Minor disorders in pregnancy
- 2. Course Outline 1. Review the anatomy and physiology 2. Gynaecological assessment 3. Description of various gynaecological disorders to include: – Menstrual disorders – Abortions – Pelvic congestion syndrome – HydatidIform Mole – Ectopic pregnancy
- 3. Outline cont… • Inflammatory & acute gynecological conditions • Infertility • Fistulas • Genital prolapse • Neoplastic disorders; Vulva, vagina, cervix, uterus, ovary. • Benign conditions; endometriosis; Adenomyosis, Genital polyps; cysts, Leiyomyomas • Breast pathology
- 4. Outline cont… • Human sexuality • Adolescent Reproductive health; • Menopause and andropause • Structural defects of female genitalia • Rape • Female genital mutilation • Pathology of male reproductive system • Toxic shock syndrome • Polycystic ovary syndrome
- 5. Outline cont…… The gynaecology disorders should be described under the following headings; – Definition – Types/ classes – Causes/ risk factors – Pathophysiology – Signs and symptoms – Management – Complications
- 6. MENSTRUAL CYCLE DISODERS • Amenorrhoea:absence of menstruation • Hypomenorrhoe: extremely light menstrual blood flow (period occurs on a regular basis but is minimal) • Oligomenorrhoea: is infrequent menses. • Menorrhagia: Excessive bleeding in amount and duration. • Hypermenorrhoea: Excessive flow in amount but at regular intervals and of normal duration
- 7. MENSTRUAL CYCLE DISODERS … • Epimenorrhoea / polymenorrhoea: periods occurring in shorter intervals than usual i.e. shorter than 21 days • Dysmenorrhoea: painful menstruation • Metrorrhagia : irregular genital bleeding. Also bleeding between periods
- 8. ORGANIC UTERINE BLEEDING CAUSES • Adenomyosis • IUCD • Systematic diseases e.g. coagulation disorders • Cervical polyps • Ectopic pregnancy • Infection • Trauma • Tumours MANAGEMENT -Treat the cause - HB monitoring and manage anemia -Psychotherapy
- 9. ABNORMAL UTERINE BLEEDING Types • Dysfunctional uterine bleeding (non organic) abnormal uterine bleeding without any physical sign on examination. • Organic uterine bleeding- abnormal bleeding with an identifiable cause
- 10. DYSFUNCTIONAL UTERINE BLEEDING • Abnormal bleeding per vaginal with no identifiable pathology. • Diagnosis- Ruled out the usual causes of vaginal bleeding through uterine biopsy, ultrasound, physical exam. • Common at the beginning and end of the reproductive years • In most cases there is unovulation.
- 11. TREATMENT • Combined oestrogen and progesterone pills for 3-6 cycles • D&C • Surgery • Anaemia management
- 12. ABORTION DEFINITION • The expulsion of the foetus before the 28th week of pregnancy.
- 13. CLASSIFICATION Abortions can be classified as follows: Depending on Cause; – Spontaneous – Induced - Therapeutic - Criminal (illegal) Depending on gestation: – Early up to 12weeks – Late between 13-28 weeks
- 14. What is the difference between miscarriage and abortion??????
- 15. Risk factors for induced abortion • Sexual activity at a young age • Lack of knowledge about family planning • Unwillingness to use family planning methods • Inability to use a contraceptive method effectively • Contraceptive failure • Lack of awareness about the harmful effects of unsafe abortion.
- 16. Risk factors for induced abortion • Low educational status • Low economic status • Previous history of unwanted pregnancy and abortion.
- 17. CAUSES OF MISCARRIAGE • Most of them are idiopathic • Foetal causes e.g. foetal abnormality structural or chromosomal, abnormal attachment of the placenta. • Maternal causes to include: Diseases like hypertension, malaria, diabetes, malnutrition Cervical incompetence
- 18. CAUSES C0NT… Structural abnormalities of the uterus. Hormonal insufficiency e.g. insufficiency production of progesterone by the corpus luteum. Drugs e.g. oxytocics, cigarette smoking and alcohol Trauma Emotional disturbance
- 19. CLINICAL TYPES/STAGES • Threatened abortion • Inevitable/ Imminent abortion • Complete abortion • Incomplete abortion • Missed abortion • Septic abortion • Recurrent/ habitual abortion
- 20. Threatened abortion Features • Minimal bleeding • Cervix is closed • Uterus is of appropriate size for gestation • Patient may feel some abdominal pain or mild pain
- 21. Management • Bed rest prn • Give mild sedatives e.g. phenobarbitone • If painful administer analgesics • Monitor:contractions, v/s,blood loss • Reassure the patient • Advice not to have sexual intercourse and any heavy physical • Advice the patient to take diet high in fibre
- 22. Possible outcomes of threatened Abortion • Inevitable abortion • Intrauterine growth retardation • Normal pregnancy
- 23. Inevitable/ Imminent abortion Features •Dilated cervix •Strong uterine contractions •Severe bleeding •Products of conception may be felt through the cervical os.
- 24. Management – Manage shock – Analgesics – If pregnancy is less than 16 weeks evacuation of uterine contents – If more than 16 weeks infuse oxytocin 40 units in 1L iv fluids at 40 drops per minute to expel then evacuate – Antibiotics administration especially for induced abortion
- 25. Complete abortion This is an abortion in which all the products of conception have been expelled Features • Pain is absent • Bleeding is slight • Cervix is closing or has closed
- 26. Management • Ultra sound to confirm that the cavity is empty • Advice the patient to report if bleeding recurs or develops fever • Check HB after 24hrs • Curettage only if bleeding persists • Antibiotics if febrile
- 27. Incomplete abortion This abortion in which some products of conception have passed (usually the fetus) but some (usually the placental tissue) has been retained. Features • Cervix is open • Vaginal bleeding which may be moderate to severe. • Abdominal pain present
- 28. Management • Manage shock if present • Administer plasma expanders, Take blood for grouping and cross matching. • Remove any placental tissue distending the cervix • Analgesics • Oxytocics • Evacuate the uterus
- 29. Missed abortion This occurs when the embryo dies but the gestational sac is retained in the uterus for several weeks or months. Feature Uterus stops growing Cervix is closed Brownish vaginal discharge.
- 30. Management • Most of them are expelled spontaneously. Empty the uterus by curettage if this does not happen. • Give psychological support
- 31. Recurrent/ Habitual abortion • This is used to refer to three or more consecutive spontaneous loss of pre-viable pregnancies. • Most of these patients will have obvious causes which include: diabetes, abnormalities of the uterus and cervical incompetence.
- 32. Septic abortion This is an abortion accompanied by infection Clinical features Fever Tachycardia Offensive vaginal discharge Tenderness in the lower abdomen General features of abortion.
- 33. Management • This is usually an emergency. The following principles are followed; -Replace blood lost Evacuation once the patient has stabilized*. -Parenteral broad-spectrum antibiotics administration. Take sample for culture and sensitivity before administering the antibiotics.
- 34. severe infection involving deep tissue: Ampicillin 2 g IV stat every 6 hours, Gentamicin 5 mg/kg body weight IV every 24 hours, Metronidazole 500 IV every 8 hours for 5 days. If infection does not involve deep tissue: Amoxicillin 500 mg orally 3 times a day for 5 days, Metronidazole 400 mg orally 3 times a day for 5 days. Gentamicin 5mg/kg body weight IV every 24hours for 5 days.
- 35. NURSING MX • Monitor urinary output to rule out any renal interference. • Monitor vital signs-rapid pulse and high temperature indicates severity of the infection. Low blood pressure, rapid weak pulse and low temp indicate shock or impending shock.
- 36. Management cont… • High fluid intake to compensate fluid loss due to fever, bleeding and also to flush the system off toxins. • Perform vulva toilet four hourly with antiseptic • Administer anti-tetanus vaccine • Position the patient in a propped up position if not in shock. This helps to localize infection • High protein ,high calorie diet to promote healing
- 37. COMPLICATIONS OF ABORTIONS Haemorrhage Sepsis Perforation of the uterus Psychological trauma Renal damage Amniotic embolism Anaemia as a result of bleeding and haemolysis of red blood cells
- 38. POST ABORTAL CARE This has 3 components; • Emergency treatment of complications arising from the abortion • Family planning counselling and services • Access to comprehensive reproductive health care.
- 39. Pelvic Congestion Syndrome • Also known as pelvic vein incompetence • A disorder characterized by chronic pain caused by ovarian vein and pelvic varices • Pain typically worsens as the day progresses and is reduced by lying • Aggravated by: Standing /sitting for long Sexual intercourse, menstruation, some physical activities e.g. cycling
- 40. Other clinical features • Enlarged uterus and a thicker endometrium. • Ovarian cysts, • Dysmenorrhea • Back pain • Abdominal bloating • Mood swings or depression • Fatigue • Varicose veins in the thigh, buttock regions, or vaginal area
- 41. Diagnosis • Venogram • Ultrasound • Laparoscopy • CT scan • MRI
- 42. Treatment • Pain medication using nonsteroidal anti- inflammatory drugs. • Hormonal medications to suppress ovarian function • Embolization through transcatheter techniques. • Surgical (e.g. laparoscopic) ligation of the ovarian vein.
- 43. Embolization
- 44. ECTOPIC PREGNANCY DEFINITION • This is a condition in which the embryo implants outside the uterine cavity e.g. tubes (most common site), cervix, abdominal cavity, ovary also called extra uterine pregnancy.
- 45. TUBAL PREGNANCY Causes •Previous inflammation in the tube e.g. acute PID which heals with scarring blocking the tube •Occlusion by peritoneal adhesions e.g. after appendicectomy •Endometriosis in the tubes •Congenital anatomical abnormalities of the tube. •Too long tubes-more than 10cm
- 46. PATHOPHYSIOLOGY When the uterus has implanted in the tube, corpus luteum remains and produces progesterone which ensures that the endometrium is not shed off.This causes amenorrhoea As the embryo continues to grow in size, it stretches the wall of the uterine tubes causing pain.
- 47. The erosion of the tubal wall by the implantation causes some bleeding into the peritoneal cavity which also causes irritation of the peritoneum resulting in pelvic pain and referred shoulder pain. Since the tubal walls are not adopted for embryo development, the tubal pregnancy results to one of the following:
- 48. Outcomes of tubal pregnancy • Tubal rupture. • Tubal mole. • Tubal abortion • Abdominal pregnancy
- 49. Acute tubal rupture/ fulminating This is sudden rupture of the tube. Characteristics • Sudden onset of lower abdominal pain • Vomiting due to sudden bleeding in to the peritoneum • Vaginal bleeding-this may be delayed until some hours later after the rupture. • Pain on moving the cervix with fingers during vaginal exam
- 50. Acute tubal rupture cont… • Patient is in severe pain • Signs and symptoms of shock to include cold skin, rapid weak pulse, low blood pressure • Very tender abdomen with muscle guarding. Signs of free fluid in the abdomen e.g. fluid thrill and shifting dullness
- 51. Chronic tubal rupture Characteristics • Lower abdominal pain usually marked on one side. • Amenorrhoea • Irregular vaginal bleeding which may be confused for threatened abortion. • Nausea and vomiting • Feeling of faintness • Anemia • Tachycardia • Low blood pressure • Tenderness and guarding in the lower abdomen
- 52. Diagnosis – Ultrasound – Culdocentesis – Urine testing for HCG
- 53. Management • This is an emergency and requires immediate medical attention. • Start the patient on plasma expanders e.g. normal saline as you wait for blood. • Take blood for grouping and crossmatching and start blood transfusion • Administer a strong analgesic • Prepare for an emergency laparatomy where salpingotomy (making an opening in the tube) or salpingectomy (excision of the affected tube)
- 55. HYDATIDIFORM MOLE The chorion degenerates in early pregnancy and form a mass of vesicles making the foetus fail to develop
- 57. Signs and symptoms • Amenorrhoea followed by: Vaginal bleeding Passage of balloon like vesicles in brown vaginal discharge Vomiting and headache Gross ankle oedema, high B.P and protenuria Larger uterus than expected Foetal heart sounds and parts not detectable Pregnancy test strongly positive
- 58. classification • Complete –has no sign of embryo and has very high risk of malignancy • Incomplete-Has some evidence of embryo and has a lower risk of malignancy.
- 59. MANAGEMENT Most will be expelled spontenously: • Manage as complete abortion. • Oxytocin • Evacuation-gentle after 5 days If not expelled: Evacuate the uterus Monitor hCG levels-Should be normal within a week. Review weekly initially then monthly for an year. This is to rule out metastasis
- 60. Complications • Malignant change • Hemorrhage • Sepsis • Pre-eclampsia • Perforation of the uterus
- 62. GENITAL PROLAPSE Definition • This is the downward displacement of the pelvic organs due to relaxation of the pelvic support
- 63. Causes • Chronic coughs • Constipation • Obesity • Traumatic deliveries • Menopause • Multiparty • Pelvic tumours • Sacral nerve disorders • Heavy lifting
- 64. CYSTOCELE • This is the herniation of the bladder through the anterior vaginal wall. Classification • Mild cystocele-the anterior vaginal wall prolapses to the introitus upon straining • Moderate cystocele- the vaginal wall extends beyond the introitus upon straining • Severe cystocele- the vaginal wall extends beyond introitus in the resting state
- 65. Features • The patient will complain of vaginal pressure • A protruding mass on vaginal examination • Urinary incontinence or incomplete bladder empting
- 66. Management Conservative management • Insertion of pesseries or tampon in the lower vagiana which provides temporally support. • Kegel exercises to improve the muscle tone. • Oestrogen administration in post menopausal women which improves tone and vascularity of the musculo-fascial support. Surgical measures • For large cystocele an anterior vagina coloporrhaphy is done
- 67. Preventive measures • Doing kegel exercises during postpartum to strengthen the pelvic muscles. • Avoid obesity • Treat chronic coughs and constipation • Avoid traumatic deliveries • Oestrogen therapy after menopause.
- 68. RECTOCELE • This is herniation of the rectum through the posterior vaginal wall Features • Usually asymptomatic • Difficult in evacuating faeces • Sensation of vaginal fullness • Presence of a soft reducible mass in the posterior vaginal wall. Management • Posterior colpoerineorrhaphy • Advice the patient to avoid straining activities, coughing, constipation and vaginal deliveries after the surgery.
- 69. UTERINE PROLAPSE Classification • 1st degree- the cervix is at the mid portion of the vagina • 2nd degree- the cervix is at the introitus • 3rd degree- the cervix is behold the introitus
- 70. Features • Sensation of fullness in the vagina • Low backache • Uterus may protrude at the introitus • Bleeding if the cervix become eroded by the drying effect • Dyspareunia • Leucorrhoea due to uterine engagement • Change in micturation patterns e.g. incomplete emptying due to bladder displacement by the uterus.
- 71. Management Medical measures • Vaginal pessaries • Oestrogen therapy post menopause • Treat any underlying cause e.g. reduce weight, malignancy, cough etc. Surgical • Vaginal hysterectomy • For 1st and 2nd degrees ,and for women of reproductive age colporrhaphy and amputation of the cervix is done. This is referred to as the Manchester repair
- 72. FISTULAE Definition • A communication between two internal hallow organs or between an internal hallow organ and the skin. Types • VesicoVaginal fistula • RectoVagianl fistula
- 73. Causes • Obstructed labour which causes necrosis due to pressure by the presenting part. • Congenital malformations • Radiotherapy for gynaecological conditions • Disease e.g. tuberculosis and tumours • Surgeries
- 74. Features • Dribbling of urine through the vagina for VVF and faeces and flatus for RVF • Large fistulas can be seen on speculum exam, small VVF can be seen on cytoscopy • Some patients may complain of lack of sexual enjoyment • Psychological amenorrhoea • Vulval excoriation • Social isolation
- 75. Management • Some recently formed fistulas heal spontaneously when the bladder is drained continuously (VVF) for about 21-28 days and also low residue diet given for the same period (RVF) • The fresh fistula requiring surgery should be repaired at once while fistulas noticed several days after injury should be repaired after 2-3 months in order to allow the local damage and infection to settle
- 76. Preoperative care • Enema on the morning of operation • Sterilize the gut with Cabbracol 500mgs BD for five days before RVF repair • Antibiotics for a few days before RVF repair • Blood for HB • Examination under anaesthesia to note the type • High protein and vitamin diet to promote healing and fitness for the operation. • Psychological support
- 77. Postoperatively • Ensure continuous drainage of the bladder for 10-14 days • Analgesics to relieve the discomfort • Antibiotics to prevent infections • High protein and vitamin diet which is low residue • Ensure perineal hygiene through perineal irrigation and douching • Liquid paraffin for RVF to avoid constipation
- 78. INFERTILITY Definition • This is the apparent inability to achieve conception for one year of normal intercourse.
- 79. TYPES • Primary infertility • Secondary infertility
- 80. General factors affecting fertility • Age • Nutrition • Health • Drugs • Psychological factors e.g. anxiety • Ignorance of coitus and some cases excessive coitus
- 81. Female factors affecting fertility – Structural abnormalities e.g. Mullerian agenesis – Tubal blockage – Endocrine disoders – Uterine fibroids – Cervical hostility where the cervical mucus is hostile to spermatozoa – Cervical incompetence which leads to secondary infertility due to abortions – Endometriosis
- 82. Male factors affecting fertility • Structural abnormalities e.g. hypospadias, undescended testes • Impotence • Oligospermia and azoospermia
- 83. TREATMENT OF INFERTILITY • Thorough assessment in order to identify the cause and treat • Emphasize to the couple if no abnormality if found that pregnancy is possible even after many years. • Assisted reproduction-In vitro fertilization, Artificial insemination
- 84. TREATMENT OF INFERTILITY • Counsel the clients on general measures to include 1. Good diet and exercise 2. Avoid excessive consumption of alcohol, caffeine and tobacco. 3. Avoid excessive coitus 4. Have adequate sleep 5. Advice on weight loss if obese 6. Avoid excessive or prolonged exposure of the scrotum to heat e.g. hot bath, tight underwear or prolonged sitting in hot environment
- 85. PELVIC INFLAMMATORY DISEASE Definition: • Its infection of the upper genital tract-uterus, fallopian tubes and the ovaries. Causative micro-organisms • Gonococci • Staphylococci • Streptococci • Tubercle bacilli • E. coli
- 86. Sources • Through blood spread e.g. Tuberculosis • Direct spread e.g. from the endometrium to the fallopian tubes • Via lymph • Ascending infection from lower genital tract • Introduction by contaminated instruments e.g. during abortions and pelvic operations
- 87. Clinical features • General signs of infection e.g. fever, malaise, vomiting, anorexia • Lower abdominal pains • Purulent vaginal discharge • Vaginal bleeding may be present
- 88. Management • Antibiotics • Avoid intercourse, douches as this may worsen the infection process • Position in semi fowlers to enhance downward drainage • Analgesics • Document the amount, type, odor etc. of the vaginal discharge • Maintain perineal hygiene by sitzs baths and cleaning of the perineum frequently.
- 89. MANAGEMENT CONT.. • Surgery to drain abscesses in acute cases and for removal of pelvic organs in chronic cases if treatment is unsuccessful • Psychological support to the client since PID may be caused by STI, there may be guilt feelings • Health information provision on hygiene and how to prevent a recurrence. • Balanced nutrition high in fluid and proteins • Adequate rest and exercise
- 90. ENDOMETRIOSIS Def; • Is an abnormal condition in which the endometrial tissue is located in other tissues. Pathophysiology • Despite the location, the Ectopic endometrial tissue responds to hormonal changes hence there is cyclic bleeding in the affected organs .This causes inflammation and scarring resulting in adhesions formation.
- 91. Clinical features • This relates to the location • General features include -pain that begins just before menstruation, lasting during menstruation and some times for a few days after -dyspareunia -menstrual irregularities -infertility -cyclic bleeding from the rectum/ hematuria etc.
- 92. Diagnosis • History of cyclic bleeding e.g. from the rectum, scar • Pelvic examination • Laparoscopy
- 93. Management • Analgesics • Hormonal therapy e.g. contraceptive pills, danazol • Surgical management-removal of the Ectopic endometrial tissue. More radical surgery involving removal of the uterus and the ovaries.
- 94. Polycystic ovary syndrome • Involves disruption of the menstrual cycle and a tendency to have high levels of male hormones (androgens) that is causes by increased production of luteinizing hormone. • It gets its name from the many fluid-filled sacs (cysts) that often develop in the ovaries, causing them to enlarge.
- 95. Symptoms • Develop during puberty and worsen with time. Symptoms vary from woman to woman. • Primary Amenorrhoea • Irregular vaginal bleeding • Unovulating. • Masculinization or virilization. Symptoms include acne, a deepened voice, a decrease in breast size, and an increase in muscle size and in body hair (hirsutism). • Most are obese.
- 96. Diagnosis Is based on symptoms. Blood tests to measure levels of hormones such as follicle-stimulating hormone and male hormones are done. Ultrasonography is done to see whether the ovaries contain many cysts and to check for a tumor in an ovary or adrenal gland.
- 97. Treatment • Exercise • Decrease carbohydrate intake • Metformin • Clomiphene • Other fertility drugs if above fails • Remove unwanted hair • OCP for those who don’t want pregnancy.
- 99. CLASSIFICATION Classification is by: The organ affected: Uterine, cervical, ovarian, breast, vulva and vaginal Type of tumor i.e. if malignant or benign
- 100. Differences between Benign and Malignant tumours • Benign usually grow very slowly, while malignant grow more quickly in size. • Benign are well circumscribed while malignant have irregular edges • The cells of a benign have less dysplasia and anaplasia compared to malignant cells • Benign don’t metastasize, Malignant do • Benign don’t invade surrounding tissues, Malignant do • Benign rarely changes colour or cause Ulceration like Malignant • Benign are usually encapsulated but malignant never have capsules.
- 101. FIBROIDS
- 102. • Definition: Common benign tumors develop in the muscular wall of the uterus. • Also referred as leiomyoma, leiomyomata, myoma and fibromyoma. • They are mainly made of muscle cells
- 104. TYPES/SITES
- 105. Clinical features • Changes in menstruation: menorrhagia, dysmenohorrea, metrorrhagia • Pain in the lower abdomen/lower back/legs • Dyspareunia • Difficulty or frequent micturition • Constipation, rectal pain, or difficult bowel movements • Abdominal cramps • Enlarged uterus and abdomen • Miscarriages • Infertility • Pelvic pressure
- 106. Diagnosis Ultrasound Others: •Hysteroscopy •Hysterosalpingography:A special X-ray •Laparoscopy: for fibroids on the outer side of the uterus. •MRI •CT Scans
- 107. Management Fibroids require treatment only if; •Heavy or painful menstrual periods that cause anemia or that disrupt a woman’s normal activities •Bleeding between periods •Uncertainty whether the growth is a fibroid or another type of tumor •Rapid increase in growth of the fibroid •Infertility •Pelvic pain
- 108. Management • Drug therapy for pain and abnormal bleeding • Uterine Fibroid Embolization • Hysterectomy and myomectomy
- 109. Drug Therapy • Hormonal contraceptives ; to control heavy bleeding and painful periods. • Gonadotropin-releasing hormone (GnRH) agonists—These drugs stop the menstrual cycle and can shrink fibroids. They sometimes are used before surgery to reduce the risk of bleeding • Progestin–releasing intrauterine device—This option is for women with fibroids that do not distort the inside of the uterus. It reduces heavy and painful bleeding.
- 110. Uterine Fibroid Embolization • A radiological procedure that blocks flow to fibroids in the uterus using embolic agents
- 111. HYSTERECTOMY
- 112. Indications • Abnormal uterine bleeding unresponsive to medical management • long-term pelvic pain • Tumours
- 113. Types: organs affected • Total hysterectomy – the uterus and cervix are removed. • Subtotal hysterectomy – the uterus is removed cervix in place • Total hysterectomy with bilateral salpingo- oophorectomy – the womb, cervix, fallopian tubes (salpingectomy) and the ovaries (oophorectomy) are removed • Radical hysterectomy – the womb and surrounding tissues are removed, including the fallopian tubes, part of the vagina, ovaries, lymph glands and fatty tissue
- 114. Types: route used There are three ways to carry out a hysterectomy: •Vaginal hysterectomy – where the uterus is removed through an incision in the top of the vagina •Abdominal hysterectomy – where the uterus is removed through an incision in the lower abdomen •laparoscopic hysterectomy (keyhole surgery) – where the uterus is removed through several small incisions in the abdomen.
- 115. Pre-operative management • Advised to quit smoking 2 to 6 weeks before surgery. Smoking may cause breathing problems during surgery and delay healing. • Patient teaching on the procedure • Pain management • NPO for 6 hours • Laxative or enema PRN to empty the bowels before surgery • Cleanse the abdominal and perineal area and shave the perineal area PRN
- 116. Post operative management • Monitor vital signs every 4 hours, auscultate lungs every shift and measure intake and output. These data are important indicators of hemodynamic status and complications. • Assess for complications, including infection, ileus, shock or hemorrhage, thrombophlebitis, and pulmonary embolus. • Assess vaginal discharge; instruct the woman in perineal care. • Assess bowel sounds every 4 hrs . • Encourage turning, coughing, deep breathing, and early ambulation
- 117. Post operative management cont… • Encourage fluid intake. • Teach to splint the abdomen and cough deeply. • Instruct to restrict physical activity for 4 to 6 weeks. Heavy lifting, stair climbing, douching, tampons, and sexual intercourse should be avoided. The woman should shower, avoiding tub baths, until bleeding has ceased • Pain Management • Antibiotics to prevent infection • Psychotherapy
- 118. Patient teaching post hysterectomy Side effects 1.Fatigue and general weakness for a while. 2.Nausea and vomiting. 3.Loss of appetite 4.Constipation 5.Loss of bladder control 6.Amenorrhea 7.Hot flashes, vaginal dryness and night sweats
- 119. • Avoid heavy lifting • Sexual activity • Signs of complications • Follow up care
- 120. UTERINE CANCER
- 121. Risk Factors to Uterine Cancer • Endometrial hyperplasia • Obesity • Early menarche before 12 years • Late menopause after 55yrs • Null parity • Estrogen therapy • Tamoxifen a drug used in treatment and prevention of breast cancer
- 122. Risk factors continued • Radiation therapy to the pelvis • Family history of uterine/colorectal cancer • Ovarian tumors that release estrogen • Polycystic ovarian syndrome • A high-fat diet; can cause obesity and also affect estrogen metabolism • History of breast and ovarian cancers • Increasing age > 50yrs
- 123. Factors that reduce risk of uterine Cancer • Combine oral contraceptive pills • Pregnancy • Use of an intrauterine device • Physical activity
- 124. Clinical features • Abnormal vaginal bleeding • Pelvic pain • Dyspareunia • Dysuria
- 125. Diagnostic procedures • Pelvic physical exam • Ultra sound • Biopsy for histology (confirmatory)
- 126. Metastasis diagnostic procedures - Pap smear: check if it has spread to cervix - Blood tests for liver and kidneys functions, and CA-125 test. Cancer cause a high level of CA-125. - Chest xray: check for lung metastasis - CT scan: Pelvis, chest, abdominal to detect metastasis to these organs and lymph nodes. - MRI
- 127. Staging A stage of a cancer indicates the extent of the disease .Staging is based on whether the cancer has invaded nearby tissues or spread to other parts of the body.
- 128. UTERINE CANCER STAGING stage 0 - carcinoma in situ stage I - limited to the body of the uterus • Ia - no or less than half myometrial invasion • Ib - invasion equal to or more than half of the myometrium stage II - cervical stromal involvement NB/ endocervical glandular involvement only is stage I stage III - local or regional spread of the tumour - IIIa - tumour invades the serosa of the body of the uterus and or adenexae - IIIb - vaginal or parametrial involvement - IIIc - pelvic or para-aortic lymphadenopathy – IIIc1 - positive pelvic nodes – IIIc2 - positive para-aortic nodes with or without pelvic nodes stage IV - Involvement of rectum and or bladder mucosa and or distant metastasis -IVa - bladder or rectal mucosal involvement -IVb - distant metastases , malignant ascites, peritoneal involvement FIGO 2009
- 129. CERVICAL CANCER
- 130. RISK FACTORS • Human papilloma virus infection • Smoking. • Immunosuppression • Using contraceptive pills for five or more years. • Multiparity. • Having several sexual partners. • Chlamydia infection • A diet low in fruits and vegetables • Obesity • Being younger than 17 at first pregnancy/first intercourse • Diethylstilbestrol (DES) a hormonal drug that used to prevent miscarriage • Having a family history of cervical cancer • Systemic lupus erythematosus or rheumatoid arthritis
- 131. Clinical features • Abnormal vaginal bleeding, • Abnormal foul smelling vaginal discharge • Dyspareunia • Bladder and rectum involvement: constipation, hematuria, fistula, ureteral obstruction, urinary incontinence • The triad of leg edema, pain, and hydronephrosis suggests pelvic wall involvement
- 132. Clinical features cont… • bone pain • loss of appetite • weight loss • tiredness and a lack of energy
- 133. Diagnosis • Colposcopy • Biopsy Cystoscopy and proctoscopy to check invasion of the bladder and the colon Screening is done through Papanicolaou (Pap smear) testing and VIA VILLI (visual inspection with acetic acid (VIA), Lugol's iodine (VILI) 25 years and below : No screening recommended 21-29 years : Every 3 years 30-65 years –Every 5 years >65 years – No screening recommended if adequate prior screening has been negative and high risk is not present.
- 134. CERVICAL CANCER STAGING stage 0: cervical intraepithelial neoplasia (CIN III) stage I: confined to cervix – stage Ia: invasive carcinoma only diagnosed by microscopy. – Ia1: stromal invasion <3 mm in depth and <7 mm in extension – Ia2: stromal invasion >3 mm depth and not >5 mm and extension <7 mm – stage Ib: clinically visible lesions limited to the cervix or pre-clinical cancers >stage 1a – Ib1: clinically visible tumour <4 cm in greatest dimension – Ib2: clinically visible tumour >4 cm in greatest dimension stage II: beyond cervix though not to the pelvic sidewall or lower third of the vagina. – stage IIa: involves upper 2/3rd of vagina without parametrial invasion – stage IIa1: clinically visible tumour <4 cm in greatest dimension – stage IIa2: clinically visible tumour >4 cm in greatest dimension – stage IIb: with parametrial invasion •stage III – stage IIIa: tumour involves the lower third of the vagina with no extension to pelvic sidewall – stage IIIb: extension to pelvic side wall or causing obstructive uropathy, MR imaging findings that are suggestive of pelvic sidewall involvement include tumour within 3 mm of or abutment of the internal obturator, levator ani, and pyriform muscles and the iliac vessel 6 •stage IV: extension beyond pelvis or biopsy proven to involve the mucosa of the bladder or the rectum – stage IVa: extension beyond pelvis or rectal/bladder invasion – stage IVb: distant organ spread FIGO 2009
- 135. Management • Surgery • Radiation therapy • Chemotherapy • Hormone therapy Depends on: – Stage of the tumour – Grade of the tumor – Age and general health of the patient
- 136. Side effects of radiotherapy • Side effects depend on; Type of radiation therapy Amount of radiation Type of body part is treated.
- 137. External radiation cause: – Nausea, vomiting, diarrhea, or urinary problems. – Also loss of hair in genital area. – Skin changes in the treated area like reddening, dryness and tenderness. – Amenorrhea – Hot flashes and other features of menopause – Dryness, itching, or burning in the vagina
Editor's Notes
- #53: Mostly is asymptomatic