gas or fluid in the abdomen. Fluids could be blood or ascites.

AUSCULTATION

Listen for bowel sounds or for fetal heart sounds and rate in case of pregnancy using a stethoscope or fetal stethoscope (fetoscope) respectively.

PELVIC EXAMINATION

The pelvic examination should be done on an examination couch with patient supine, knees and hips flexed, hips abducted and feet together.
The examiner stands on the patient’s (right or left) side.
A good and adjustable light source is needed for inspection of the vulva and for the speculum examination.
Sterile gloves, sterile lubricant (preferably colourless without any antiseptics), speculum, sponge holding forceps and swabs are required.
Pelvic examination is usually required when a patient presents with lower abdominal pain, menstrual disorders, abnormal vaginal discharge or to obtain a pap smear.
Pelvic examination should never be missed unless the patient is a virgin.
To examine a minor or unmarried, a consent from the parent or guardian is required
Lower bowel (rectum and pelvic colon) should preferably be empty.

Pelvic examination includes:

1. Inspection of the external genitalia

2. Vaginal examination

Inspection of the cervix and vaginal walls
Palpation of the vagina and vaginal cervix by digital examination
Bimanual examination of the pelvic organs

3. Rectal examination

4. Recto-vaginal examination.

Positions during pelvic examination:

Lithotomy position (patient lying supine with her legs on stirrups) is ideal for examination.

Inspection of the vulva:

To note any anatomical abnormality starting from the pubic hair, clitoris, labia, and perineum.
To note any palpable pathology over the areas.
To note the character of the visible vaginal discharge, if any
To separate the labia using fingers of the left hand to note external urethral meatus, visible openings of the Bartholin’s ducts (normally not visible unless inflamed), and character of the hymen.
To ask the patient to strain in order to find out Stress incontinence—urine comes out through the urethral meatus or Genital prolapse and the structures involved— anterior vaginal wall, uterus alone or posterior vaginal wall or all the three.
Lastly, to look for haemorrhoids, anal fissure, anal fistula, or perineal tear.

Vaginal examination:

We shall look at the following variations of performing vaginal examination:

Inspection of the cervix and vaginal walls
Palpation of the vagina and vaginal cervix by digital examination
Bimanual examination of the pelvic organs

Inspection of the vagina and cervix:

Inspection of the vagina and cervix is done by speculum examination. Two types of speculum are commonly used—Sims’ or Cusco’s bivalve. While in the dorsal position, Cusco is widely used, but in the lateral position, Sims’ variety has advantages.

Introduction of Cusco’s speculum:

(A) The transverse diameter of the closed blades is placed in the anteroposterior position and inserted slightly obliquely to minimize pressure on the urethra;

(B) Blades are inserted in a downward motion and then rotated. Rotate to 90° and then open up the blades. Inspection is then made using good light. The cervix is best visualized with Cusco’s variety. But while the vaginal fornices are only visualized by Cusco, the anterior vaginal wall is to be visualized by Sims’ variety. Sims’ speculum is advantageous in cases of genital prolapse. Speculum examination should preferably be done prior to bimanual examination.

Bimanual Digital examination:

Explain every step to the patient and reassure her. Inform her that an internal examination is to be performed.
The labia are gently parted with the gloved index finger and thumb of the non-dominant hand.
Initially the lubricated index finger of the examiner’s dominant hand is inserted through the introitus into the vaginal canal.
If the patient is comfortable with this, the lubricated middle finger of the same hand is also inserted.
If not, due to pain, a limited bimanual examination with one finger can be performed.
The full length of the finger is introduced, assessing the vaginal walls in transit until the cervix is located.

GYNAECOLOGICAL INVESTIGATIONS

After taking a thorough history and conducting a complete physical examination, some investigations may be required to confirm the diagnosis or rule out differential diagnosis.

1. Blood Values:

Full Complete Blood Count (FBC or CBC): Evaluation of haemoglobin levels in cases of excessive bleeding and white blood cell count in infections.
VDRL Test for Syphilis: Screening for syphilis infection.
Serological Test for HIV Infection: Identification of HIV infection.

2. Urine Examination and Culture:

Collection Method: Midstream urine.
Purpose: Detection of urinary tract infections or confirmation of pregnancy. Urinalysis for suspected urinary tract infections.

3. Vaginal Swab:

Indication: Abnormal vaginal discharge.
Tests Conducted: Microscopic examination, culture & sensitivity.
Diagnosis: Trichomoniasis, bacterial vaginosis, and vaginal candidiasis.

4. Pap Smear: Routine screening for cervical cancer.

5. Hormonal Assays:

Hormones Assessed: FSH, testosterone, progesterone, luteinizing hormone, prolactin, among others.
Applications: Diagnosis of menopause, polycystic ovarian syndrome (PCOS), and assessment of ovarian function.

6. Pelvic Ultrasound:

Purpose: Evaluation of structural disorders in the genital tract.
Diagnostic Significance: Detection of pelvic masses or fluid.

7. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI):

Indication: Suspected malignant diseases of the genital organs.
Considerations: Reserved for cases with a serious clinical need due to cost implications.

8. Hysterosalpingography:

Indication: Assessment of fallopian tube patency in cases of infertility.
Procedure: Injection of radio-opaque substance through the cervix.
Monitoring: Progress tracked on a screen as the substance fills the uterus and fallopian tubes.

Special Procedures in Gynecology

These are useful to fill gaps which remain after history taking during clinical assessment.

1. Evacuation: Removal of cavity contents, typically performed when a pelvic examination is not feasible. Anaesthesia is utilized, but tenderness signs may be overlooked.

2. Curettage: Scraping the internal organ or body cavity surface using a spoon-shaped instrument (curette).

Purpose:

Remove retained products of conception.
Obtain diagnostic specimens.

3. Biopsy: Removal of a small living tissue piece for microscopic examination, aiding in disease exclusion.

Sites: Cervix, endometrium, etc.

4. Ultrasound Scan: Utilizes high-frequency sound waves to produce images of pelvic organ structures. Widely used for disease detection and pregnancy monitoring.

5. Hysterosalpingography: X-ray imaging of the uterus and fallopian tubes.

Diagnoses tubal obstruction, adhesions, uterine malformations, small intracavity tumors, and internal os issues causing abortion.

6. Laparoscopy: Examination of abdominal structures using a laparoscope.

Applications:

Biopsy.
Cyst aspiration.
Adhesion division.
Ova collection for in vitro fertilization.

Gynaecological Operations

1. Hysterectomy: Surgical removal of the uterus.

Types:

Wertheim’s Hysterectomy (Radical).
Subtotal Hysterectomy.
Total Hysterectomy.
Indications: Fibroids, cancers, ruptured uterus.

2. Salpingectomy: Surgical removal of fallopian tubes.

Indications: Ruptured ectopic pregnancy, chronic salpingitis.

3. Vesico-vaginal Fistula Repair: Operation to correct abnormal bladder-vagina communication.

4. Oophorectomy: Surgical removal of ovaries.

Indications: Ovarian tumors, chronic oophoritis.

5. Myomectomy: Surgical removal of uterine fibroids.

6. Rectal Vaginal Fistula Repair: Operation to correct abnormal rectum-vagina communication.

7. Mastectomy: Surgical removal of the breast.

Types:

Radical Mastectomy.
Simple Mastectomy.

8. Tubal Ligation: Permanent family planning method involving tying and cutting fallopian tubes.

9. Vulvectomy: Surgical removal of the vulva.

Types:

Simple Vulvectomy.
Radical Vulvectomy.

10. Dilatation and Curettage: Procedure involving cervical dilation and endometrial scraping for purposes like abortion product removal and biopsy.

11. Perineoplasty: Operation to enlarge the vaginal opening by hymen and perineum incision.

12. Perineorrhaphy: Surgical repair of a damaged perineum resulting from childbirth tears.

HISTORY, PHYSICAL EXAMINATION AND INVESTIGATIONS IN GYNAECOLOGY Read More »

THREATENED ABORTION

Clinical Features of Threatened Abortion

Management of Threatened Abortion

INEVITABLE ABORTION

Causes of Inevitable Abortion

Clinical Features of Inevitable Abortion

Management of Inevitable Abortion

Prevention of Inevitable Abortion

Complications of Inevitable Abortion

ABORTIONS

Causes of Abortion

Predisposing Factors to Abortion

PREVENTION OF ABORTIONS.

Types of Abortion

Spontaneous Abortion

Induced Abortion

General Nursing Interventions and Actions for Patients with Abortion

PREMENSTRUAL SYNDROME

Causes of Premenstrual Syndrome

Signs and symptoms of Premenstrual Syndrome

Management of Premenstrual Syndrome (PMS)

DYSFUNCTIONAL UTERINE BLEEDING

Associated Causes of Dysfunctional Uterine Bleeding

Types of Dysfunctional Uterine Bleeding (DUB):

Signs and Symptoms of Dysfunctional Uterine Bleeding

Investigations

MANAGEMENT OF D.U.B

POLYMENORRHOEA/ EPIMENORRHOEA

Causes of Polymenorrhea/Epimenorrhoea:

Signs and Symptoms of Polymenorrhea/Epimenorrhoea:

Investigations for Polymenorrhea/Epimenorrhoea:

Medical and Nursing Management of Polymenorrhea/Epimenorrhoea:

METRORRHAGIA/INTERMENSTRUAL BLEEDING

Causes of Metrorrhagia

Signs and symptoms of Metrorrhagia

Investigations of Metrorrhagia

Management of Metrorrhagia

MENORRHAGIA

Causes of Menorrhagia

Signs and symptoms of Menorrhagia

Diagnosis and Investigations of Menorrhagia

Management of Menorrhagia

Nursing Management

DYSMENORRHOEA

Types of dysmenorrhoea

Primary dysmenorrhoea.

Cause

Secondary dysmenorrhoea

Common Causes of Secondary Dysmenorrhoea

Signs and Symptoms of Dysmenorrhoea

Predisposing factors

Diagnosis

Management of Dysmenorrhoea

Primary dysmenorrhea treatment

Secondary dysmenorrhea treatment

Nursing Management

Nursing Concerns

Nursing Interventions

AMENORRHOEA

Types of Amenorrhoea

1. Primary amenorrhoea.

2. Secondary amenorrhoea.

Causes of Amenorrhoea

Diagnosis and Investigation

Laboratory Investigations

Signs and Symptoms of Amenorrhoea

Management of Amenorrhoea

Nursing Management:

Medical Management:Medical management of amenorrhea encompasses treating the root cause identified through investigations done. Various medical management options include:

Surgical Management:Surgical management is rarely required for the treatment of amenorrhea. However, in certain cases, surgery may be necessary to address structural abnormalities or correct anatomical issues contributing to the condition. For example:

Psychological Management:Psychological management plays a crucial role in providing support for women with amenorrhea, as it significantly impacts their emotional well-being. It involves:

History taking:

EXAMINATION

Physical Examination

General Examination

Gynaecology Examination

Breast examination

Abdominal examination

INSPECTION:

Medical Management:
Medical management of amenorrhea encompasses treating the root cause identified through investigations done. Various medical management options include:

Surgical Management:
Surgical management is rarely required for the treatment of amenorrhea. However, in certain cases, surgery may be necessary to address structural abnormalities or correct anatomical issues contributing to the condition. For example:

Psychological Management:
Psychological management plays a crucial role in providing support for women with amenorrhea, as it significantly impacts their emotional well-being. It involves: