Gynaecology

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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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 »

FIBROIDS (FIBROMYOMAS)

Fibroids are benign / non-cancerous tumors that originates from the
smooth muscle layer (myometrium) of the uterus.
Fibroids are benign tumors arising from the smooth muscle of the uterus.

Other common names are :uterine leiomyoma, myoma, fibromyoma,
fibroleiomyoma.

They occur usually after the age of 30 years and commonly in women who have not had children. Fibroids are more likely to arise in the body of the uterus than the cervix. They are composed of muscle and fibrous tissue may be single or multiple and may be from a pinhead size to enormous size.

Risk factors for uterine fibroids

Age: Uterine fibroids are more common in women between the ages of 30 to 40 years.
Parity: Women who have never given birth (nulliparous) or have had few pregnancies (low parity) are at a higher risk.
Race: Uterine fibroids are more prevalent in individuals of African descent (negro or black) compared to those of Caucasian (white) ethnicity.
Family History: If a woman has close relatives (such as mother, sister) with a history of uterine fibroids, her risk may be increased.
Hyper-estrogenemia: Elevated levels of estrogen, a female hormone, can promote the growth of fibroids.
Obesity: Being overweight or obese is associated with a higher risk of developing uterine fibroids.
Early Onset of Menarche: Starting menstruation at a young age may be linked to an increased likelihood of fibroid development.
Low Level of Vitamin D: Some studies suggest that insufficient vitamin D levels might be associated with a higher risk of uterine fibroids.
Drugs (Estrogen Replacement Therapy): Long-term use of estrogen replacement therapy, particularly without progesterone, can be a risk factor for uterine fibroids.

$\"Classes$

Classes or types of Uterine fibroids

Submucosal Fibroids: These fibroids grow into the uterine cavity. They are located just beneath the inner lining of the uterus (endometrium). Submucosal fibroids can cause various symptoms, including heavy menstrual bleeding and infertility.
Intramural Fibroids (Interstitial): Intramural fibroids are the most common type and grow within the muscular wall of the uterus, known as the myometrium. They may expand and distort the shape of the uterus, leading to pain, pressure, and other symptoms.
Subserosal Fibroids: These fibroids grow on the outside surface of the uterus. They can project outward and may become quite large. Subserosal fibroids can cause pelvic pain and pressure on nearby organs.
Cervical Fibroids: Located on the cervix, the lower part of the uterus, cervical fibroids are relatively rare. They may cause symptoms such as pain and discomfort, and in some cases, they can affect fertility or lead to difficulties during labor.
Fibroid of the Broad Ligament: This type of fibroid develops in the broad ligament, which is a supportive structure that helps hold the uterus in place within the pelvis. Broad ligament fibroids are relatively uncommon and may require specific management depending on their size and location.

Location or Sites of Uterine Fibroids

The locations or sites of uterine fibroids can be described as follows:

I. Subperitoneal (Under the Peritoneal Surface): These fibroids grow on the outer surface of the uterus, just beneath the peritoneum (the thin, protective layer covering the abdominal organs). They can extend and project outward, leading to symptoms such as abdominal discomfort and pressure.

II. Submucous (Bulging/Protruding into the Endometrial Cavity): Submucous fibroids grow into the uterine cavity, bulging and protruding into the endometrial lining. They can cause heavy menstrual bleeding, irregular periods, and even affect fertility.

III. Pedunculated Fibroids: These fibroids are attached to the uterus by a narrow stalk or pedicle that contains blood vessels. Pedunculated fibroids can be either subserosal or submucous, depending on their location.

IV. Intramural (Within the Wall of the Uterus or Centrally within the Myometrium): Intramural fibroids are the most common type and grow within the muscular wall of the uterus (myometrium). They can cause the uterus to enlarge and lead to symptoms such as pelvic pain and pressure.

V. Subserosal (At the Outer Border of the Myometrium): Subserosal fibroids grow on the outer surface of the uterus, just beneath the serosa (the outermost layer of the uterus). These fibroids can be large and cause pelvic discomfort.

VI. Cervical Fibroids: Cervical fibroids are located on the cervix, the lower part of the uterus that connects to the vagina. They are relatively rare and can cause symptoms similar to other types of fibroids, such as pain and pressure.

Wondering what\’s the difference?
The difference between \”types\” and \”location\” of uterine fibroids lies in what they describe:

Types of Uterine Fibroids: The types of uterine fibroids refer to the different categories or classifications based on their specific characteristics and growth patterns. The main types of uterine fibroids are:
a. Submucous (bulging into the endometrial cavity)
b. Intramural (within the wall of the uterus or centrally within the myometrium)
c. Subserosal (at the outer border of the myometrium)
d. Pedunculated (attached to the uterus by a narrow stalk or pedicle)
e. Cervical (located on the cervix)
These types help healthcare professionals understand the nature of the fibroids and how they may be affecting the uterus and surrounding structures.
Location of Uterine Fibroids: The location of uterine fibroids refers to the specific sites within or around the uterus where the fibroids are situated. The different locations are:
a. Subperitoneal (under the peritoneal surface)
b. Bulging/Protruding into the endometrial cavity (submucous)
c. Attached to the uterus by a narrow pedicle containing blood vessels (pedunculated)
d. In the wall of the uterus or centrally within the myometrium (intramural)
e. At the outer border of the myometrium (subserosal)
f. Cervical (located on the cervix)
The location of the fibroids is crucial because it determines their proximity to other organs, how they may impact the uterine cavity or the cervical region, and how they might be approached for treatment.

In summary, the \”types\” of uterine fibroids describe the different categories based on their growth patterns, while the \”location\” refers to the specific sites within or around the uterus where the fibroids are found

Changes (degenerative) that can take place in the fibroid

Degenerative changes in uterine fibroids refer to alterations in the fibroid tissue that can occur over time or due to specific circumstances.

Red Degeneration: This type of degeneration often occurs during pregnancy. It happens when the fibroid\’s blood supply is disrupted, leading to necrosis (cell death) of the fibroid tissue. The fibroid becomes reddish and soft, with a \”beefy\” appearance.
Atrophy: After menopause, when hormone production decreases, fibroids may undergo atrophy. Atrophy refers to a decrease in size or wasting away of the fibroid due to the reduction in hormonal stimulation.
Hyaline Degeneration: In hyaline degeneration, the fibroid tissue becomes soft, and the muscle fibers are replaced by a homogenous, structureless material.
Parasitic Fibroid: This occurs when the blood supply to a fibroid is cut off due to torsion (twisting) of its pedicle. The fibroid then establishes a new blood supply from the surrounding tissues.
Cystic Change: Following hyaline degeneration, the fibroid\’s tissue can become fluid-filled, giving it a cystic appearance similar to an ovarian cyst.
Fatty Change: The muscle fibers of the fibroid are replaced by fat tissue.
Calcification: In calcification, calcium salts are deposited in the fibroid, causing it to harden and become similar to a stone.
Eggshell Fibroid (Calcification): In this type of calcification, the calcium deposits form on the outside of the fibroid, leaving the inside with its usual consistency.
Womb Stone: This term describes a fibroid that is entirely deposited with calcium salts, causing the entire fibroid to become hardened like a stone.

Causes of Uterine Fibroids.

Causes of uterine fibroids are not fully understood, but research suggests that hormones and genetics play significant roles in their development. Here\’s a more detailed explanation:

Hormones: The hormones estrogen and progesterone, which regulate the menstrual cycle, have a close association with the growth and development of uterine fibroids. During each menstrual cycle, the lining of the uterus (endometrium) thickens under the influence of estrogen and progesterone. These hormones also seem to stimulate the growth of fibroids. As a result, fibroids often grow and enlarge during the reproductive years when hormone levels are at their highest. Conversely, as hormone production decreases during menopause, fibroids tend to shrink and become less symptomatic.
Genetics: There is evidence to suggest that genetics can play a role in the development of uterine fibroids. Women with a family history of fibroids are at a higher risk of developing them themselves. This suggests that certain genetic factors may predispose individuals to fibroid formation.
Other Factors: Although hormones and genetics are the main factors associated with uterine fibroids, some other factors may contribute to their development or growth. These factors include obesity, race (fibroids are more common in women of African descent), and dietary factors.

$\"Clinical$

Clinical Presentation of Uterine Fibroids.

Painful and Prolonged Menstrual Periods: Fibroids can cause heavy and prolonged menstrual bleeding, leading to painful periods (dysmenorrhea).
Vaginal Bleeding after Menopause: Postmenopausal women with fibroids may experience vaginal bleeding, which is abnormal after menopause.
Difficulty with Urination and Constipation: Large fibroids or fibroids pressing on the bladder can cause frequent urination or difficulty emptying the bladder. Fibroids pressing on the rectum can lead to constipation.
Pressure in the Pelvic Area: Women with fibroids may feel pressure or heaviness in the lower abdomen or pelvis.
Fullness or Pressure in the Belly: Enlarged fibroids can cause the abdomen to appear distended and feel full.
Lower Back and Leg Pain: Some women may experience lower back pain or pain in the legs due to the pressure exerted by fibroids on surrounding structures.
Pain During Sex (Dyspareunia): Fibroids can cause pain or discomfort during sexual intercourse.
Difficulty in Getting Pregnant (Infertility): Depending on their size and location, fibroids can interfere with the implantation of a fertilized egg or lead to difficulties in conception.
Pressure Symptoms: Fibroids can create pressure on the bladder, leading to increased frequency of urination. They can also exert pressure on the rectum, causing constipation. Additionally, pelvic vein pressure can lead to hemorrhoids and varicose veins.
Acute Degeneration: In some cases, fibroids may undergo acute degeneration, which can cause severe pain.
Enlargement of the Abdomen: Large fibroids or multiple fibroids can cause the abdomen to become visibly enlarged due to their projection into the abdominal cavity.

$\"investigations$

Diagnosis and Investigations

History Taking: A comprehensive medical history is taken to understand the patient\’s symptoms, menstrual patterns, reproductive history, and any relevant medical conditions. This helps in assessing the likelihood of uterine fibroids and guides further evaluation.
Physical Examination: A physical examination is conducted to assess general health and look for specific signs related to uterine fibroids. This may include checking for signs of chronic anemia (pallor) due to heavy menstrual bleeding.
Abdominal Examination: An abdominal examination is performed to detect any large pelvi-abdominal swelling, which can be associated with significant fibroid growth.
Pelvic Examination: During a pelvic examination, the healthcare provider assesses the size, shape, and position of the uterus. Uterine fibroids may cause the uterus to be symmetrically or asymmetrically enlarged. A speculum examination may also reveal the presence of fibroid polyps.
Investigations: Various diagnostic tests are used to confirm the presence of uterine fibroids and assess their characteristics. These investigations may include:
- Pregnancy Test: To rule out pregnancy as a cause of symptoms.
- Full Blood Count (FBC) and Iron Studies: To check for anemia, which can result from heavy menstrual bleeding caused by fibroids.
- Pelvic Ultrasound (U/S): An ultrasound is a common imaging test used to visualize the uterus and detect fibroids. It is a non-invasive and relatively simple procedure.
- Saline Hysterosonography: This procedure involves injecting saline into the uterus during an ultrasound to enhance visualization of the uterine cavity and identify submucous fibroids.
- Hysterosalpingogram (HSG): An HSG is an X-ray procedure that uses contrast dye to visualize the uterine cavity and fallopian tubes. It can help detect intrauterine fibroids.
- Transvaginal Ultrasound (TVUSS): This type of ultrasound involves inserting a small probe into the vagina for a clearer view of the pelvic organs, which can be especially useful in obese patients.
- Hysteroscopy: A hysteroscope, a thin, lighted instrument, is used to directly visualize the uterine cavity, enabling the identification and removal of submucous fibroids.
- Bimanual Examination: A two-handed examination of the pelvic organs to assess the size, shape, and mobility of the uterus and detect any abnormal masses.
- MRI (Magnetic Resonance Imaging): Although not always necessary, MRI is highly accurate in providing detailed information about the size, location, and number of fibroids.

$\"\"$

Management of Fibroids.

Most fibroids do not require treatment unless they are causing symptoms. After menopause, fibroids usually shrink, and it is unusual for fibroids to cause problems. The choice of management depends on several factors:

Age
Parity
Size and location of fibroids
Desire for uterine preservation
If need for more children

For example:

Multiple myomas and completed childbearing benefit from hysterectomy.
Nulliparous women may undergo myomectomy.
Submucosal myomas can be treated with hysteroscopic resection.
Subserosal pedunculated myomas can be removed through laparoscopic resection.

Emergency Treatment:

Blood transfusion is given to correct anemia.
Emergency surgery is indicated for infected myoma, acute torsion, and intestinal obstruction.

Medical Management:

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help manage pain.
Antifibrinolytic agents like tranexamic acid may reduce menorrhagia.
Low-dose birth control pills or an intrauterine device with a slow-release hormone (Mirena) can control heavy menstrual bleeding.
Haematenics like ferrous sulphate or folic acid are used to improve hemoglobin levels in cases of Menorrhagia.
Levonorgestrel intrauterine devices effectively limit menstrual blood flow and improve other symptoms with minimal side effects.
Gonadotropin-releasing hormone (GnRH) agonists like Lupron and Synarel can temporarily reduce estrogen and progesterone levels, leading to fibroid shrinkage.
Mifepristone (25-50mg twice weekly) is a progesterone receptor inhibitor that can reduce fibroid size and bleeding.
Danazol, an androgen, interrupts ovulation.

Surgical Management:

Myomectomy: Surgical removal of one or more fibroids, often recommended for women who want to preserve fertility.
Hysterectomy: Removal of the uterus, suitable for women with multiple myomas and completed childbearing.
Endometrial ablation: Removal of the uterine lining.
Uterine artery embolization: Limiting blood supply to the myoma by injecting polyvinyl particles via the femoral artery.
Radiofrequency ablation: Shrinking fibroids by inserting a needle-like device into the fibroid and heating it with radiofrequency.

Indications:

Myomectomy: Young women who want more children, small or few fibroids, heavy or prolonged bleeding.
Hysterectomy: Possible malignant changes, large or numerous fibroids, desire to limit family size, or approaching menopause.

Pre and Post Operative Care/Management

This involves providing care for patients undergoing surgery of gynecological procedures.

1. Admission and History Taking:

Obtain personal, medical, social, and gynecological history.
Conduct a physical examination, including vital signs (temperature, respirations, blood pressure, and pulse), head-to-toe examination to rule out anemia, dehydration, jaundice, and vaginal examination to assess any abnormalities.
General assessment by the gynecologist.

2. Informed Consent:

Explain the reasons for the operation, its benefits, risks, and expected results to the patient and involve the partner if necessary.

3. Investigations:

Conduct various tests, including urinalysis, hemoglobin (HB) level, blood grouping and cross-match, abdominal ultrasound scan, urea and electrolytes, INR/PT (International Normalized Ratio/Prothrombin Time), and ECG/ECHO if required.

4. Patient Education:

Educate the patient about the surgery, its purpose, potential complications, and side effects of anesthesia.
Provide reassurance and counseling to relieve anxiety.

5. Preparing for Surgery:

Ensure the patient fasts from food and drinks on the day of the operation.
Arrange for IV line insertion, blood booking in the laboratory, and catheterization of the patient.
Administer pre-medications as prescribed.

6. Assisting with Theatre Preparation:

Help the patient change into theatre gown.
Continue providing counseling and emotional support.

Post-Operative Management:

After the operation, prepare the post-operative bed for the patient.
Obtain reports from the surgeon, recovery room nurses, and anesthetists.
Wheel the patient to the ward.
Receive the patient in a warm bed, keeping her in a flat position, or turning her to one side depending on the surgery type (supine for abdominal surgery or a comfortable position for vaginal surgery).

Observation:

Monitor the patient closely, taking vital signs regularly (every ¼ hr for the first hour and every ½ hr for the next hour until discharge).
Observe temperature, pulse, respiration, blood pressure, and signs of bleeding or edema at the surgical site.
Check the IV line and blood transfusion line if applicable.

Upon Consciousness:

Gently welcome the patient from the theater, explain the surgery, and assist with face sponging.
Provide a mouthwash and change the gown.

Medical Treatment:

Administer analgesics, such as Pethidine 100mg every 8 hours for 3 doses, and switch to Panadol to complete 5 days.
Prescribe antibiotics, such as ampicillin or gentamicin, as ordered.
Offer supportive care with vitamins like vitamin C, iron, and folic acid.
Monitor and care for the wound in case of abdominal surgery, leaving the wounds untouched if bleeding occurs and re-bandaging if necessary.

Nursing Care:

Assist the patient with hygiene, including bed baths and oral care.
Allow the patient to feed herself as soon as she is able and provide plenty of fluids.
Encourage regular bowel and bladder emptying, offering assistance as needed.
Initiate chest and leg exercises to avoid swelling and bleeding in the wound.
Gradually increase the exercise routine to prevent deformities and contractures.

Vaginal Surgery Management:

Insert a vaginal pack to control hemorrhage and inspect it frequently for severe bleeding.
Apply vulval padding after pack removal until bleeding stops, changing it when necessary to prevent infections.
Swab or clean the vulva at least every 8 hours to prevent infection.

Advice on Discharge:

For Myomectomy patients, advise avoiding conception for 2 years following the operation and delivering via cesarian section.
For hysterectomy patients, inform them that they will not conceive again or have periods.
Recommend abstaining from sexual intercourse for about 6 weeks and avoiding douching. Vaginal bleeding may persist for up to 6 weeks.

Complications of Uterine Fibroids:

Menorrhagia (heavy menstrual bleeding)
Premature birth, labor problems, and miscarriage
Infertility
Twisting of the fibroids
Anemia
Urinary tract diseases
Postpartum hemorrhage

Complications during pregnancy and labor may include:

Antepartum hemorrhage (placenta previa, placental abruption)
Abortion
Fetal restricted growth
Malpresentation
Cesarean section
Labor dystocia
Premature labor
Uterine inertia leading to postpartum hemorrhage
Obstructed labor
Subinvolution of the uterus with increased lochia.

FIBROIDS (FIBROMYOMAS) Read More »

PELVIC INFLAMMATORY DISEASES (PID)

Pelvic Inflammatory Diseases (PID)

Pelvic inflammatory disease (PID) refers to various inflammatory conditions affecting the upper genital tract in females.

Pelvic Inflammatory Diseases (PID) refer to infections that affect the pelvic organs, pelvic peritoneum, and the pelvic vascular system.

Pelvic inflammatory diseases are diseases of the upper genital tract.

It is a spectrum of infection and inflammation of the upper genital tract organs involving the endometrium, fallopian tubes, ovaries, pelvic peritoneum and surrounding structures.

Infections, often ascending from the vagina, can lead to salpingitis, endometritis, pelvic peritonitis, or the formation of tubo-ovarian abscesses.

Aetiology of Pelvic Inflammatory Diseases

PID is often attributed to multiple pathogens, including

Neisseria Gonorrhoeae: A bacterium that causes the sexually transmitted infection gonorrhoea. If left untreated, gonorrhoea can ascend from the cervix to the upper reproductive organs, leading to PID.
Chlamydia Trachomatis: The bacterium responsible for chlamydia, another common sexually transmitted infection. Chlamydia can infect the cervix and ascend to the uterus and fallopian tubes, leading to PID.
Mycoplasma: Certain species of Mycoplasma, such as Mycoplasma genitalium, have been implicated in PID. These bacteria can cause inflammation and infection in the reproductive tract.
Gardnerella Vaginalis: An overgrowth of Gardnerella vaginalis can lead to bacterial vaginosis, an imbalance of vaginal bacteria that can contribute to the development of PID.
Bacteroides: Bacteroides species are anaerobic bacteria that can be involved in the polymicrobial infection associated with PID.
Gram-Negative Bacilli like Escherichia Coli: Certain gram-negative bacteria, including Escherichia coli, commonly found in the gastrointestinal tract, can cause infections in the reproductive organs, contributing to the development of PID.

Risk Factors/Other Factors.

The aetiology of pelvic inflammatory diseases (PIDs) can be attributed to several other factors, including:

Sexually Transmitted Infections (STIs): Infections such as chlamydia and gonorrhoea are common causes of PID. These bacteria can travel from the cervix to the upper genital tract, leading to inflammation and infection.
Bacterial Vaginosis: Imbalance of normal vaginal bacteria can increase the risk of developing PID. The overgrowth of harmful bacteria can lead to inflammation and infection of the reproductive organs.
Postpartum or Post-Abortion Infections: Infections following childbirth or abortion can lead to inflammation of the reproductive organs, increasing the risk of PID.
IUD Insertion: Insertion of intrauterine devices (IUDs) for contraception can introduce bacteria into the reproductive tract, potentially leading to PID.
Endometrial Procedures: Certain medical procedures, such as endometrial biopsy or dilation and curettage (D&C), can introduce bacteria into the uterus, increasing the risk of PID.
Unprotected Sexual Activity: Engaging in unprotected sexual activity with multiple partners can increase the risk of acquiring STIs, which can lead to PID.
Douching: Douching is the practice of washing or flushing the vagina with water or other fluids. It can disrupt the natural balance of bacteria in the vagina, increasing the risk of developing PID.
Previous PID Infections: Individuals with a history of pelvic inflammatory disease are at an increased risk of developing recurrent episodes of PID.
Multiple or New Sexual Partners: Engaging in sexual activity with multiple partners or having a new sexual partner can elevate the risk of acquiring sexually transmitted infections (STIs) that can lead to PID.
History of STIs in the Patient or Her Partner: A history of sexually transmitted infections, such as chlamydia or gonorrhea, in either the patient or her partner can increase the likelihood of developing PID.
History of Abortion: Previous induced abortions can be a risk factor for PID, particularly if the procedure leads to infections in the reproductive tract.
Young Age (Less Than 25 Years): Younger individuals, particularly adolescents, are at a higher risk of PID, possibly due to increased sexual activity and immature cervix, which may facilitate the spread of infections.
Postpartum Endometritis: Infections following childbirth, particularly involving the lining of the uterus (endometritis), can increase the risk of developing PID.

Pathophysiology of Pelvic Inflammatory Diseases

Pelvic Inflammatory Disease is often caused by multiple microorganisms, with gonorrhoea and Chlamydia being the most common causes.

The infection starts in the vagina and then ascends through the endocervical canal to reach the Fallopian tubes and ovaries.

During menstruation, the endocervical canal is slightly dilated, facilitating the entry of bacteria into the uterus. Once inside the reproductive tracts, the bacteria rapidly multiply and can spread further to the fallopian tubes, ovaries, and even the peritoneum or other abdominal organs.

Clinical Manifestations of Pelvic Inflammatory Diseases (PID)

The clinical presentation of PID can vary, and common symptoms include:

Lower Abdominal Pain (usually <2 weeks): Patients with PID commonly experience pain in the lower abdominal region, usually lasting for less than two weeks. This pain is often a result of the inflammation and infection affecting the pelvic organs. The nature of the pain is bilateral, affecting both sides of the lower abdomen.
Dysuria, Fever: Dysuria (painful or difficult urination) and fever are indicative symptoms of PID. These manifestations result from the inflammatory response and the body’s attempt to combat the infection.
Smelly Vaginal Discharge Mixed with Pus: PID can lead to an alteration in vaginal discharge, which may become malodorous and contain pus. This change is a consequence of the infection affecting the reproductive organs and the discharge’s composition.
Purulent Vaginal Discharge: About 90% of PID patients have purulent (pus-like) vaginal discharge. The discharge may have a foul odour and appear yellowish or greenish.
Painful Sexual Intercourse (Dyspareunia): Dyspareunia, or pain during sexual intercourse, is a common symptom of PID. Inflammation and infection can make sexual activity uncomfortable or painful.
Cervical Motion Tenderness: Cervical motion tenderness is a clinical sign observed during a pelvic examination. It involves pain or discomfort when the cervix is moved, indicating inflammation in the pelvic region, specifically around the cervix.
Abnormal Uterine Bleeding: PID may cause irregular or abnormal uterine bleeding. The inflammatory processes can disrupt the normal menstrual cycle, leading to unusual bleeding patterns.
Palpable Swellings in Severe Cases: In severe cases of PID, palpable swellings may be detected, indicating the presence of pus in the fallopian tubes or the development of a pelvic abscess. Signs of peritonitis, such as rebound tenderness (pain upon release of pressure), suggest an advanced and serious stage of the disease.
Urinary Symptoms: PID can sometimes affect the nearby urinary structures, leading to symptoms like increased frequency or urgency of urination. This occurs due to the proximity of the reproductive and urinary organs in the pelvic region.
Gastrointestinal Symptoms: PID’s inflammatory processes can extend to the gastrointestinal tract, causing symptoms such as nausea, vomiting, or diarrhoea. These symptoms may result from the proximity of the reproductive and digestive organs in the pelvic cavity.
Painful Bowel Movements: PID can cause inflammation around the pelvic organs, leading to pain during bowel movements. This symptom is a consequence of the infection affecting the nearby structures.
Adnexal Mass: The presence of an adnexal mass, indicating swelling or enlargement in the region near the uterus and ovaries, can be detected in PID cases. This mass is a clinical finding associated with pelvic inflammation.
Speculum Examination: A speculum examination may reveal a congested cervix with purulent discharge, providing visual evidence of cervical involvement in PID.
Intermenstrual Bleeding: Intermenstrual bleeding, occurring between regular menstrual cycles, is another symptom associated with PID, contributing to the spectrum of abnormal bleeding patterns.
Post-coital Bleeding: Post-coital bleeding, or bleeding following sexual intercourse, is highlighted as a distinctive symptom of PID, reflecting the impact of inflammation on the reproductive organs.
Menstrual Changes: PID can disrupt the normal menstrual cycle, leading to various menstrual irregularities. These changes may include dysmenorrhea (painful periods), menorrhagia (heavy or prolonged periods), or oligomenorrhea (infrequent or scanty periods).

Diagnosis and Investigations for Pelvic Inflammatory Diseases (PID)

Gram Staining: Gram staining to detect intracellular diplococci, providing microscopic evidence of bacterial presence. This method aids in identifying pathogens like Neisseria gonorrhoeae.
Cervical Culture and Sensitivity: Collecting pus samples for culture and sensitivity from the cervix helps identify the specific microorganisms causing the infection and their sensitivity to antibiotics.
Abdominal Pelvic Ultrasound Scan: An ultrasound scan assesses the abdominal and pelvic regions. While it may appear normal in some cases, it is crucial for detecting complications such as pelvic tubo-ovarian abscess or hydrosalpinx.
Pelvic Tubo-Ovarian Abscess: Visualization of a pelvic tubo-ovarian abscess is a diagnostic indicator, revealing a localized collection of pus and inflammatory tissue within the pelvic region.
Physical Examination – Must Include:

Lower Abdominal Pain (LAP): Assessment of lower abdominal pain,, as PID commonly presents with pelvic discomfort.
Cervical Motion Tenderness: Tenderness observed during movement of the cervix is a clinical sign of PID.
Adnexal Tenderness: Tenderness in the adnexal region (near the uterus and ovaries).

Speculum Examination: A speculum examination assists in assessing the cervix and vaginal canal.
Pregnancy Test: Conducting a pregnancy test is essential to rule out pregnancy-related causes of pelvic symptoms.

Management of Pelvic Inflammatory Diseases

Aims of Management

To eliminate the infection.
To relieve symptoms.
To prevent complications.

Medical Management:

Outpatient treatment involves a combination of medications covering multiple microorganisms.

Ceftriaxone 250 mg IM (or cefixime 400 mg stat if ceftriaxone is not available)
Doxycycline 100 mg orally every 12 hours for 14 days
Metronidazole 400 mg twice daily orally for 14 days
In pregnancy, erythromycin 500 mg every 6 hours for 14 days replaces doxycycline.
Do not use doxycycline during pregnancy and breastfeeding.

For severe Cases, Admission is considered.

Severe cases or those not improving after 7 days require referral for ultrasound scan and parenteral treatment.
Patients with severe PID should be admitted and injectable antibiotics should be given for at least 2 days then switch to the oral antibiotics.
IV Clindamycin 900 mg 8 hourly plus gentamycin 2 mg/kg loading dose then 1.5mg/kg 8 hourly. OR Ceftriaxone 1 g IV daily plus metronidazole 500mg IV every 8 hours until clinical improvement, then continue oral regimen.
Note: A number of patients have repeated infection resulting from inadequate treatment or re-infection from untreated partners.
Therefore: Male sexual partners should be treated with drugs that cover N.gonorrhoeae and C. Trachomatis to avoid reinfection.ie. Cefixime 400 mg stat Plus Doxycycline 100mg 12 hourly for 7 days.

Nursing Interventions for Pelvic Inflammatory Disease (PID):

Assessment (History and Physical Examination): Thorough assessment, including a detailed history and physical examination, helps identify specific symptoms, risk factors, and the extent of pelvic involvement.
Fever Management: Effective management of fever involves monitoring temperature regularly and implementing interventions such as antipyretic medications and cooling measures to ensure patient comfort and prevent complications.
Pain Management: Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen, can alleviate pelvic pain and inflammation. Prescription pain medications may be considered for severe cases.
Anxiety Alleviation: Addressing emotional well-being is crucial. Provide support and information to alleviate anxiety related to the diagnosis, treatment, and potential complications of PID.
Health Education: Patient education focuses on understanding PID, its causes, and the importance of compliance to prescribed medications. Information on preventive measures, symptom recognition, and follow-up care is also provided.
Rest and Sleep Promotion: Encouraging adequate rest and sleep aids in the body’s recovery process. Assist in creating a conducive environment for rest, addressing discomfort and promoting relaxation.
Hygiene (Bowel and Bladder Care): Maintaining proper hygiene, especially regarding bowel and bladder care, is emphasized to prevent infections and promote overall well-being during the recovery phase.
Dietary Guidance: Provide dietary recommendations to support healing. Adequate nutrition is essential for recovery, and guidance may include hydration, balanced meals, and nutritional supplements if necessary.
Discharge Advice: Comprehensive discharge instructions cover post-treatment care, prescribed medications, and potential signs of complications. Patients are educated on when to seek medical attention and the importance of completing the entire course of antibiotics.
Sexual Partners: Educating and treating sexual partners exposed to the same STIs is A MUST. This preventive measure aims to interrupt the cycle of reinfection and reduce the transmission of STIs.
Follow-up Care: Post-treatment follow-up ensures the effectiveness of antibiotic therapy. Recommend additional tests or visits to confirm resolution and assess for any complications.
Prevention: Emphasize preventive measures, including safe sex practices, consistent condom use, regular STI testing, and limiting sexual partners. Vaccination against specific STIs, such as HPV and hepatitis B, is promoted to reduce the risk of PID. Education on maintaining a healthy sexual lifestyle is also provided.

Complications of Pelvic Inflammatory Disease (PID):

Infertility: PID poses a high risk of infertility by causing scarring and damage to the reproductive organs. This can impair fertility by obstructing the fallopian tubes, disrupting normal ovulation, or affecting the uterus.
Ectopic Pregnancy: The increased likelihood of scarring in the fallopian tubes from PID raises the risk of ectopic pregnancies. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in the fallopian tubes, posing a serious medical emergency.
Chronic Pelvic Pain: Persistent or recurrent pelvic pain may develop as a long-term consequence of PID.
Pelvic Abscess: In some cases, untreated or severe PID can lead to the formation of a pelvic abscess—a collection of pus within the pelvic cavity.
Pelvic Peritonitis: Pelvic peritonitis refers to inflammation of the peritoneum, the lining of the pelvic cavity. It can result from the spread of infection within the pelvis, leading to severe abdominal pain, tenderness, and potential complications.
Tubo-ovarian Abscess (TOA): A tubo-ovarian abscess is a localized collection of infected fluid involving the fallopian tubes and ovaries. This serious complication may necessitate surgical intervention, such as drainage or removal of the abscess.
Adhesions and Scarring: PID can contribute to the formation of adhesions and scarring within the pelvic organs. These adhesions may lead to structural changes, increasing the risk of complications such as bowel obstruction or chronic pain.

CERVICITIS

Cervicitis refers to the inflammation of the cervix, which is the lower part of the uterus that opens into the vagina.

It is often caused by infections, most commonly sexually transmitted infections (STIs) like Chlamydia and Gonorrhea.

Signs and Symptoms of Cervicitis:

Redness of the Cervix: Inflammation may cause the cervix to appear red and swollen when examined by a healthcare provider.
Slight Bleeding on Intercourse: Cervicitis can lead to cervical friability, making the cervix more prone to bleeding, especially during sexual intercourse.
Itching and Burning: Some individuals with cervicitis may experience itching and a burning sensation around the vaginal area.
Vaginal Discharge: An abnormal vaginal discharge, which may be watery, yellowish, or greenish, can be present in cervicitis.
Pelvic Pain: Some individuals may experience mild pelvic discomfort or pain.

SALPINGITIS:

Salpingitis is the inflammation of one or both fallopian tubes.

It often occurs as a result of infections ascending from the vagina and uterus. Common causes of salpingitis include untreated or inadequately treated STIs, particularly Chlamydia and Gonorrhea.

Signs and Symptoms of Salpingitis:

Abdominal or Back Pain: Salpingitis can cause lower abdominal or back pain, which may range from mild to severe.
Dyspareunia: Pain during sexual intercourse, known as dyspareunia, can be a symptom of salpingitis.

OOPHORITIS:

Oophoritis is the inflammation of one or both ovaries.

It can occur independently or in conjunction with other pelvic infections, such as salpingitis.

Signs and Symptoms of Oophoritis:

Abdominal or Back Pain: Similar to salpingitis, oophoritis may cause abdominal or back pain.
Dyspareunia: Pain during sexual intercourse may also be present in cases of oophoritis.

ENDOMETRITIS:

Endometritis is the inflammation of the endometrium, which is the inner lining of the uterus.

It can be acute or chronic and is often caused by bacterial infections, most commonly occurring after childbirth, abortion, or the insertion of an intrauterine contraceptive device (IUD).

Signs and Symptoms of Endometritis:

Fever: The patient may have an elevated body temperature as a response to the infection.
Abdominal Pain: Pain or discomfort in the lower abdomen is a common symptom.
Enlargement of the Uterus: In some cases, the uterus may appear larger than usual upon examination.
Vaginal Discharge: Abnormal vaginal discharge may be present, which can be foul-smelling and may vary in color.

HOSPITAL MANAGEMENT:

AIMS:

Prevent complications
Relieve pain
Prevent the disease from spreading

Admission:

Admit the patient to a clean and well-ventilated gynecological ward for complete bed rest.
Start an I.V. line immediately to prevent dehydration and encourage oral fluids.

Position:

Place the patient in a comfortable position, especially semi-fowler’s, to aid discharge drainage.

Histories and Examination:

Take patient histories and conduct a comprehensive general examination.

Observations:

Monitor vital signs (TPR & BP).
Observe and record color, amount, and smell of the discharge daily.
Monitor the general condition of the patient.

Investigations:

Conduct high vaginal swab for culture and sensitivity to identify the causative organism.
Perform urinalysis for culture and sensitivity.
Rule out malaria with a malaria slide.
Take a blood sample for culture and sensitivity to check for a hematogenous source.
Perform an ultrasound scan to rule out other causes of abdominal pain.

Diet:

Advise the patient to take a highly nutritious diet with plenty of oral fluids.

Elimination:

Provide a bedpan or urinal and advise the patient to urinate whenever needed.
Observe and record the color, amount, and smell of the urine.
Disinfect urine and feces with JIK before disposal.

Hygiene:

Make the bed daily and remove wrinkles for cleanliness.

Exercise:

Encourage the patient to do some physical exercise, such as walking around. Psychotherapy may be necessary.

Care of Mind:

Reassure the patient and relatives.
Provide newspapers, TV, radios, etc.

Medical Treatment:

Start treatment immediately while waiting for culture and sensitivity results.
Use broad-spectrum antibiotics (chloramphenicol 2 gm stat, then I gm 6 hourly for 5 days, gentamicin 160 mg OD for 5 days, ceftriaxone 2 gm daily for 5 days). If the discharge reduces, switch to oral antibiotics.
Use other drugs based on sensitivity results (metronidazole 500 mg TDS i.v., azithromycin 1g as a single dose, ciprofloxacin, tetracycline, doxycycline, Septrin).

Analgesics:

Use narcotics for severe pain. Other options include Panadol, ibuprofen, Diclofenac to reduce pain and inflammation.

Advice on Discharge:

Reduce sexual partners, use condoms, avoid intrauterine contraceptive devices, seek early treatment for sexually transmitted infections, maintain hygiene, and follow prescribed drugs.
Instruct the patient to return for review in case of any problems like pain, discharges, or itching.

Complications

Untreated or poorly managed endometritis can lead to several complications, including:

Pelvic Abscess: Accumulation of pus in the pelvic region.
Infertility: Inflammation and scarring can affect the fallopian tubes and reduce fertility.
Ectopic Pregnancy: An abnormal pregnancy outside the uterus, usually in the fallopian tubes.
Chronic Pelvic Pain: Persistent pelvic pain lasting for an extended period.
Pelvic Adhesions: Scar tissue formation that can cause organs to stick together.
Salpingitis: Inflammation of the fallopian tubes.
Peritonitis: Inflammation of the abdominal lining.
Tubal Ovarian Mass: Formation of masses involving the fallopian tubes and ovaries.
Intestinal Obstruction: Partial or complete blockage of the intestine

PELVIC INFLAMMATORY DISEASES (PID) Read More »

Infertility

INFERTILITY

Infertility is the inability of a couple to conceive or to get a child after one year of regular coitus without having used any form of contraception.

Infertility refers to failure to conceive in spite of regular unprotected sex during the child bearing age that is 15-49 years without any contraception for at least one year.

Types of infertility

Primary infertility

Primary infertility is the inability to conceive in a couple that has had no previous pregnancies.
Primary infertility is the term used for a couple who have never achieved a pregnancy at any time after 1 year of unprotected sex.

Secondary infertility

Secondary infertility is where one has ever conceived but then stops to produce when she is not on any method of family planning.
Secondary Infertility also refers to a couple who have previously succeeded in achieving at least one pregnancy even if this ended in spontaneous abortion being unable to conceive again.

Forms of Infertility

Male Infertility

Male infertility means a man is not able to start a pregnancy with his female partner.

Female Infertility

Female infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex.

Causes of infertility

In males

Depression: Mental health conditions, such as depression, can affect the ability of a man to engage in sexual intercourse since it can affect sustaining an erection. Stress and emotional factors may contribute to the release of immature or abnormal sperm.
Poor Sperm Movement: Factors like extreme heat, prolonged fever, or exposure to excessive heat can reduce sperm count, impair movement, and increase the number of abnormal sperm in semen.
Ejaculation Issues: Difficulties in ejaculation, including poor or failed ejaculation, can contribute to male infertility.
Hydrocele: Excessive fluid collection in the scrotum (hydrocele) can hinder proper sperm production, impacting fertility.
Varicocele: Varicose veins in the scrotum can affect blood supply and drainage, leading to increased temperatures and reduced sperm production. It may also impact ejaculation.
Drug-Induced Erectile Dysfunction: Certain medications, such as amebicides, anti-hypertensives (e.g., aldomet), and diabetic drugs, may cause erectile dysfunction, contributing to infertility.
Diseases like Mumps: Mumps can lead to orchitis, an inflammation of the testes, affecting sperm production.
Hormonal Imbalance: Inadequate production of testosterone hormone can result in the production of immature sperm.
Degenerative Changes in Sperm: Nitrofurantoin, a medication, can cause degenerative changes in sperm.
Lifestyle Factors: Excessive smoking, alcohol consumption, and obesity can negatively impact sperm quality and fertility.
Retrograde Ejaculation: Ejaculation into the bladder can occur, affecting fertility. This can be assessed through urinalysis after ejaculation.
Exposure to Toxins: Exposure to toxic chemicals or radiation can adversely affect spermatogenesis.
Genetic Factors: Genetic conditions like Klinefelter’s syndrome (XXY chromosomes) and Turner’s syndrome (45XO chromosomes) can lead to infertility in males.

Causes/factors in females

Are best discussed under the following headings;

Defective Implantation
Endocrine Disorders
Ovarian Disorders
Defective Transport
Physical / Psychological Disorders
Systemic Disorders

DEFECTIVE IMPLANTATION

Major cause is tubal blockage due to PID (in Uganda especially). This contributes to 60 – 70%.

Salpingitis caused by infection after abortion or delivery by gonorrhoea, chlamydia or tuberculosis or by pelvic peritonitis from acute appendicitis may damage the tubal epithelium and in severe cases bring about tubal blockage.
When the tubes are not completely blocked, fertilization of the ovum may still take place but because of the damage to the ciliated epithelium the fertilized ovum may not be carried down the tube to the uterus and an ectopic pregnancy results.
Abnormalities of the uterus. Some people are born with no uterus or with a bicornuate uterus or Didelphys uterus with 2 horns).
Tubal factors eg tubal blockage due to adhesions resulting from STIs.eg gonorrhoea
Uterine fibroids: Large uterine fibroids can cause irregular implantation surfaces.
Endometrial Abnormalities: Severe inflammation (endometritis) or intrauterine adhesions can affect implantation.
Endometriosis: Presence of endometrial-like tissue outside the uterus can cause inflammation, scarring, and infertility.
Over curettage of the uterus or surgery of the uterus i.e. Hysterectomy, Stenosed Cervix due to trauma or injury due to dilatation and curettage. May be acquired or congenital Gynatresia i.e. a very small hole with a blind end of the vagina.

ENDOCRINE DISORDERS

Hormonal Inefficiency: Alterations in hypothalamic function due to stress, drugs, or weight changes can lead to anovulation.
Prolactin Hormone Issues: Pituitary tumours causing excessive prolactin production can lead to anovulation.
Thyroid and Adrenal Function: Changes in thyroid or adrenal function can result in anovulation.
Age-Related Factors: Fertility declines with age, impacting women during menopause.

OVARIAN CAUSES

Ovary Malfunction: Absence of FSH receptors or disturbances in FSH-follicle interaction can lead to anovulation or polycystic ovarian syndrome.
Premature Menopause: Early cessation of ovarian function can result in infertility.
Surgery and Infection: Surgical removal of ovaries or infections like PID can damage ovarian tissue.

DEFECTIVE TRANSPORT

Allergy to the man’s sperms/cervical hostility – This is a condition in which the cervical mucus is unreceptive to spermatozoa either preventing their progressive advance or actually killing them. It may be due to infection or to the presence of sperm antibodies.
Vaginal Ph: Acidic environment in the vagina destroying the motility of the sperms.

PHYSICAL/ PSYCHOLOGICAL CAUSES

Other conditions preventing union of ova and sperm in female are;

Dyspareunia and Vaginismus: Painful intercourse (dyspareunia) or psychological conditions like vaginismus can affect conception.
Physical Abnormalities: Physical abnormalities like a retroverted uterus can impact fertility.
Psychological Factors: Stress, depression, and wrong timing of intercourse can influence fertility.

SYSTEMIC CAUSES

Systemic Diseases: Diseases like diabetes, hypertension, and renal failure can affect reproductive health.

Conditions that should be fulfilled for implantation to occur.

For successful implantation to occur, the following conditions must be fulfilled:

Two individuals engaging in unprotected sexual intercourse must be actively involved and share a mutual desire to conceive.
The sexual intercourse should involve the right sexual route, with the male ejaculating healthy semen containing normal spermatozoa into the female’s vagina.
Both individuals should be within the age range of conception, ranging between 14 to 49 years, to optimize the chances of successful fertilization and implantation.
The female partner must release a normal, healthy ova from her ovary during her menstrual cycle.
The released ovum must be fertilized by the sperm to form a zygote.
The fertilized ovum, or zygote, must then successfully implant itself in the lining of the uterus to initiate pregnancy.

NOTE: It is important to note that the term “sterility” should only be used when there is no available treatment to enable a couple to conceive, such as in cases where a man lacks testes or a woman lacks a uterus.

GENERAL INVESTIGATIONS

All couples who complain of infertility should be investigated but the length to which the investigations should be carried out will vary.
Both partners should be seen for the initial interview.

Female Investigations	Male Investigations
1. History Taking	1. General Physical Examination
2. Urinalysis	2. Medical History
3. Full Blood Count	3. Semen Analysis
4. Pelvic Ultrasound Scan	4. Scrotal Ultrasound
5. Hysterosonography	5. Hormone Testing
6. Laparoscopy	6. Post-Ejaculation Urinalysis
7. Cervical Mucus Analysis	7. Genetic Tests
8. Endometrial Biopsy	8. Testicular Biopsy
9. Testing for Tubal Patency	9. Specialized Sperm Function Tests
– Tubal Insufflation/Rubin Test	10. Transrectal Scan
– Hysterosalpingography
10. Ovarian Reserve Testing
11. Post Coital Test (Sims Huhner Test)

Evaluation in Women (Females):

History:

Menstrual History: Menarche and length of menstrual periods.
Gynaecological History:

Previous contraceptive use and outcomes.
History of procedures like dilatation and curettage, salpingectomy.
Any history of abortions or suggestive Pelvic Inflammatory Diseases (PID).
Previous obstetric history, including pregnancies and children fathered.

Pelvic Infection History: History of pelvic infections.
General Health and Nutrition: Assess general health and nutritional status.
Age and Weight: Age of both partners and consider weight; very lean or obese women may face fertility challenges.
Visual Examination: Assess hair distribution, including pubic hair and general body hair.
Vaginal Examination: Confirm vaginal normality through visual examination and ultrasound.
Hormonal Investigations:

Check progesterone levels on day 21 of a 28-day cycle to assess ovulation.
Serial ultrasound for ovulation.
FSH and LH levels, especially in cases of premature menopause or ovary removal.

Special Tests:

Hysterosalpingogram to check tubal patency.
Post-coital test to assess sperm allergy.
Basal body temperature charting for ovulation confirmation.
Examination of cervical mucus for ovulation characteristics.
Blood progesterone level testing.

Histology: Premenstrual endometrial biopsy to show secretory changes after ovulation.
Laparoscopy: Tubal patency test, with methylene blue injection to observe spillage.
Tubal Insufflation: Carbon dioxide test via the vagina, coupled with X-rays to assess blockages.
Hysterosalpingogram: Radiographic test with opaque radio aqueous solution to check patency.
Post-Coital Test (Huhner’s Test): Conducted around ovulation to assess sperm motility and quantity.
Prolactin Tests: Conducted when prolactin levels are elevated.
Endometrial Biopsy: Performed 10-12 days after ovulation.
Transvaginal Ultrasound (TVS): Used for evaluation with certain contraindications and risks.

Evaluation in Men (Male):

Obesity Assessment: Check for associations with diabetes mellitus, hypertension, and infertility.
Hair Distribution and Genitalia Development: Assess hair distribution and genitalia development.
Undescended Testis: Check for undescended testes, with corrective surgery before puberty if necessary.
Breast Examination: Check for breast enlargement indicating increased oestrogen levels.
Testes Examination: Assess testis size and position.
Blood Tests: Sperm Count/Seminal Fluid Analysis:

Normal count is ≥20 million/ml; below 10 million may indicate an issue (oligospermia).
Decreased androgen levels may indicate infertility.

Normal Findings in Semen Analysis:

Volume: Normal volume is ≥2 ml or 2.5ml.
pH: 7-8.
Total Sperm Count: More than 20 million/ml.
Liquefaction: Complete in 1 hour.
Motility: ≥50% with forward motility.
Morphology: 30% or more with normal shape.
Concentration: ≥20 million/ml.

Note:

Azoospermia: Lack of sperms in semen.
Oligospermia: Few sperms, less than 20 million/ml.
Asthenospermia: Decreased sperm motility.
Teratospermia: Excessive abnormality of sperms in semen.

MANAGEMENT AND TREATMENT OF INFERTILITY.

Treatment In Females

Management of infertility involves a range of strategies, including

Medication,
Surgery,
Artificial insemination, or advanced reproductive technologies.

The choice of treatment depends on factors such as;

The cause of infertility,
Age of the individual,
Duration of infertility, and individual preferences.

Medical Management(Chemotherapy): This Involves stimulating ovulation using fertility drugs. Fertility drugs regulate or stimulate ovulation. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders.

Fertility drugs generally work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They’re also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include:

Clomiphene citrate:

Clomiphene is taken by mouth and stimulates ovulation by causing the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
Dose: Clomiphene Citrate (Clomid): 50mg daily for 5 days, with potential second course.
The treatment is usually started on the fifth day of your menstrual period. But can still be taken at any time.
If ovulation does not occur a second course of 100 mgs daily for 5 days may be given starting as early as 30 days after the previous one, In general 3 courses of therapy are adequate to assess whether ovulation is obtainable. Clomiphene induces ovulation by stimulating the Hypothalamic pituitary system.

Gonadotropins:

Instead of stimulating the pituitary gland to release more hormones, these injected treatments stimulate the ovary directly to produce multiple eggs.
Gonadotropin medications include human menopausal gonadotropin or hMG (Pregonal) or Pure FSH (Metrodin) may be used if clomiphene has failed.
Another gonadotropin, human chorionic gonadotropin is used to mature the eggs and trigger their release at the time of ovulation.
Administered via syringe pump every 90 minutes to trigger ovulation. 10-25 micrograms released via a syringe pump every 90 minutes. It’s given intravenously or subcutaneously.
The treatment is continued throughout the menstrual cycle
The success rate of 60-70% has been shown.
Concerns exist that there’s a higher risk of conceiving multiples and having a premature delivery with gonadotropin use.

Metformin:

Metformin is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of Polycystic ovary syndrome (PCOS). Metformin helps improve insulin resistance, which can improve the likelihood of ovulation.

Letrozole:

Letrozole belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene.
Letrozole may induce ovulation. However, the effect this medication has on early pregnancy isn’t yet known, so it isn’t used for ovulation induction as frequently as others.
One study found that 27.5% of women who took letrozole achieved a successful birth. Other studies suggest that compared to women who took Clomid, women who took letrozole had higher rates of ovulation, pregnancy, and live birth.

Bromocriptine:

Bromocriptine(also called parlode lactodel, dopagon or Brameston), a dopamine agonist, may be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.
Initially 1.25 mgs at bed time which is increased gradually to the usual dose of 2.5mgs 3 times a day with food. Increased if necessary to a maximum dose of 30 mgs daily.

Tamoxifen:

Tamoxifen Is in the same class of medication as Clomiphene and works in a similar fashion. It has been shown to effectively induce ovulation in 65-75 percent of women, a rate similar to that of Clomid.
Give Tamoxifen 20 mgs daily on days 2, 3, 4 and 5 of the menstrual cycles. Dose may be increased to 40 mgs the 80mgs.

Surgery

Tubal Blockage:
Surgery is performed in an attempt to unblock them and remove adhesions. Success rate is low.

Salpingolysis: This is when peritubal adhesions around the ampullary ends of the tubes are divided and
function restored.
Salpingostomy: This is when the fimbriae are turned back to produce a new opening of the tube.
Tubal Anastomosis and Repair: This is usually done when the blockage is at the Isthmus. The blocked segment is incised and cut ends are anastomosed.
Laparoscopic or hysteroscopic surgery: These surgeries can remove or correct abnormalities to help improve your chances of getting pregnant. Surgery might involve correcting an abnormal uterine shape, removing endometrial polyps and some types of fibroids that misshape the uterine cavity, or removing pelvic or uterine adhesions.
Uterine, Cervix, or Vaginal Issues: Corrective surgeries, e.g., Myomectomy for uterine fibroids.

TREATMENT IN MALE

Surgical Interventions:

Varicocele Correction: Surgical correction of varicoceles, common dilations of the spermatic veins, is a viable option.
Vas Deferens Repair: Surgical procedures can address obstructions in the vas deferens, facilitating the passage of sperm.
Vasectomy Reversal: Reversal procedures can be performed for individuals who had previously undergone vasectomies.
Sperm Retrieval Techniques: In cases of absent sperm in ejaculate, direct retrieval from the testicles or epididymis using specialized techniques may be employed.

Management of Infections:

Antibiotic treatments are considered to address reproductive tract infections, aiming to restore fertility. However, efficacy varies.

Addressing Sexual Dysfunction:

Conditions like erectile dysfunction or premature ejaculation impacting fertility can be managed with medications or counseling.

Hormone Therapies and Medications:

Hormone Replacement: In cases of hormonal imbalances affecting fertility, hormone replacement therapy may be recommended.
Human Gonadotropin Therapy: Clomiphene citrate might be administered to stimulate sperm production.
Testosterone Treatment: Prescribed to stimulate sexual desire, caution is exercised in cases of impaired spermatogenesis. It is administered subcutaneously or intramuscularly 2 to 3 times per week at doses of 2,000 to 3,000 international units (IU).

Surgical Measures:

Reproductive Tract Obstruction Relief: Surgical procedures aim to alleviate obstructions in the reproductive tract.
Inguinal Hernia Repair: Surgical correction is performed for inguinal hernias.
Assisted Reproductive Technology (ART): ART involves various methods to obtain sperm, including normal ejaculation, surgical extraction, or from donor individuals.

Lifestyle Modifications:

Diet and Exercise: Encouraging a healthy lifestyle with a balanced diet and regular exercise can positively impact sperm quality.
Avoidance of Environmental Hazards: Minimizing exposure to environmental factors like toxins and excessive heat can contribute to improved fertility.
Increase frequency of sex. Having sexual intercourse every day or every other day beginning at least 4 days before ovulation increases your chances of getting your partner pregnant.
Have sex when fertilization is possible. A woman is likely to become pregnant during ovulation — which occurs in the middle of the menstrual cycle, between periods. This will ensure that sperm, which can live several days, are present when conception is possible.
Advise the patient to avoid the use of lubricants. Products such as Astroglide or K-Y jelly, lotions, and saliva might impair sperm movement and function. Supplements with studies showing potential benefits on improving sperm count or quality include: Herbal supplements, Chewing dry coffee, Eating plenty of ground nuts, Chewing roots of herbal plants e.g. Mulondo.

Medications for Specific Conditions:

Depending on the underlying causes, specific medications targeting conditions affecting fertility, such as anti-inflammatory drugs, may be prescribed.

OTHER CONSIDERATIONS FOR BOTH PARTNERS

In Vitro Fertilization (IVF):

Developed in 1978, by Robert Edwards who received the nobel prize in Physiology for development of IVF. It is a type of Assisted reproductive technology.
IVF is an infertility treatment for women unable to conceive naturally.
Involves retrieving a healthy ovum from the woman or a donor, fertilizing it with sperms, and implanting the embryo in the uterus.
Often results in multiple pregnancies due to transferring several fertilized ova to enhance implantation chances.

Intrauterine insemination (IUI).

During an intrauterine insemination (IUI) procedure, sperm is placed directly into the uterus using a small catheter.
The goal of this treatment is to improve the chances of fertilization by increasing the number of healthy sperm that reach the fallopian tubes when the woman is most fertile.
During IUI, millions of healthy sperm are placed inside the uterus close to the time of ovulation.

Surrogate Parents:

In situations where the woman lacks a uterus, her ova can be fertilized with the husband’s sperms and implanted in another woman’s uterus.
As soon as the baby is born the surrogate mother hands over the child to the rightful parents.

Adoption of Children:

If still eager to have children, they can visit an adoption centre, fill in forms and apply for adoption of a child of choice.

Artificial Insemination by a Sperm Donor (AID):

Artificial insemination is often used by couples who have tried to conceive naturally for at least one year without success.
Treatment for couples struggling with male fertility problems, including low sperm counts, decreased sperm motility, or ejaculation dysfunction disorders.

NURSING DIAGNOSES

Anxiety and fear related to unknown procedures, treatment and outcome evidenced by the patient’s verbalization.
Low self esteem related to inability to conceive evidenced by low mood, negative attitude and social isolation.
Knowledge deficit related to the process of ovulation, pregnancy and sexual relationship evidenced by inadequate verbalization of correct sexual behavior information.
Knowledge deficit related to sexual anatomy and physiology/ causes of infertility evidenced by inadequate verbalization of related information.

Nursing Interventions

Assessment: Conduct a thorough assessment of the patient’s medical history, reproductive health, and lifestyle factors influencing fertility.
Emotional Support: Provide empathetic support to address the emotional distress associated with infertility. Offer counseling or refer to mental health professionals when needed.
Educational Guidance: Offer education about the various causes of infertility, available treatments, and assisted reproductive technologies (ART) to empower patients with knowledge.
Lifestyle Modification: Collaborate with patients to identify and modify lifestyle factors that may impact fertility, such as smoking cessation, reducing alcohol intake, and maintaining a healthy diet.
Medication Education: Educate patients on the proper administration, potential side effects, and expected outcomes of fertility medications prescribed..
Fertility Monitoring: Instruct patients on methods of monitoring fertility, such as tracking ovulation cycles and recognizing fertile periods.
Assistive Reproductive Technologies (ART): Explain the processes and options associated with ART, including in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and other advanced techniques.
Infection Prevention: Emphasize the importance of preventing and treating reproductive infections that may contribute to infertility.
Nutritional Counselling: Collaborate with a dietitian to provide nutritional counselling, ensuring patients are aware of the impact of diet on fertility and overall reproductive health.
Sexual Health Education: Offer guidance on maintaining a healthy sexual relationship and addressing any concerns related to sexual dysfunction or discomfort.
Monitoring Medication Adherence: Regularly assess and monitor the patient’s adherence to prescribed medications and treatments, addressing any concerns or challenges.
Facilitate Support Groups: Arrange or recommend participation in support groups where patients can share experiences, coping strategies, and emotional support with others facing similar challenges.
Referral to Specialist: Collaborate with fertility specialists, reproductive endocrinologists, or other healthcare professionals to ensure a multidisciplinary approach to care.
Advocacy: Advocate for patients’ needs and ensure they have access to comprehensive fertility care, addressing any barriers or challenges they may face during the diagnostic and treatment process.

Prevention of Infertility

Cease Smoking: Smoking is associated with reduced fertility in both men and women. Quitting smoking enhances reproductive health by improving sperm quality and reducing the risk of reproductive complications in women.
Moderate Alcohol Consumption: Excessive alcohol intake can adversely affect fertility. Limiting alcohol consumption promotes overall reproductive well-being. It is advisable for both partners to maintain moderation.
Adopt a Nutrient-Rich Diet: A well-balanced diet rich in essential nutrients supports reproductive health. Key elements include antioxidants, vitamins, and minerals that contribute to optimal hormonal balance and overall fertility.
Timed Intercourse: Understanding the menstrual cycle and engaging in timed intercourse during the fertile window increases the chances of conception. Regular sexual activity throughout the menstrual cycle is encouraged.
Stress Reduction Techniques: Chronic stress can impact fertility. Incorporating stress-reduction practices such as meditation, yoga, or mindfulness can contribute to a healthier reproductive environment.
Maintain a Healthy Weight: Both obesity and being underweight can affect fertility. Maintaining a healthy weight through regular exercise and a balanced diet supports hormonal balance and reproductive function.
Safe Sex Practices: Protecting against sexually transmitted infections (STIs) is crucial. STIs can lead to pelvic inflammatory diseases (PID) that may result in infertility. Consistent and correct use of barrier methods, like condoms, helps prevent STIs.
Regular Health Check-ups: Routine health check-ups for both partners can detect and address potential reproductive health issues early on. Identifying and managing health conditions timely contributes to fertility preservation.
Avoid Exposure to Environmental Toxins: Limit exposure to environmental pollutants and toxins, such as certain chemicals and radiation, which may impact fertility. Precautions in the workplace and living environment are essential.
Manage Chronic Health Conditions: Proper management of chronic conditions like diabetes, hypertension, and thyroid disorders is crucial. Uncontrolled health conditions may negatively impact fertility.

Complications of Infertility

Depression: Experiencing infertility can lead to emotional distress and, in some cases, clinical depression. The frustration, disappointment, and uncertainty about the future can contribute to mental health challenges.
Strain on Relationships: Marital Challenges and Divorce: Infertility may strain relationships, leading to conflicts and challenges. The pressure to conceive can create emotional distance, and, in extreme cases, contribute to marital strain and even divorce.
Sexual Morality: The stress of infertility might impact the couple’s intimate life, leading to challenges in maintaining a healthy sexual relationship.
Polygamy: Cultural or societal expectations, combined with the desire for children, may lead some individuals to consider polygamy as a solution, introducing additional complexities to relationships.
Social Stigma: Societal attitudes towards fertility and parenthood can contribute to stigmatization, causing individuals or couples to feel isolated or judged.
Financial Strain: Economic Impact: Fertility treatments can be financially demanding. The cost of various procedures, medications, and assisted reproductive technologies may contribute to economic stress.
Health Risks and Treatment Complications: Health Concerns: Fertility treatments, especially hormonal interventions, may pose certain health risks.
Treatment Complications: Some fertility treatments carry risks and potential complications that individuals and couples need to be aware of.

Image References: https://www.invitra.com/en/female-sterility/

Infertility Read More »

Ectopic Pregnancy

ECTOPIC PREGNANCY

Ectopic pregnancy is a condition in which a fertilized egg implants and grows outside the uterus. Instead of the fertilized egg traveling to and implanting in the uterus as it should during a normal pregnancy, it implants in a location where it cannot develop properly.

Ectopic pregnancy is when the fertilized ovum embeds outside the uterine cavity.

Causes of Ectopic Pregnancy.

Fallopian tube damage: Scarring or blockage in the fallopian tubes, caused by previous infections, surgeries, or conditions like endometriosis, can interfere with the the movement of the fertilized egg through the tube and increase the likelihood of implantation outside the uterus. Congenitally long tubes which are liable to kink, Congenital narrowing of the fallopian tube also increases the risk.
Hormonal factors: Certain hormonal imbalances or abnormalities can affect the movement and implantation of the fertilized egg, increasing the risk of ectopic pregnancy.
Previous ectopic pregnancy: Women who have had an ectopic pregnancy in the past are at a higher risk of experiencing another ectopic pregnancy in the future.
Reproductive system abnormalities: Structural abnormalities of the reproductive system, such as a misshapen uterus or an abnormally located fallopian tube, can contribute to the occurrence of ectopic pregnancy.
Pelvic inflammatory diseases.eg salpingitis. This cause destruction or erosion of Cilia, formation of adhesions interfering with peristalsis in the tubes.
Tumours: pressing on adjacent sides of the tube causing partial or complete blockage of the tube.
Endometriosis ie development of the endometrium in other places other than the uterus.
Repeated induced abortions
Tubal surgery ie surgical procedures on the fallopian tubes may cause intraluminal or extraluminal adhesions.
Intra Uterine Devices. This can interfere with implantation of the fertilized ovum.

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SITES OF ECTOPIC PREGNANCY

The commonest is the uterine tube but can also occur in the broad ligament, ovary and abdominal cavity.

Fallopian tubes(commonest)
Ovary
Intraperitoneal abdominal cavity
Cervix

Tubal pregnancy

This is when a fertilized ovum embeds it self in the fallopian tubes.

Sites for tubal pregnancy

Ampulla(commonest)
Isthmus (e most dangerous because it has tendency to rupture
very early sometimes even before the mother realizes she is pregnant)
Fimbriated end(infundibulum) – rare
Interstitial part(rare)

POSSIBLE OUTCOMES OF TUBAL PREGNANCY

Tubal mole: The zygote dies but it is retained in the fallopian tubes surrounded by a blood clot. This may result into a slow leaking ectopic pregnancy
Tubal abortion: The zygote separates from the fallopian tube lining and it is expelled through the fimbriated end. It may die out or continue to survive on abdominal organs resulting into abdominal pregnancy which can go up to term.
Tubal rapture: The tube becomes too small for the growing zygote so it raptures causing internal bleeding into the abdominal cavity.
It is one of the obstetric emergencies since it causes a lot of internal bleeding and thus shock.
Tubal erosion: The zygote erodes the fallopian tube lining causing bleeding in to the abdominal cavity.

Signs and symptoms ectopic pregnancy (tubal rapture)

On history taking

History of amenorrhea 6 – 10 weeks
Patient complains of a feeling of fainting, dizziness, thirsty and vomiting.
Patient complains of acute abdominal pain localized in the iliac fossa which is colicky in nature. It can be referred to the shoulder especially on lying down due to blood irritating the diaphragmic nerve and peritoneum.

On examination

Signs of pregnancy are present. eg darkening of areolar.
Signs of shock i.e. cold, clammy skin, rapid and thread pulse, low blood pressure and temperature.
Patient is anxious and restless.
Pallor of the mucous membrane.

On palpation

Abdominal tenderness especially on the affected side
Abdominal muscles become rigid due to mother guarding against pain.
Abdominal distension due to presence of blood in the abdominal cavity

On vaginal examination

Amount of bleeding doesn’t correspond to the mother’s condition.
Tenderness on movement of the cervix and a mass is felt in the lateral fornix of the vagina.
Painful mass in the pouch of Douglas
Dark brown blood on the examining finger.

Investigations

Ultra sound scan will reveal the rupture and collection of blood on the affected side. Ultrasound scan will confirm the diagnosis
Blood for Hb, grouping and cross match.
On CBC, Haemoglobin level will be low
Pregnancy test is positive
In an emergency if scan is not available a puncture into the Pouch of Douglas fresh blood will be found on aspiration

Differential diagnosis

Salpingitis if associated with irregular menses
Appendicitis
Abortion
Twisted ovarian cyst
Urinary tract infection

Management of Ectopic Pregnancy

In health centre.

This is an emergency and everything must be done as quickly as possible to save life of the mother.

Aims

To prevent shock
To relieve pain
To reassure the patient

Admission: Mother is admitted temporarily on gynaecological ward. Histories are taken, general examination, observations, abdominal and vaginal examination done. A diagnosis is then made.
Histories: these are taken including personal, social, surgical, medical, obstetrical history, how the condition started etc
Examination: This is carried out from head to toe to rule out anaemia, dehydration, shock etc
Observation: Temperature, pulse, respiration and blood pressure are taken and recorded to assess functioning of vital organs.
Resuscitation: A drip of normal saline is put up and morphine 15 mg given intramuscularly. The foot of the bed should be raised to allow blood to move to vital centers.
Transport: Send for transport as soon as possible and inform the patient and relatives about the decision made and why it is necessary.
Transfer: The decision is explained to the patient and relatives, a well written note made stating time of admission, treatment given condition on arrival and leaving. Transport is arranged then the mother is transferred to hospital. The midwife escorts the mother and hands her over to the hospital staff.
Treatment: Put up intravenous infusion of normal saline to prevent or treat shock. This is to elevate the low blood pressure. Administer morphine or pethidine to relieve pain as prescribed.
Nursing care: The vulva is swabbed and a clean pad is applied. Send the patient to hospital with a written note stating when the patient reported to the center, condition on admission and at time leaving and treatment given.

Hospital Management

In the hospital

It is a gynecological emergency, so everything must be done quickly as possible and all nurses must work as a team to see that the patient is taken for operation as soon as possible.

Aims

To treat anaemia
To prevent or treat shock
To reassure the patient
To prevent complications
Admission: Admit the patient in a well-ventilated room and warm admission bed. Establish a good nurse patient relationship.
Histories :Histories are taken from the patient if able or from the relatives if patient is unable (collateral history).These will include social, medical, surgical, obstetrical, gynaecological histories. More emphasis is put on history of the presenting complaint i.e. when the condition started, amount of bleeding, site of pain, any vomiting or if any treatment has been given. Weeks of amenorrhoea are estimated.
The doctor is then informed
General examination: This carried out from head to toe to rule out anemia, shock, dehydration etc
Observations: Vital observations like temperature, pulse, respiration and blood pressure.
Investigations: On arrival of the doctor, he orders for the following investigations;
> Haemoglobin estimation to rule out malaria
> Blood group and cross matching because blood transfusion may be necessary
> Pregnancy test to confirm that the mother was pregnant and the pain is not due to other conditions
> Ultra sound scan to confirm the diagnosis
> Urinalysis to rule out urinary tract infection
Resuscitation: Intravenous Normal saline is started to prevent or treat shock. Morphine 15 mg I.M. will be given as ordered by doctor. If mother is in shock it is also managed. Intravenous fluids eg normal saline are put up and fluid balance chart is maintained.
Blood transfusion: This carried out depending on the haemoglobin results.
Pain relief: Analgesics such as morphine is administered to relieve pain as prescribed by the doctor.

Pre-operative care

The doctor will determine the operation.

Preparation for theatre

Nursing care

A bed bath is given, theatre gown offered, observations done and recorded, all charts collected then the patient is wheeled to theatre.
Explain the nature of operation to the patient and obtain an informed consent.
Reassure the patient to allay anxiety
Theatre staffs are informed
Pass an intravenous line for infusion
Vulva swabbing is done to minimize infections
Catheterization is done and a fluid balance chart is started.
Pass a naso-gastric tube for aspiration gastric or stomach contents or an anti-acid like magnesium trisilicate is given to make the stomach contents alkaline. This prevents aspiration of acidic contents into the lungs.
Pre- medication is given like atropine to dry the secretions.
Repeat vital observations and compare with the baseline observations and record.
Compile the clinical charts and notes, dress the patient in gown and transport her carefully to theatre.
In theatre give a full report to the theatre nurse about the patient.
Book about 1-2 units of blood.
The patient is handed over to the theatre staff and if possible the ward nurse stays with the patient until she is anesthetized. The nurse goes back to the ward and makes a post-operative bed with all its requirements.

In theatre

Laparatomy and salpingectomy is done to remove the ruptured portion and repair the area to control bleeding. The other tube is examined for patency and unblocked if possible. If the rupture was acute and the blood is fresh it may be collected, sieved into an anticoagulant (sodium citrate) and re-transfused into the patient. This is known as auto transfusion. If this is not possible cross matched blood is transfused.

Post- operative care

Post-operative bed should be made with all its accessories such as a drip stand, oxygen machine, vital observation tray, emergency tray, resuscitation tray e.t.c. ready to receive the patient.
When the operation is complete, the ward staff are informed and two qualified nurses go to theatre to collect the patient.
In theatre, receive a full report from the anesthetic and the theatre nurse in a recovery room should report the condition of the patient.
Confirm the report while patient is still in the recovery room by;

Checking airway, breathing and circulation.
Taking vital observations
Observing the site of operation for bleeding
Observe the catheter to see if it is draining well and in good position.

After confirming, the patient is gently wheeled to ward in a recumbent position with the head turned to one side meanwhile observing the airway.

On ward

The patient is lifted from the trolley with care to a well made post-operative bed with all its accessories close to the nurse’s station for close observations.
The patient is put in a recumbent position with the head turned to one side to allow drainage of secretions and also to prevent falling back of the tongue.

Observations and records

Vital observations of temperature, respiration, blood pressure and pulse are taken1/4 ,1/2, 1, 2 hourly according to surgeon’s instructions and duration is increased as the patient stabilizes.

These observations are continued until the patient is discharged.

Observe the site of operation for bleeding
Observe the catheter if it is draining well, colour and the quantity of urine passed.
Maintain a fluid balance chart and balance it every 24 hours to rule out renal failure.
On gaining consciousness, the patient is welcomed from theatre, face is sponged, theatre gown changed, mouth wash is done to remove anesthetic smell and a pillow is offered.

Fluid/hydration

Intravenous fluid.eg 0.9% are continued to replace lost fluids.
Observation of IV infusion are done such as observing the cannular site for swelling, drip rate and incase of anything it should be corrected.
Keep monitoring fluid intake and out put to avoid over hydration.
IV fluids are stopped when bowel sounds are heard and the patient is able to take by mouth.
Cannula is also removed when necessary.eg if patient has completed intravenous drugs.

Drug therapy

Administer prescribed antibiotics to counteract infections and administer prescribed strong analgesics for pain relief.

Antibiotics
> Ampicillin 500 mg 6 hourly for 5 days
> Ceftriaxone 2 gm o.d. for 5 days
> Metronidazole 500 mg 8 hourly for 5 days
> Gentamycin 160 mg o.d. for 5 days
Analgesics
> Pethidine 100mg 8 hourly for 3 doses
> Diclofenac 75 mg 8 hourly for 12 hours
> Panadol 1 gm 8 hourly to complete 5 days as soon as patient can take orally.
Monitor the patient for side effects of the drugs given.
Supportive drugs such as ferrous and folic acid are given to prevent anaemia.

Wound care

Observe the wound for bleeding and if so add more dressing if soiled change the dressing. Also check signs of infections.
Carry out daily wound dressing.
Stitches are removed on the 7th and 8th day alternatingly.

Physiotherapy.

Encourage the patient to do deep breathing exercise to prevent chest complications like hypostatic pneumonia.
Also encourage the patient to start with passive exercises such as limb movement then active exercises like walking around to prevent deep vein thrombosis.

Psychotherapy

In addition to the psychological care given to the patient pre-operatively, she is continuously reassured to allay anxiety.

Diet

First carryout digestion test and if positive the bowel sounds are heard, start the patient on small sips of water. Soft foods are introduced and given according to the tolerance and should be rich in;

Proteins to help in tissue repair
Roughages to prevent constipation
Carbohydrates for energy

NB: The nasal gastric tube is removed as long as the patient can take orally without any complaint.

Hygiene

Carryout bed bath on the first day of operation when the patient is still weak and later assist her to the bathroom.
Carryout mouthcare to prevent neglected mouth complaints like stomatitis, halitosis e.t.c.
Ensure that the patient’s clothing, bed linen and the surrounding environment are clean.

Bowel and bladder care

If urine is clear in 24-48 hours, the urethral catheter is removed and patient is encouraged to pass urine.
The patient is encouraged to pass stool, offered privacy and also given foods rich in roughages to prevent constipation.
Incase of constipation and conservative measures have failed, give purgatives such as bisacodyl 5-10mg O.D or NOCTE.

Rest and sleep

The patient is kept in a quiet well-ventilated room, visitors restricted, bright light avoided so as to create a conducive environment for the patient to sleep and rest.

Advice on discharge

When the patient is fit for discharge advise on the following;

Should have enough rest at home
Avoid heavy lifting so as to avoid straining the abdominal muscles.
To come back for review on appointed dates
To attend ANC clinics when pregnant
To bring the husband for treatment if the cause of ectopic pregnancy was PIDs.
To complete the prescribed medications

Complications of ectopic pregnancy

Immediate complications

Shock
Peritonitis
Dehydration

Long term complications

Sepsis
Anaemia
Fibrosis
Adhesions following surgery
Recurrence

Ectopic Pregnancy Read More »

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:

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:

PALPATION

PERCUSSION

AUSCULTATION

PELVIC EXAMINATION

GYNAECOLOGICAL INVESTIGATIONS

Special Procedures in Gynecology

Gynaecological Operations

FIBROIDS (FIBROMYOMAS)

Risk factors for uterine fibroids

Classes or types of Uterine fibroids

Location or Sites of Uterine Fibroids

Changes (degenerative) that can take place in the fibroid

Causes of Uterine Fibroids.

Clinical Presentation of Uterine Fibroids.

Diagnosis and Investigations

Management of Fibroids.

Pre and Post Operative Care/Management

Post-Operative Management:

Complications of Uterine Fibroids:

Pelvic Inflammatory Diseases (PID)

Aetiology of Pelvic Inflammatory Diseases

Pathophysiology of Pelvic Inflammatory Diseases

Clinical Manifestations of Pelvic Inflammatory Diseases (PID)

Diagnosis and Investigations for Pelvic Inflammatory Diseases (PID)

Management of Pelvic Inflammatory Diseases

Nursing Interventions for Pelvic Inflammatory Disease (PID):

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: