FAMILY PLANNING

Objectives

 By the end of this session students

will be able to:

 Define the term gynaecology

 Define the term family planning

 Classify different methods of

family planning with their modes of

action
  Understand advantages and

disadvantages of different methods

of family planning

 Understand indications,

contraindications and side effects of

different methods of family planning

 To provide family planning care

based on individual needs

Definition of Gynecology

Etimology; the word “gynecology‘’comes

from the greek ‘’gyn’’which means

woman and logia, study.

It is a medical practice dealing with the

health of the female reproductive

systems (vagina, uterus and ovaries) and

breast.

Definition of family planning

It is defined as the practice of having

children by choice and not by chance,

It involves spacing of births for the

optimum health of all family members.

Family planning policy does not

discriminate men; they also have great

roles to play for the success of care.

 Unplanned pregnancies constitute

major public health problems .The

United Nations International Children's

Emergency Fund (UNICEF) estimates

that over 800,000 women worldwide die

each year as a result of pregnancy and

pregnancy-related causes and an

additional 15 million women are

severely disabled by pregnancy.

Countries in which women utilize

contraception have lower birth rates

and the lowest rates of maternal

mortality. Every method of birth control

prescribed is safer than pregnancy.

Benefits of family planning

 Family planning enables sexually

active couples to prepare for their

pregnancies, in order to optimize

both fetal and maternal outcomes

 Helps predict population Growth.

 Helps the couple prepare for their

children

 Avoids unwanted pregnancies

 Avoids associated complications

of pregnancy such as; anemia, poor

health mothers, cesarean section and

its complications, maternal child

deaths, etc.

 Reduces maternal mortality rate

 Ensures adequate breastfeeding

for the child

 Adequate love and care for the

child so the family has time to

concentrate on other income

generating activities

 Some of the methods are

protective against HIV and other STIs

  Strengthens child’s immunity and

increases chance of child survival

 Improves standards of living

Characteristics of a good family

planning method

 It should be effective

 No side effects

 Independent of sexual intercourse

 Should not require health

professional for use

 Should be widely available

 Should be readily distributed

 Cheap
  Acceptable to all cultures and

religions

 Should be readily reversible

Classification of family planning

methods

There are 2 broad types of family

planning:

 Non hormonal methods

 Hormonal methods

NON HORMONAL METHODS

They are so-called because they are not

manufactured with hormone basis.

These include:

Fertility awareness method, couples use

another method (usually condoms)

during the woman's fertile days.

Periodic abstinence, abstaining from

sexual intercourse during woman’s

fertile time.

Calendar or rhythm

Observing fertility signs like:

 Basal body temperature, there

is an increase of 0.2-0.8oC above

the normal individual body

 temperature with the absence of

any infection.

 Cervical mucus (billings), the

method uses changes in the

cervical mucus secretions as

affected by menstrual cycle,

hormonal alterations to predict

ovulation.

The cervical mucus may be thin and

watery, whereas, at other times the

mucus is thick and opaque.

Advantages
  Readily available

 Low cost

 Relative simplicity and lack of

sharting requirement

 Safe and free from side effects

Disadvantages

 It may be hard to control,

difficulty in evaluating mucus in

the presence of vaginal infection

and the reluctance of some

women to evaluate such

secretions.
  The couple needs to maintain

fidelity

Barrier methods, barrier methods work

by preventing the passage of sperm into

the female genital tract. Female barrier

methods include the diaphragm, cervical

cap, FemCap, and the condom to both

females and males and Spermicides

Male and female condom

A condom is a latex sheath put on an

erect penis before coitus and worn

during coitus.

Mechanism of action of condom

 Acts as a barrier, preventing sperm

from entering the female genital tract

For condoms that are coated with

spermicide, the spermicide immobilizes

and kills sperm.

Advantages of male and female condom

 Effective when used correctly

(95 - 97%).

 Helps to prevent spread of STIs

including HIV

 Easy to obtain (can easily be

distributed by Community Based

Health Workers and commercial

sector)

 Planning, STI and HIV

prevention

 Probably protects women from

development of Intra-epithelial

Neoplasm, i.e. cervical cancer;

 Easy to use

 Usually inexpensive

 Safe, effective, and portable

 Helps some men with

premature ejaculation to maintain

erection
  Convenient when short-term

contraception is required

 Safe, no side effects

Disadvantages

 Allergic reactions in some

individuals

 Reduce the quality of sex

 Requires male partner

cooperation

 Can be damaged by exposure

to oil-based lubricants, heat,

humidity or light
 May decrease sensitivity for

man so that intercourse is not as

enjoyable

 Small possibility of slipping or

tearing during sexual intercourse,

especially among

 Necessary to interrupt sexual

act to put condom on erect penis

 Can deteriorate if not properly

stored, e.g. in too much heat,

sunlight or humidity

 Some men cannot maintain an

erection with a condom on

  Some men have rare latex

allergy

 User must be highly motivated

to use consistently and correctly

Spermcides

Vaginal spermicides come in the form of

foam, cream, jelly, tablet or suppository

and is inserted

Into the vagina just before sexual

intercourse to prevent pregnancy.

Mechanism of action of spermicide

 Inactivates and kills sperm;

  Blocks path of sperm to the

uterus.

Effectiveness of spermicides

 Fairly effective, depending on

the user (79-97%);

 If used with condom,

effectiveness is 99%;

 Effectiveness lasts only 30 to 40

minutes after insertion.

Advantages of spermcides

 Can be obtained without a

prescription
 Can be kept available for

immediate protection

whenever needed

 Can provide additional

lubrication during intercourse

 Can be made more effective

if used with condoms

 Is a simple back-up option

for a woman who is waiting to

start oral contraceptives or

have an IUD inserted, for a

woman who forgets two or

 more Pills or runs out of Pills,

or for an IUD user who

suspects her IUD has been

expelled

 Can be used as an

emergency measure if a

condom breaks, An application

of spermicides should be

quickly done in this instance.

Disadvantages and side effects

 May interrupt sexual

intercourse (forsuppositories or
Foaming Tablets, must allow 10

minutes for dissolving before they

will be effective)

 Must be used before each act of

sexual intercourse

 Causes more wetness of vagina

for several hours after

intercourse;

 A few women are sensitive or

allergic to spermicide and develop

irritation and discomfort,

especially with frequent use;

 Effectiveness rates are lower in

preventing pregnancy than the

IUD, Hormonals;

 Some women develop Candida

Vaginitis when they use

spermicides.

 Much less effective than most

other modern methods

 Can increase urinary and yeast

tract infections in women

 Can be messy, cause mild

discomfort or minor allergic

reaction
Lactational amenorrhea method –

LAM, this is the prevention of

conception through exclusive

breastfeeding.

Mechanism of action: Suckling

stimulate the a reduction in the release

of gonadotropin releasing hormone,

luteinizing hormone (LH), and follicle

stimulating hormone (FSH).

-Endorphins induced by suckling also

induce a decline in the secretion of

dopamine, which normally suppresses

the release of prolactin. This results in a

condition of amenorrhea and

anovulation

Advantages:

 For the mother:

 Does not interfere with sex

 Create good relation with the

baby

 Low cost

 No side effects

 Effective when the woman

keeps exclusive breastfeeding,

cumulative pregnancy rate ranges

 from 0.9–1.2%. However, at 12

months, pregnancy rates rose as

high as 7.4%.

For the baby:

 Protects the baby from life

threatening diseases (immunity)

such as diarrhea and bacterial,

fungal and viral infections

 It is a major factor for normal

growth and development

Disadvantages

For the mother:

  Effectiveness stops after 6

months and exclusive

breastfeeding is very paramount,

the failure to comply exposes the

mother to unwanted pregnancy.

 No protection against HIV/AIDS

and STDS to both mother and

baby.

For baby:

 Affects the health of the baby if

mother’s nutritional status is

poor.
Withdrawal or coitus interruptus,

this requires that the man moves his

penis away from the woman's genitalia

prior to ejaculation.

Advantages

 Low cost

 Does not impair with sex

 No side effects

Disavantages

 Not easy to comply with

 Requires discipline and self-

control
  Emergency contraception can

be used as a backup

 Does not protect against

STIs/HIV

 Least effective method

Surgical methods,( vasectomy in

males and tubal ligation in females)

Male-Vasectomy, it is a permanent

operation in the male where a segment

of vas deferrens of both sides are

resected and the cut ends are ligated.

Female -Tubal ligation, which is

interruption of continuity of fallopian

tubes.

Advantages

 Simple surgical procedure

 Can be done as out- patient

procedure.

 Few complications.

 Reversal anastomosis easier

50% chance of success.

 It is highly effective; failure

rate is minimal (0.15%).

  It does not interfere with

sexual life

 The operation is performed

under anesthesia so it is not

painful

Disadvantages

 It does not provide protection

against HIV and STDs.

 A reversal is very expensive

 Desired family size

 Sometimes it involves some

important family member’s

consent.
 Injury to internal organs

 Anaesthesia risks

 Post surgical complications

such as Infection and bleeding

 Additional contraception is

needed for about 2-3 months

following i.e. till semen becomes

free of sperm

 Impotency

 Frigidity(Sexual

unresponsiveness ,especially of

women and inability to achieve

orgasm during intercourse)

  Stigma

Important points to think about before

the use of a permanent contraception

 Counceling

 Reasons for choosing permanent

methods

 Screening for risk indicators for

regret :

 Young Age

 Low Parity

 Single Parent Status

 Marital Instability.
  Completion of informed consent

process

 Details of the procedure

 The possibility of failure

 If a patient has a positive

pregnancy test result after a tubal

ligation, ectopicpregnancy should be

ruled out.

 The need to use condoms for

protection against sexually

transmitted diseases.

Intra uterine contraceptive device

(IUCDs), these are Flexible, plastic

devices that are placed in a woman’s

uterus to prevent pregnancy and

renewed in 3-5 years. They are made of

Copper impregnated with gold, silver,

and stainless steel.

Various design types:

 The Copper T 380A (the most

common IUD in Uganda) is a T-

shaped device with Copper on the

stem and the arms of the T.Its

duration of effectiveness is 10 years

and its shelf life is 7 years.

 Multiload 375 lasts 5 years

Mechanism of action

 Makes the endometrium

unsuitable for implantation of

fertilised ovum

 Copper emits metal ions that are

spermicidal

Advantages

 Very effective, 99-99.5%

 Highly effective & works

instantly

 A long term method

  No interference with

intercourse

 Immediate return to fertility

upon removal.

 Few side effects

 No supplies needed by client.

Disadvantages and side effects

 Mild cramps during the first

few 3-5 days post-insertion;

 Longer and heavier menstrual

blood loss in the first 3 months

 Increased cramping pain

during menses
 Provider dependent for

insertion & removal

 Need to check for strings after

menstruation

 Increased bleeding in first few

months

 May be spontaneously expelled

 Uterine perforation; very rare

(1:1000)

 May increase risk of pelvic

inflammatory diseases (PID)

 Pain especially with large

devices
 Increased menstrual loss;

intermenstrual spotting may

also occur.

 Expulsion especially in 1st 6

months during menses

 Translocation to peritoneal

cavity or broad lig.

 Pregnancy & increased risk of

ectopic pregnancy

 No protection against STI/HIV,

ovarian, endometrial cancer or

cervical cancer
When to insert an intrauterine device

(IUCD)

 During or immediately after

menstruation

 At a postnatal examination

 After termination of a pregnancy

Contraindications

 Pregnant women or those

suspected to be

 Women with menorrhagia or

abnormal bleeding
  Women with PID, current or in

past 3 months

 Purulent per vaginal discharge,

gonoccoccal or chlamydial.

 Malignant trophoblastic disease

(trophoblast: The outer layer of the

fertilised ovum which attaches the

ovum to the wall of the uterus and

supplies nutrition to the embrio)

 Pelvic tuberculosis

 Women with genital tract cancer

Dual method use

Means - Use of two methods

Mainly to enhance protection from STI

and HIV/AIDS and pregnancy

Examples:

 Dual Method; Use of other

methods e.g. norplant, injectables,

intrauterine devices & OCs as

primary methods for pregnancy

prevention; and then condom for

STI, HIV&AIDS prevention

 Alternative Approach; Use of

condom as primary method for

STI, HIV and pregnancy

 prevention, and then emergency

contraception (Pills)if condom is

not used, or it breaks or slips

Post coital douche

Plain water,vinegar and a number of

feminine hygiene products are widly

used as post coital douches

Mode of action

Theorically the douche flushes the

semen out of the vagina and the additive

water may possesse some spermicidal

properties.
Advantages

 Simple technique

 No interaction with the physiology

of the system

Disadvantages

 The method is ineffective and

unreliable

 The products reduce the normal

flora of the vaginal mucus hence

expose to some infection of the

vulva, vagina even the deep

 structure of the female

reproductive system

Vaginal Diaphragm

Diaphragm is a mechanical barrier

placed between the vagina and cervical

canal .They are designed to fit in the cul-

de-sac and cover the cervix.

The contraceptive jelly or creams should

be placed on the cervical side of the

diaphragm before insertion because the

device itself is ineffective. Again, this

medication serves as lubricant for

insertion of a device.

The device is inserted 6 hours prior to

intercourse and should be left in place 6-

24 hours after intercourse

Advantages

 Easy to use

 It offers some protection against

STDs

 Well used, it protects from

conception with the failure rate as

 low as 6% of women per year of

exposure.

Disadvantages

 It require fitting by a well trained

medical professional

 Fitting may loose during

intercourse

 It cannot be effective in women

with significant pelvic relaxation,a

sharply retroverted or anteverted

uterus or shortened vagina.

Side effects
  Vagina irritation

 Increased risk of urinary tract

infection due to pressure of the rim

against the urethra and alterations

in the composition of vaginal

normal flora

Cervical Cap (CAP)

Cervical caps, are small cuplike

diaphragms placed over the cervix that

are held in place by suction .To provide

a successful barrier against the sperms,

they must be tightly fit over the cervix

therefore, individualization is essential

because of variability in cervical size.

It has few advantages because

Unpleasant odor often develops after

approximately 1 day of use

Dislodgment (as in diaphragm)

The cup should remain in place 1 or 2

days before intercourse and should be

left in place for 8 -48 hours after

intercourse.
HORMONAL CONTRACEPTIVE

METHODS

Hormonal contraceptive refers to birth

control methods that act on the

endocrine system (hormones).

Almost all methods are composed of

steroids hormones. Hormonal

contraceptive methods are highly

effective when used according to the

right prescription and schedule .The

contraception rates are usually around

0.3% or less .Currently Hormonal

contraceptive method is only applied for

women, its use in males is still not yet

discovered .

There are two main types of hormonal

contraceptive formulations:

 Combined hormonal

contraceptive methods which contain

both estrogen and progestin thus,

they are called combined oral

contraceptives (COCs)

 One which contains only

progesterone or one of its synthetic

analogues (Progestins) thus, it is

 called progestogen-only pills (POPs)

method.

Mechanisms of action

Combined methods work by:

 Suppressing the ovulation

(oestrogenic effect)

 Thickening cervical mucus

making it difficult for the sperms to

penetrate and enter the uterus

 Making the endometrium

unsuitable for implantation of

 fertilized egg (thin and atrophic due

to constant progestogenic action)

 Reduce sperm transport in upper

genital tract (fallopian tubes).

The progestogen only pills methods

 Reduces the frequency of

ovulation

 Thickening the cervical mucus

making it difficult for the sperms to

penetrate and enter the uterus

 Partially inhibits ovulation

Combined oral contraceptive methods

Effectiveness

 92 – 99.9% effective, depending on

user compliance

 In very young women, typical

effectiveness can be as high as 95.3%

Failure rates decline as duration of

use increases;

 Failure rates decline as age of user

increases

 Failures may be due to:

 Method failure

 Client error
  Service provider not giving

complete and/or correct information

 Drug interactions (Enzyme

inducers drugs )

 Severe vomiting/diarrhea

 Expired Pill

Advantages

 Are very effective if taken

correctly

 Effective immediately

 Are easily reversible

 Few side effects

 Convenient and easy to use

 Do not interfere with intercourse

 Cause periods to be regular and

predictable

 May improve anemia

 Reduce dysmenorrhea and

premenstrual tension

 Protect against ovarian and

endometrial cancer, and some causes

of (Pelvic Diseases Infections)PID

 Reduce risk of ovarian cysts,

benign breast disease, and ectopic

pregnancy
  Can be provided by trained non-

medical staff.

Disadvantages

 Effectiveness depends on client

remembering to take pill everyday;

strong motivation needed to take

pills correctly/day

 Increases chances of promiscuity

 Candida vulvitis and vaginitis due

to an environment that mimicks that

of pregnancy

 Thromboembolism
  Benign and malignant tumours of

the liver

 Require regular and dependable

supply

 Reduces breast milk, especially in

the first 6 months after delivery and

is therefore not the most appropriate

choice for lactating women (unless

no other method is available and

there is a high risk of getting

pregnant);

Indications
 Women who require a highly

effective method

 Women who want an easily

reversible method. There is no

evidence that COC causes a loss of

fertility. Some women may

experience a short delay (on average

2-3 months) in becoming pregnant

compared to the length of time it

would have taken if she had not been

on the COC. Most women will

conceive soon after stopping the COC,

and should be provided with another

method if an unwanted pregnancy is

to be avoided;

 Non-breastfeeding women or

breastfeeding women after 6 months;

 Women who are anaemic and

have heavy menstrual bleeding.

Because COCs reduce menstrual

blood loss, users may lose only one-

third to one-half the blood iron lost

by women not on COCs during

menstruation;

 Women with history of ectopic

pregnancy; COC consistently prevents

ovulation and thus prevents ectopic

pregnancy

 Nulliparous woman; COC provides

temporary, reversible protection for

women wishing to postpone first

pregnancy. COC considered

extremely safe for young women and

far safer than pregnancy. Return to

fertility is usually within 2-3 months;

 Women with history of benign,

functional ovarian cysts; COC

prevents ovulation and usually

prevent large ovarian cysts from

forming

 Women with family history of

ovarian cancer (mother/sister); COCs

provide protective effect against

epithelial ovarian and endometrial

cancer (which can be hereditary by

nature). Even one year of COC use

reduces the risk of endometrial

cancer by about 50%, and of ovarian

cancer by 40% after only 3-6 months

of use.
 Women with menstrual cycle

symptoms (heavy bleeding/severe

cramping/ovulation pain,

premenstrual syndrome). COCs

decrease many of these symptoms,

flow is often painless and lighter, and

cycles become more regular

 Women who have irregular

menstrual cycles; women with

history of irregular menstrual cycles

will find they become quite regular

on COCs. However, causes of

 irregular bleeding should be

determined before beginning COC

Contraindications

Absolute Contraindications

 Cardiovascular diseases (past or

present) such as :

o Aterial/Venous thromboembolism,

severe hypertension, alvula

disease, ischaemic heart disease,

hyperlipidaemia, focal migraine.

  Liver disease; e.g history of

cholestatic jaundice in pregnancy,

ademona, cancer.

 Others:

o Pregnancy, undiagonise per vaginal

bleeding, oestrogen dependant

neoplasms e.g cancer of breast.

Relative contraindications

 Obesity, varicosities, epilepsy,

asthma, mood disorders, nursing

mothers in the Ist 6 months, smoking,

gall bladder disease.

Side effects of COCs

Major

 Hypertension, Venous

thromboembolism, cholestatic

jaundice.

Minor

 Can be due to oestrogen (OGN),

Progestin (PGN) or both.

 Nausea, Vommiting, headache, leg

cramps, mastalgias, weight gain,

chloasma & acne, break through

 bleeding, hypomenorrhea,

amenorrhea, leucorrhea and

decreased libido.

Danger signs of COCs

 Acute abnormal pain;

 Severe headaches with blurred

vision;

 Pain in the chest with difficulty in

breathing;

 Pain in the cap muscles.

Indications for withdraw

 Severe migraine,
  Visual disturbance,

 Sudden chest pain,

 Severe cramps,

 Excessive weight gain,

 Severe depression,

 Patient wanting pregnancy,

 Awaiting major surgery.

Drug interaction

 Decrease effectiveness of:

methyldopa, oral anticoagulants, oral

hypoglyceamics.
 Increases effectiveness of; B

blockers, corticosteriods, diazepam,

aminophylline, alcohol.

 Other drugs; increase the

metabolism of COC e.g

phenobarbitone, antiepileptics except

sodium valporate and clozepam,

rifampicin, griseofulvin,

spironolactone and ketoconazole

WHO Medical Eligibility Criteria for

Contraceptive Use.
Category 1: A condition for which

there is no restriction for use of the

contraceptive

Category 2: A condition where the

advantages of using the method

generally outweigh the theoretical or

proven risks

Category 3: A condition where the

theoretical or proven risk outweigh

the advantages of using the method.

Category 4: A condition that

represents unacceptable health risk if

the contraceptive is used.

Who can use only if more appropriate

methods are not available (WHO class3)

 Women with high BP (greater

than 160/100 but less than 180/110)

and no vascular disease.

 Women with symptomatic gall

bladder disease.

 Women age 35 yrs or older and

light smokers (under 20 cigarettes a

day)

 Women taking drugs for epilepsy

or anti-TB.
 Women with unexplained vaginal

bleeding (only if serious problem

suspected)

 Women who are fully b/feeding (6

wks to 6 months postpartum)

 Women who are not b/feeding

who are less than 3 weeks

postpartum.

 Women with h/o breast cancer

and no current evidence of the

disease.

Who should not use COCs (WHO Class 4)

 Women with hypertension: blood

pressure diastolic above 110 mm Hg.

The health risk/benefit ratio is

dependent upon the severity of the

condition

 Women with current or history of

cardiac disease (heart disease or

stroke). Among women with

underlying vascular disease due to

thrombosis, the increased risk of

thrombosis with COCs should be

avoided;
 Women with thrombo-embolic

disease (current and a history of or

major surgery with prolonged

immobilization). The increased risk

of venous thromboembolism

associated with COCs should have

little impact on healthy women, but

may have a big impact on women

otherwise at risk for it;

 Women within 2 weeks of child

birth (Postnatal) and within 4 weeks

or elective surgery;
 Women with known or suspected

cervical cancer. Theoretical concern

that COC use may affect prognosis of

the existing disease. In general,

treatment of these conditions renders

a woman sterile;

 Women who are pregnant. As no

method is indicated, any health risk

is considered unacceptable.

However, there is no known harm

from COCs;

 Women with undiagnosed breast

lumps or breast cancer. Breast cancer

is a hormonally sensitive tumour.

The risk for progress of the condition

may be increased among women

with current or past history of breast

cancer;

 Women who are taking long-term

drugs that could affect the pill's

efficacy. Commonly used liver

enzyme inducers are likely to reduce

the efficacy of COCs. Drugs which

affect liver enzymes are the antibiotic

rifampicin (note that other

antibiotics will not affect pill

efficacy), other drugs where another

method should be used are:

o griseofulvin, and

anticonvulsants (such as

phenytoin,

carbamezapine,

barbiturates, and

primadone).

 Women with severe headache

(recurrent, including migraine with

focal neurological symptoms). Focal

neurological symptoms may be an

indication for an increased risk of

stroke( or cerebrovascular accident

(CVA) is sudden damage to brain

tissue caused either by a lack of

blood supply or rupture of a blood

vessel . The affected brain cells die

and the parts of the body they control

or receive sensory messages from

ceaseto function.)

 Women who are retarded or

forgetful.
  Women with sickle cell disease, as

they have increased risk of

thrombosis;

 Women with trophoblast disease

(current trophoblastic tumor)

 Women who are to undergo major

elective surgery with prolonged bed

rest.

Client information

 Start between 1st and 7th day of

monthly period
 Take pills daily at the same time –

at bed time if possible

 Do not miss taking the pill any day

 If you start after the 7th day of

monthly period; you need to use

another FP method such condoms or

to abstain from sex for one week.

 Contraception is 7 days after

initiation

 You will have your monthly

period when you are taking the

brown pills. Do not stop taking the

pills.
If a client misses, they should do the

following:

 If you miss one white pill, take it

as soon as you remember, then

continue normally.

 If you miss 2 white or more days

in a row; take two pills each day until

all missed pills are taken and you are

back on schedule. You must also use

a condom for the next 7 days.

 If you miss the brown pill, no

worry. Just skip and continue

  If you keep forgetting – may need

to change method

Progestin-only Pills (POPs)

Progestin-Only Pills are oral

contraceptive pills which contain

synthetic progestin and are taken orally

every day at the same time of day to

prevent pregnancy

Types of POPs available in Uganda:

 Microval: 35 white pills each

containing 0.03 mg Levonorgestrel;

  Ovrette: 28 yellow pills each

containing 0.075 mg Norgestrel.

Effectiveness

 Depends on user compliance

 Very effective if used correctly

(83%-99%)

 It is particularly important that

POPs should be taken at the same

time every day, because of the loss

of effectiveness even if taken a few

hours late;

 In lactating women, the POP is

nearly 100% effective. Moreover,

 POPs do not alter the quantity of

milk, so they represent an effective

form of contraception for lactating

women

Advantages of POPs

 Do not suppress lactation;

 Have no estrogenic side effects;

 Suitable for a large group of

women, for example, those with

hypertension, thrombolic, cardiac,

and sickle cell diseases

 Can be started at any time of the

menstrual cycle and in the early

Postpartum period (immediately or

six weeks post-delivery)

 Decreased menstrual cramps

 Decreased amount of bleeding

during periods

 Decreased severity of anemia

 Do not increase blood clotting

 Some protection against pelvic

inflammatory disease (progestins

make cervical mucus thicker, so

infection in the vagina or cervix is

 less likely to reach the uterus and

tubes).

Disadvantages of POPs

 Amenorrhea

 Must be taken at the same time

every day

 Irregular periods, including

spotting or bleeding between

periods

 Prolonged or heavy vaginal

bleeding; For women who have

had ectopic pregnancy, POPs do

NOT prevent ectopic pregnancy as

 well as they prevent intrauterine

pregnancy, because they do not

consistently suppress ovulation.

 For women who have had

problems with ovarian cysts, POPs

will not protect against the

development of future ovarian

cysts.

Indications

 Women of any reproductive age

or parity (including nulliparous

women) who want protection against

pregnancy.
  Women who are breastfeeding (6

weeks or more postpartum).

 Postabortion women (may start

immediately).

 Women who smoke.

 Women who have BP over

180/110, blood clotting problems or

sickle cell disease

 Women who cannot take COCs but

want to take Pills

Who should use POPs Class 3

 Women who are b/feeding and

less than 6 weeks postpartum

 Women with jaundice

 Women taking anti-epileptic and

anti-TB

 Women with unexplained vaginal

bleeding (only if serious problem

suspected)

 Women with breast cancer.

 Women who express concern

about having any changes in their

menstrual bleeding pattern

  Women who cannot remember to

take a pill every day at the same time

(no more than 3 hrs late)

Who should not use POPs class 4

 Women who are known or

suspected to be pregnant. POPs

should not be initiated if a woman is

pregnant. However, there is no

known harm to mother or foetus if

POPs are used during pregnancy;

  Signs of problems from POPs

warranting immediate return to

clinic

 Severe lower abdominal pain.

 Heavy bleeding (twice as long and

as much)

 Migraine headaches, repeated

very painful headaches, or blurred

vision

Client instructions
 Start between 1st and 7th day of

monthly period

 If you start after the 1st day of

bleeding, abstain from intercourse or

use another method for the next 48

hrs.

 Take pills daily at same time.

 Do not miss taking the pill any

day.

 Return to the clinic for more pills

before you have finished your last

pack of pills.

 If client misses taking pills:

 If you take a pill more than 3 hrs

late, take it as soon as you remember,

then take next pill at usual time. Must

use a back-up method or abstain for

the next 48 hrs.

 If you miss two or more days in a

row, take one as soon as you

remember. Continue to take the pills

as usual. Must use back-up method or

abstain for the next 48 hrs.

 If you keep forgetting to take pills

you may need to use another method

that is easier for you to use. She

 should return to clinic for counseling

on another method.

 Severe diarrhoea of vomiting

reduces the effectiveness of the pills,

client shd therefore use a back-up

method or abstain from sex while

taking the pills and for 48 hrs after.

Injectable

 Depomedroxy Progesterone

acetate (DMPA), single dose of 150mg

I.M every 12 weeks.

  Noristerat (Norethisterone) 200mg

every 8 weeks for 24 weeks, then

every 12 weeks.

 Cyclofem (25

medroxyprogesterone acetate and

5mg estradiol cypionate)

 Mesigynon (50mg norethidrone

enanthanate plus 5mg estradiol

valerate) ; Both given monthly.

Mechanism of action and Advantages

 Inhibition of ovulation: By

suppressing mid cycle Luteinizing

Hormones(LH )peak.
  Changes in cervical mucus and

endometrial atrophy.

 Require no frequent medication

like COCs, no oestrogen side effects,

safe in lactation, decrease menstrual

symptoms and incidence of cancers.

N.B. Failure rate 0-0.3 per 100 women

year. Return of fertility 4-8 months.

Sub dermal implants

 Jadelle, 2 rods of levornogestrel

each 75mg.
  Norplant, 6 rods each with 36mg

levornogestrel

 Others: implanon

Mechanism of action:

 It inhibits Ovulation in 90% of the

cycles in the first year.

 Produces cervical and

endometrial changes.

Insertion: Inner aspect of non dominant

arm, 6 – 8 cm above elbow fold under

local anesthesia. This is at day1,

immediate after abortion or 3weeks

postpartum.
Removal: Approximately 3 to 5 years

Advantage:

 Highly effective and rapidly

reversible.

 Rate is 0.1 per 100 women years.

Adverse effects

 Irregular bleeding: Frequent

spotting, daily bleeding, complete

amenorrhoea.

 Headache, acne, weight gain,

mastalgia, moods disorders, hyper

pigmentation over implantation site,

 hirsutism, galactorrhea, symptomatic

functional ovarian cyst.

Emergency Contraception| Post Coital

Contraception.

This is used following; unprotected

intercourse, condom rapture, missed

pills, sexual assault. It can be hormonal,

anti progestins and others.

Examples:

 Ethinly estradiol 2.5mg b.d X 5/7

 Conjugated oestrogen 15mg b.d X

5/7
  Levonorgestrel 0.75mg stat and

after 12 hours.

 Mifepristone 600mg stat – single

dose.

 Copper IUDs inserted within 5

days.

 Others: Postinor, microgynon,

Eugynon.

Counseling clients to make informed

choice on a family planning method

Learning outcomes:

 By the end of this session students

should be able to:

 Define and use correctly the term

counseling in family planning

 Discuss the general principles of

counseling for family planning and

describe the contexts in which

counseling can take place

 Steps and approaches in family

planning counseling

 The rights of the clients

  Describe the factors influencing

family planning counseling outcomes

Definition of counseling

This is a continuous process that you as

health care provider, as a counselor

provide to help clients and people in the

community or health facility make and

arrive at informed choices about the size

of their family (i.e. the number of

children they wish to have)

Is a face to face communication that you

have with your client or couple in order

to help them arrive at involuntary and

informed decisions.

Definition of informed choice; it is

defined as involuntary choice or

decision based on the knowledge

relevant to the choice or decision.

In order to allow people to make an

informed choice about family planning,

you must make them aware of all

available methods and advantages and

disadvantages plus side effects of each .

They should know how to use the

chosen method safely and effectively as

well as understanding possible side

effects.

Aims of Counseling

 The primary objective of

counseling in the context of family

planning is to help people decide the

number of children they wish to have

and when to have them.

 To help clients choose voluntarily,

the method that is personally and

medically appropriate to them.

 To ensure they understand how to

use their chosen method correctly for

safe and effective contraceptive

protection

 To clear rumors and

misconceptions a client may have

about family planning methods

There are varieties of approaches for

different types of family planning

counseling:

 Individual counseling

 Couple counseling

 Group counseling and

information sharing

Individual counseling

This is a counseling approach that

involves only one client .it involves

individual privacy and confidentiality

during communication or counseling

with you.

It is mostly important when dealing with

confidential matters that relate to family

planning and other reproductive health

issues .

E.g.in HIVcouples, the woman wants to

use family planning but the husband

does not.

Couple counseling
Couples counseling refers to counseling

sessions in which a woman and her

partner are present in discussions with

the provider.

However, it must be recognized that

couples counseling requires special

sensitivity and skills to deal with gender

related issues.

Group counseling and information

sharing
This is counseling approach involving a

group of many people.

It is used when individual counseling is

not possible or there are people in the

village who are more comfortable in a

group.

It is a cost effective of information

sharing and answering general

questions but people are not likely to

share their more personal concerns with

you in this situation.

General principles of counseling

 Privacy-find a quiet place to talk

 Take sufficient time

 Maintain confidentiality

 Conduct a discussion in a helpful

atmosphere

 Keep it simple-use words people

in your village will understand

 First things first –do not cause

confusion by giving too much

information

 Say if again –repeat the most

important instructions
  Use available visual aids like

posters and flip charts etc.

Characteristics of a good counselor

The most important characteristics of a

good counselor are:

 Respect the dignity of others

 Respect the clients’ concerns and

ideas

 Be non-judgmental and open

 Show that you are being an active

listener

 Be empathetic and caring

  Be honest and sensitive

Overview of stages of counseling

General counseling

This is the first contact of family

planning counseling .it involves

counseling on general issues to address

the client’s needs and concerns.

The counselor needs to talk about the

following:

 To give general information about

family planning methods

  To clear up any mistaken belief or

myths about specific family planning

methods

 Give information on other sexual

and reproductive health issues like;

STDSs, HIV and infertility

All these will make the client arrive at

the informed decision on the best

contraceptive method to use.

Method-specific counseling

The information is given about the

chosen method.
The following points are considered:

o Examination for fitness (screening)

(Blood pressure, weights, age and

other health parameters)

o Instruct on how and when to use

given method

o Tell the client when to return for

follow-up and ask them to repeat

what you have said on key

information.

BRAIDED,
Family planning counseling the

BRAIDED approach, the acronym

BRAIDED can help to remember what to

talk about when counseling clients on

specific methods.

It stands for:

B-Benefits of the method

R-Risks of the method including

consequences of the method failure

A-Alternative to method, including

abstinence and no method

I-Inquiries about the method (Individual

rights and responsibilities to ask)

D-Decision to withdraw from a method

without a penalty

E-Explanation of the method chosen

D-Documentation of the session for your

own records

Return follow-up

Follow-up counseling should always be

arranged after the counseling process.

The aims;
  To discuss and manage any

problem and side effects related to

the given contraceptive method

 It gives the opportunity to

encourage the continued use of the

chosen method unless problems

exist.

 It helps to find out whether the

client has other concerns and

questions

Steps in family planning counseling

GATHER approaches
The counseling process should follow a

step-by –step process.

GATHER acronym will help you

remember the 6 steps for family

planning counseling.

G-Greet the client respectfully

A-Ask them about their family planning

needs

T-Tell them about different

contraceptive options and methods

H-Help them to make decisions about

choices of methods
E-Explain and demonstrate how to use

the methods

R-Return /Refer, schedule and carryout a

return visit and follow-up

It is important to give more emphasis to

the points during counseling steps

Greet the client

 In the first case give your full

attention to your client

 Greet them in respective manner

and introduce yourself to them often

offering seats
  Ask them how you can help them

 Tell them that you will not tell

others what they have told you.

 If the counseling takes place in

health facility you have to explain

what will happen during the visit

describing physical examinations

and laboratory tests if necessary

 Conduct counseling in a place

where no one can overhear your

conversation

Ask
 Help them to talk about their

needs, doubts, concerns, and any

question they might have

 If they are new ,use a standard

check list or from your health

management information system to

write down their names, age ,marital

status ,number of

pregnancies ,number of births,

number of living children ,current

and past family planning use and

basic medical history

  Explain that you are asking them

the information in order to help you

provide appropriate care

 Keep questions simple and brief,

and look at them as you speak

May people do not know diseases ,ask

specific questios .Say<< have you had

any headache in the past 2 weeks?or

have you had any genital itching? Or do

you experience any pain when

urinating?>> do not say <<have you had

any disease in the recent past?>>

If you have seen the client

preciously,ask if anything has changed

since the last visit.

Tell

 Tell them about family planning

method

 Tel them which methods available

 Ask them which methods interest

them and what they know about the

method

 Briefly, describe each method of

interest and explain how it works, its

 advantages, disadvantages and

possible side effects.

Help

 Help them to choose a method of

contraception, ask them about their

plans and family situation, if they are

uncertain about the future start with

the present situation

 Ask what the spouse /partner likes

and wants to use

 Ask if there is anything they

cannot understand and repeat

information when necessary

  When the chosen method is not

safe for them explain clearly why the

method may not be appropriate and

help them choose another method.

 Check whether they have a clear

decision and ask what method have

you decided to use?

Explain

 Explain how to use a method after

it has been chosen

 Give supply if appropriate

 If the method cannot be given

immediately, explain how, when and

where it will be provided

 For the method like voluntary

sterilization the client will have to

sign consent form .the form says that;

they want the method, have been

informed about it, and understand

the consent form.

 Explain how to use the method

 Ask the client to repeat the

instructions
 Describe and possible side effects

and warning signs and tell them

what to do if they occur.

 Ask them to repeat this

information back to you

 Give them printed material about

the method to take home if it is

available

 Tell them when to come back for a

follow-up visit and to comeback

sooner if they wish, or if side effects

or warning signs occur

Appoint a return visit follow-up at the

follow-up visit

 Ask the client if she is or they are

still using a method or whether there

have been any side effects or

problems

 Refer for treatment if severe side

effects are present

 Re assure the clients’ concerning

minor side effects are not dangerous

and suggest what can be done to

relieve them

Rights of the client

1. Information,to learn about their

reproductive health ,contraception

and abortion options

2. Access-to obtain services

regardless of religion,

ethnicity,age,marital or economical

status

3. Choice-to decide freely whether to

use contraception and which method

4. Safety-to have a safe abortion and

to practice safe, effective

contraception
5. Privacy-to have a private

environment during counseling

process

6. Confidentiality-to be assured that

any personal information will

remain confidential

7. Dignity-to be treated with

courtesy ,consideration and

effectiveness

8. Comfort-to feel ccomfortable

when receiving services

 9. Continuity –to receive follow-up

care and contraceptive services and

suppies for as long as needed

10. Optinion-to express views on the

service offered.

Factors influencing family planning

counseling outcomes

Factor related to the health care

provider

 Effective communication
  Technical knowledge and skills,

attitudes and behaviors can influence

in effectiveness of counseling process

Factors related to the client

Client’s level of knowledge and

understanding, what they choose to do

may also be affected by the extent to

which they trust and respect a service

provider.

Personnel situation (e.g. .if the spouse or

another family member has a difference

to them)
External programmatic factors

In most health facilities the space or

rooms for provision of family planning

is integrated with other reproductive

health services .This can make it very

difficult for you to find a place where

privacy and confidentiality can be

maintained .

References

1. Alan H.DeCherney,MD et al.

(2007)Current Diagnosis & Treatment

 Obstetrics & Gynecology, Tenth

Edition

2. Ministry Of Health

(2001)Integrated Reproductive Health

(Republic of Uganda)

3. V. Ruth Bennet and Linda. K

Brown (1999), Myles textbook for

Midwives,13th edition. Churchill

Livingstone, NewYork. Calander.R

and A Miller, (1993) Obstetrics

illustrated 4 th Edition Churchill and

Livingstone. New York.

 4. Dawn C.S,” Textbook of

Gynecology and contraception”,

Dawn Books, Calcutta.

ECTOPIC PRGNANCY
Objectives

 By the end of this session students

should be able to :

 Define ectopic pregnancy

 Outline different sites of ectopic

pregnancy

 Describe causes and risk factors

of ectopic pregnancy

 Diagnose ectopic pregnancy

 List signs and symptoms of

ectopic pregnancy

 List complications of ectopic

pregnancy
  Manage a patient with ectopic

pregnancy

DEFINITION: An ectopic pregnancy is a

gestation that implants outside of the

endometrial cavity.

It represents a serious hazard to a

woman's health and her reproductive

potential, and it requires prompt

recognition and early appropriate

intervention.
 An ectopic pregnancy is estimated to

occur in 1 of every 80 spontaneously

conceived pregnancies.

ANATOMICAL LOCATTION OF ECTOPIC

PREGNANCYS

Tubal (99%): anywhere in the

fallopian tube

o The most common site is the

ampulla.

o Interstitial (cornual) pregnancies

occur in the most proximal tubal

segment, which runs through the

 uterine cornua. This type of

ectopic pregnancy can grow to be

quite large, and rupture may

cause massive hemorrhage.

Ovarian (0.5%): on the ovary

Abdominal (less than 0.1%): in the

abdomen, with possible adherence to

the peritoneum, visceral surfaces, or

omentum

Cervical (0.1%): in the cervix

Heterotopic
 o Both intrauterine and ectopic

pregnancies may occur

concomitantly.

o This type of ectopic pregnancy is

extremely rare (1 in 4000 in the

general population and 1 in 100 in

those who conceived with in vitro

fertilization [IVF]).

Other less common sites of ectopic

implantation are the ovary, uterine

cervix, or a rudimentary uterine horn.

Rarely, an ectopic may be

intraligamentous or in the peritoneal

cavity.

WHY AN ECTOPIC PREGNACY

HAPPENS?

In a normal pregnancy, an egg is

fortified by sperm in one of the fallopian

tube which connect the ovaries to the

womb .The fortified egg moves into the

womb and implants itself into the womb

lining endometrial ,where it grows and

develops
So for an ectopic pregnancy, occurs

when a fertilized egg implants itself

outside the womb.

Epidemiology
From the early 1970s to the early 1990s,

the incidence of ectopic pregnancy in

the United States tripled. Currently, this

condition causes 6% of maternal deaths

in the United States and is the most

common cause of maternal mortality in

the 1st trimester. Several factors

contributed to this increased incidence:

1. Improved technology, which has

allowed for earlier and more

complete recognition of ectopic

pregnancies that would previously

have gone undetected.

2. The rising incidence of acute and

chronic salpingitis, especially related

to Chlamydia trachomatis.

3. An increasing number of tubal

surgeries, such as tubal ligation and

tubal reconstruction, resulting in

histologic and structural damage to

 the tubes.

4. Increasing use of conservative

management of tubal pregnancy,

which does not remove damaged

tissue.

The key to the successful management

of ectopic pregnancy is early diagnosis.

Today, fewer women are seen in a state

of hemorrhagic shock after tubal

rupture. As a result, mortality from

ectopic pregnancies has steadily

declined for the past 10 years. This

decrease is evidence that a high index of

suspicion and vigorous efforts at early

diagnosis are effective.

CAUSES AND RISK FACTORS FOR

ECTOPIC PREGNANCY

The occurrence of ectopic pregnancy has

been associated with abnormal function

of the fallopian tubes. Normally, the

tubes facilitate collection and transport

of the oocyte and embryo into the

uterus. The integrity of the fimbria,

lumen, and ciliated mucosa appears to

be important for transport. Conditions

thought to prevent or retard migration

of the fertilized ovum to the uterus

increase the risk for an ectopic

pregnancy.

Pelvic inflammatory disease (PID), the

inflammation and scarring of intra and

extra luminal structures resulting from

PID impair normal tubal function and

foster implantation in the tube. Severe

damage may lead to complete tubal

blockage and infertility

Tubal surgery, bilateral tubal ligation

and tubal reanastomosis may lead to

scarring and narrowing of the tube or

false passage formation. Other pelvic

and abdominal surgeries may also result

in peritubal adhesions but have not

been directly associated with ectopic

pregnancy.

Chlamydia and gonorrhea infection, the

typical cause of pelvic inflammatory

diseases, endometriosis and salpingitis

Artificial reproductive techniques

 Studies have documented increased

risk of ectopic pregnancy with in

vitro fertilization, gamete

 intrafallopian transfer. Up to 2% of

ectopic pregnancies in this

population are heterotopic.

Retrograde embryo migration maybe

a possible mechanism

 Delayed fertilization, possible

transmigration of the oocyte (A

female gametocyte that develops into

an ovum after two meiotic

divisions)to the contralateral tube,

and slowed tubal transport, which

delays passage of the

 morula(fertilized egg) to the

endometrial cavity.

Cigarette smoking Studies have shown

that cigarette smoking causes tubal

ciliary dysfunction.

Endometriosis,this makes the uterus not

suitable for implantation

Having a history of previous ectopic

pregnancy, In subsequent pregnancies

there is a 15% to 20% risk of recurrence,

in either the same or opposite tube

History of infertility, Infertile couples

have an increased proportion of ectopic

pregnancies compared to the total

number of pregnancies, regardless of

the etiology of the infertility.

Chromosomal and structural anomalies

of the conceptus, may predispose to

ectopic pregnancy

Contraceptive methods

Contraceptive Risk factors of

method ectopic pregnancy

None 1%
 Oral 1%

contraceptives

Diaphragm 1%

Intrauterine 5%

devices(IUD)

Progestasert 15%

IUD

 Intra uterine devices (IUD),

Intrauterine devices (IUDs) are

highly effective at preventing

intrauterine pregnancy. Thus, any

 pregnancy in an IUD user is more

likely to be tubal

Progestin-only contraceptives,Users of

progestin-only oral contraceptives as

well as injectable progestins are at

increased risk of ectopic pregnancy if

pregnancy occurs, possibly because of

altered tubal motility.

Peritubal adhesions, following

postabortal or puerperal infections,

appendicitis, or endometriosis.
Developmental abnormalities of the

tube, such as diverticula, accessory ostia,

and hypoplasia. Women who have been

exposed to diethylstilbestrol have a four

to five times greater risk of ectopic

pregnancy.

Increased maternal age.

CLINICAL PRESENTATTION OF ECTOPIC

PREGNANCY

Occasionally, an ectopic pregnancy does

not cause noticeable symptoms and is

only detected during routine pregnancy

testing.

However, most women do have

symptoms and these usually become

apparent between 5 to 14 weeks of

gestation.

The classic triad of symptoms of ectopic

pregnancy consists of amenorrhea,

vaginal bleeding, and lower abdominal

pain.

For any individual woman, there are

three possible clinical presentations:

(1) Acutely ruptured ectopic pregnancy

(2) Probable ectopic pregnancy in a

symptomatic woman

(3) Possible ectopic pregnancy

Acutely ruptured ectopic pregnancy.

This clinical scenario represents a

surgical emergency.

The patient who has experienced

rupture of her ectopic pregnancy will

most likely have:

 Intraperitoneal hemorrhage and

will present with severe abdominal

pain and dizziness.

 She may also complain of

ipsilateral shoulder pain from

phrenic nerve irritation due to

hemoper itoneum from the blood in

her abdomen and it occurs in up to

25% of patients

 There may be signs of

hemodynamic instability with

tachycardia, diaphoresis,
hypotension, and even loss of

consciousness.

 Her entire abdomen may be

distended and acutely tender with

guarding and rebound tenderness.

 The patient will usually have

cervical motion tenderness and a

slightly enlarged, globular uterus.

 However, she may not have a

palpable adnexal (Accessory or

adjoining anatomical parts or

appendages to an organ) mass.

Probable ectopic pregnancy

Women who present with lower pelvic

pain and vaginal spotting or bleeding,

with or without amenorrhea, can be

rapidly tested for pregnancy. There are

generally other clinical signs

presentsuch as tenderness of the

abdomen along with adnexal or cervical

motion tenderness.

Possible ectopic pregnancy

This is characterized by:

 Lower abdominal pain is present

in most cases.

 Amenorrhea or a history of an

abnormal last menstrual period is

obtained in 75% to 90% of ectopic

pregnancies.

 Abnormal vaginal bleeding is seen

in over half the patients, ranging

from spotting to the equivalent of a

normal menstrual period, this

spotting or bleeding results from an

abnormally low production of HCG

by the ectopic trophoblastic tissue

DIAGNOSIS OF ECTTOPIC PREGNANCY

 An ultrasound would reveal an

empty uterus and free fluid (blood) in

the peritoneal cavity

 The diagnosis of ectopic

pregnancy may be confirmed by the

absence of intrauterine pregnancy

(IUP) on ultrasound in a woman with

a level of hCG sufficient to normal

pregnancy,the bsence of intrauterine

pregnancy on ultrasound

examination is diagnostic for ectopic

pregnancy if the gestational age is

 known for certain or if the hCG level

is >2500 IU per ml

 Culdocentesis ,is a technique by

which a needle attached to a syringe

is inserted transvaginally through the

posterior vaginal fornix into the

pouch of Douglas to detect any fluid

within the peritoneal cavity

DIFFERENTAL DIAGNOSIS OF ECTOPIC

PREGNANCY. Gynecologic problems

 Threatened or incomplete abortion

 Ruptured corpus luteum cyst

  Indometriosis

 Gestational trophoblastic diseases

 Ruptured corpus luteal cyst

 Dysfunctional uterine bleeding

 Acute pelvic inflammatory disease

 Adnexal torsion

 Degenerating leiomyoma (especially

in pregnancy)

 Salpingitis

NONGYNECOLOGIC PROBLEMS

 Acute appendicitis

 Pyelonephritis
  Pancreatitis

MANAGEMENT

Management has two modalities:

 Surgical approach

 Medical approach

SURGICAL APPROACH

Surgical treatment of ectopic pregnancy

has the advantage of taking care of the

ectopic immediately. It is suitable for

emergency care of ectopic pregnancy.

It is critical to establish large-bore

intravenous lines and to start fluid

resuscitation.

Salpingectomy, the removal of the

fallopian tube containing the ectopic

pregnancy, is the treatment of choice in

the following situations:

 Future childbearing is not

desired.

 The tube is severely damaged.

 Bleeding cannot be controlled.

  The ectopic is in a fallopian tube

where an ectopic occurred

previously.

Linear salpingotomy, the removal of the

gestation through a linear incision in the

fallopian tube, may be performed if

future fertility is desired.

 This procedure is associated

with a persistent ectopic

pregnancy rate of 3% to 20%.

  Therefore, serial quantitative

hCG values must be followed to

ensure resolution.

Operative laparoscopy may be

performed to confirm the diagnosis of

ectopic pregnancy and to remove the

abnormal gestation via salpingectomy or

salpingostomy.

This method is typically used in

hemodynamically stable patients.

Advantages of this technique over

laparotomy include:
  Shorter hospital stay

 Faster postoperative recovery

 Better cosmetic result

 Potentially shorter operative

time

Laparotomy is typically reserved for

hemodynamically unstable patients who

require emergent surgery for a ruptured

ectopic pregnancy. This method may

also be appropriate when laparoscopy is

contraindicated or technically

challenging because of extensive

adhesive disease from prior surgery.

Cornual resection, may be performed

when an interstitial pregnancy occurs.

The interstitial portion of the tube is

removed via wedge resection into the

uterine cornu.

Cornual ectopic pregnancies have a

higher failure rate with methotrexate

and a surgical approach may be more

effective.

Oophorectomy is indicated only when

an ovarian ectopic pregnancy occurs

and salvage of the affected ovary is not

possible.

MEDICAL APPROACH

Methotrexate, a chemotherapeutic

agent, has been used successfully to

treat small, unruptured ectopic

pregnancies. This approach has the

advantage that it avoids surgery, but the

patient must be counseled that it may

take 3 to 4 weeks for the ectopic to

resolve with methotrexate therapy.Early

diagnosis is very paramount for

successful management.

Mechanism of action

 Methotrexate is a folic acid

antagonist that interferes with DNA

synthesis. Its action is principally

directed at rapidly dividing cells,

such as trophoblastic cells.

 Once an ectopic pregnancy has

been confirmed, 50 mg/m2 is

administered intramuscularly in a
single or multiple doses with folic

acid.

 Serial HCG levels are followed

every 2 to 4 days after treatment

until the HCG level starts to decrease.

This is to ensure resolution of the

pregnancy

 If a 15% reduction is not achieved

during the first week, or in

subsequent weeks a plateau occurs,

then an additional injection of MTX is

given or surgical exploration is

advocated.

 Decreased success has been noted

with ectopic pregnancies of greater

than 3.5 cm, with fetal cardiac

activity, or with high hCG levels

(greater than 5000).

 After treatment failures, surgical

management is usually necessary.

 After an ectopic gestation,

pregnancy should be avoided for at

least 3 months to allow for the

 fallopian tube architecture to

normalize.

 Contraception should be provided

Side effects (approximately 5% of

patients).

Mild gastrointestinal symptoms such as

nausea, vomiting, diarrhea, and

stomatitis are typical.

Potential life-threatening complications

include pneumonitis, thrombocytopenia,

neutropenia, elevated liver function

tests, and renal failure.

 Contraindications,

 Women who are breastfeeding

 Immunodeficiency,

 Liver disease, renal disease,

 Blood disorders,

 Peptic ulcer disease,

 Active pulmonary disease should

not receive methotrexate.

Criteria for medical management of

ectopic pregnancy

Criteria for Contraindications

receiving to medical therapy

methotrexate(MT

X)

Absolute Absolute

indications contraindications

1. Hemodyna 1. Breastfeedi

mically stable ng

without active 2. Overt or

bleeding or laboratory

signs of evidence of

hemoperitone immunodeficie

um ncy
2. Nonlaparos 3. Alcoholism,

copic diagnosis alcoholic liver

3. Patient disease, or

desires future other chronic

fertility liver disease

4. General 4. Preexisting

anesthesia blood

poses a dyscrasias,

significant risk such as bone

5. Patient is marrow

able to return hypoplasia,

for follow-up leukopenia,

care thrombocytope
No nia or

contraindications significant

to MTX anemia

5. Known

sensitivity to

MTX

6. Active

pulmonary

disease

7. Peptic ulcer

disease

Hepatic, renal, or

hematologic
 dysfunction

Relative Relative

indications contraindications

1. Unruptured 1. Gestational

mass ≤3.5 cm sac =3.5 cm

at its greatest 2. Embryonic

dimension cardiac motion

2. No fetal

cardiac motion

detected

Patients whose

hCG level does not

 exceed a

predetermined

value (6000-

15,000 mIU/Ml

COMPLICATTIONS OF ECTOPIC

PREGNANCY

The most common complication is

rupture with internal haemorrhage

which may lead to hypovolemic shock.

Death from rupture is rare in women

who have access to modern medical

facilities.

 Infertility

 Recurrence

 Severe hemorrhage leading to

shock

 Anaemia due to bleeding.

 Infections following operation.

 Adhesions due to scar formation

during healing process.

 Re-occurance of another ectopic

pregnancy.
  Infertility if both tubes are

affected.

References

1. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

2. Thomas J.Bader (2007) OBS/GYN

secrets, 3rd Edition.

3. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.
HUMAN SEXUAL FUNCTIONAL

DISORDERS

Objectives

 By the end of this session students

should be able to:

 Define human sexual

dysfunctional disorders

 Define different types of human

dysfunctional disorders in both

males and females

 Describe factors and causes of

sexual dysfunctional disorders

 Diagnose human dysfunctional

disorders

 Manage human dysfunctional

disorders
Definition:

Sexual dysfunction (or sexual

malfunction or sexual disorder) is

difficulty experienced by an individual

or a couple during any stage of a normal

sexual activity, including physical

pleasure, desire, preference, arousal or

orgasm

General factors and causes of sexual

dysfunctional disorders

There are many factors which may

result in a person experiencing a sexual

dysfunction. These may result from:

Emotional factors:

 Interpersonal or psychological

problems, which can be the result of

depression (A mental state

characterized by a pessimistic sense

of inadequacy and a despondent lack

of activity), sexual fears or guilt, past

sexual trauma, and sexual disorders,

among others.

 Anxiety disorders,ordinary

anxiousness can obviously cause

erectile dysfunction in men without

psychiatric problems, but clinically

 diagnosable disorders such as panic

disorder commonly cause avoidance

of intercourse and premature

ejaculation.Pain during intercourse is

often a together with anxiety

disorders among women.

Physical causes:

 They include the use of drugs,

such as alcohol, nicotine, narcotics,

stimulants, antihypertensives,

antihistamines, and some

psychotherapeutic drugs.
 For women, almost any

physiological change that affects the

reproductive system—premenstrual

syndrome, pregnancy and the

postpartum period, menopause—can

have an adverse effect on libido.

 Injuries to the back may also

impact sexual activity

 Problems with an enlarged

prostate gland, problems with blood

supply or nerve damage (as in spinal

cord injuries).
 Diseases such as diabetes,

multiple sclerosis, tumors, and,

rarely, syphilis may also impact the

activity

 Failure of various organ systems

such as the heart and lungs

 Endocrine disorders (thyroid,

pituitary, or adrenal gland problems)

 Hormonal deficiencies (low

testosterone, other androgens, or

estrogen) and some birth defects.

 In aging women, it is natural for

the vagina to narrow and become

atrophied. If a woman has not been

participating in sexual activity

regularly (in particular, activities

involving vaginal penetration) with

her partnern

 Hormone deficiency or hormonal

imbalance e.g:increased amounts of

prolactin in women dysfunctional

sexual disorders

 In individuals with testicular

failure like in Klinefelter syndrome,

or those who have had radiation

therapy, chemotherapy or childhood

 exposure to mumps virus, the testes

may fail and not produce

testosterone

FEMALE SEXUAL DYSFUNCTIONAL

DISORDERS

Definition

Female sexual arousal disorder (FSAD)

occurs when a woman is continually

unable to attain or maintain arousal and

lubrication during intercourse, is unable

to reach orgasm, or has no desire for

sexual intercourse
It is also called "frigidity." Other terms

for the disorder include dyspareunia

and vaginismus, both of which involve

pain during intercourse.

Causes

There are numerous causes of this

disorder. They include:

 physical problems, such as

endometriosis, cystitis, or vaginitis

 systemic problems, such as

diabetes, high blood pressure, or

hypothyroidism.
 Even pregnancy or the

postpartum period (time after

delivery of a child) may affect desire.

 Menopause is also known to

reduce sexual desire.

 medications, including oral

contraceptives, antidepressants,

antihypertensives, and tranquilizers

 surgery, such as mastectomy or

hysterectomy which may affect how

a woman feels about her sexual self.

 stress

 depression
  use of alcohol, drugs, or cigarette

smoking

Symptoms

Symptoms vary.

 A woman may have no desire for

sex, or may not be able to maintain

arousal, or may be unable to reach

orgasm.

 She may also have pain during sex

or orgasm, which interferes with her

desire for intercourse.

Diagnosis

 Through b complete medical

history to determine when the

problem started, how it presents,

how severe it is, and what the patient

thinks may be causing it.

 The doctor will also conduct a

complete physical examination,

looking for any abnormalities in the

genital region

Treatment

The physician should start by providing

education about the disorder and

recommending various nonmedical

treatment strategies. These include:

 Use of erotic materials, such as

vibrators, books, magazines and

videos

 Sensual massage, avoiding the

genitals

 Position changes to reduce pain

 Use of lubricants to moisten the

vagina and genital area

 Kegel exercises to strengthen the

vagina and clitoris

  Kherapy to overcome any

relationship or sexual abuse issues

Medical treatments include:

 Estrogen replacement therapy,

which may help with vaginal

dryness, pain and arousal

 Testosterone therapy in women

who have low levels of this male

hormone (Side effects, however, may

include deepening voice, hair

growth, and acne)

 The EROS clitoral therapy device

(EROS-CTD), recently approved by the

Food and Drug Administration; a

small vacuum pump, placed over the

clitoris and gently activated to

provide a gentle suction designed to

increase blood flow to the region,

which, in turn, helps with arousal

 Using the herb yohimbine

combined with nitric oxide has been

found to increase vaginal blood flow

in postmenopausal women and thus

 help with some forms of female

sexual arousal disorders(FSAD)

Alternative treatment

 Natural estrogens, such as those

found in soy products and flax, may

be effective.

 Herbal remedies include

belladonna, gingko, and motherwort.

However, there is no scientific

evidence to prove these herbs

actually help.
  Some women squirt vitamin E in

their vagina to increase lubrication.

 Women may also want to see a

sexual therapist for additional help.

Prevention

 Maintaining a close and open

relationship with a partner is one

way to avoid the emotional pain and

isolation that can lead to sexual

dysfunction.

 Additionally, women should learn

if any medications they take affect

sexual function, and should refrain

 from alcohol and drugs and quit

smoking.

 Women who have anxieties and

fears about sexual intercourse,

whether because of earlier abuse,

rape, or a prudish upbringing, should

deal with those issues through

therapy.

Classification of sexual dysfunction

Sexual dysfunction disorders may be

classified into four categories:

 Sexual desire disorders,

  arousal disorders,

 Orgasm disorders

 Pain disorders.

SEXUAL DESIRE DOSORDES

Hypoactive sexual desire disorder

Sexual desire disorders or decreased

libido which are characterized by a lack

or absence for some period of time of

sexual desire or libido for sexual activity

or of sexual fantasies.

The condition ranges from a general

lack of sexual desire to a lack of sexual

desire for the current partner. The

condition may have started after a

period of normal sexual functioning or

the person may always have had no/low

sexual desire.

Causes

 The decrease in the production of

normal estrogen in women or

testosterone in both men and

women.

 Increased level of prolactin

production
  Aging

 Fatigue

 Pregnancy

 Medications such as the Serotonin

selective reuptake inhibitors (SSRIs)

e.g.Fluoxetine ,Sertraline ,Paroxetine

Fluvoxamine

 Psychiatric conditions, such as

depression and anxiety.

SEXUAL AROUSAL DISORDERS

Definittion
Sexual arousal disorders were

previously known as frigidity in women

and impotence in men. Though these

have now been replaced with less

judgmental terms. Impotence is now

known as erectile dysfunction, and

frigidity has been replaced with a

number of terms describing specific

problems that can be broken down into

four categories: lack of desire, lack of

arousal, pain during intercourse, and

lack of orgasm.
So the clear definition now is an erectile

dysfunction and lack of desire, lack of

arousal, pain during intercourse, and

lack of orgasm during intercourse

For both men and women, these

conditions can manifest themselves as

an aversion to, and avoidance of, sexual

contact with a partner.

In men, there may be partial or

complete failure to attain or maintain an

erection, or a lack of sexual excitement

and pleasure in sexual activity.

Causes

 There may be decreased blood

flow

 Lack of vaginal lubrication.

 Chronic diseases e.g:Diabetes

mellitus ,heart diseases

 Nature of the relationship

between the partners.

ERECTILE DYSFUNTIONS

Definition

Erectile dysfunction or impotence is a

sexual dysfunction characterized by the

inability to develop or maintain an

erection of the penis.

Causes

Damage to the nervi erigentes which

prevents or delays erection

Psychological or physical scauses,

psychological erectile dysfunction can

often be helped by almost anything that

the patient believes in; there is a very

strong placebo effect. Physical damage is

much more severe. One leading physical

cause of erectile dysfunction is continual

or severe damage taken to the nervi

erigentes. These nerves course beside

the prostate arising from the sacral

plexus and can be damaged in prostatic

and colorectal surgeries

Diseases, diabetes as well as

cardiovascular disease, which simply

decreases blood flow to the tissue in the

penis, are also common causes of

erectile dysfunctional; especially in men.

There are also multiple sclerosis(A

chronic progressive nervous disorder

involving loss of myelin sheath around

certain nerve fibers), kidney failure,

vascular disease and spinal cord injury

are the source of erectile dysfunction.

Impotence
The Latin term impotentia coeundi

describes simple inability to insert the

penis into the vagina. It is now mostly

replaced by more precise terms.

Pharmacological treatment

The first pharmacologically effective

remedy for impotence, sildenafil (trade

name Viagra)

Premature ejaculation

Definition

Premature ejaculation is when

ejaculation occurs before the partner

achieves orgasm, or a mutually

satisfactory length of time has passed

during intercourse.

There is no correct length of time for

intercourse to last, but generally,

premature ejaculation is thought to

occur when ejaculation occurs in under

2 minutes from the time of the insertion

of the penis.

Causes
Premature ejaculation may have an

underlying neurobiological cause which

may lead to rapid ejaculation.

Diagnosis

The patient must have a chronic history

of premature ejaculation

Poor ejaculatory control, and the

problem must cause feelings of

dissatisfaction as well as distress the

patient, the partner or both.

ORGASM DISORDERS

Orgasm disorders are persistent delays

or absence of orgasm following a

normal sexual excitement phase .

Causes
 The disorder can have physical,

psychological, or pharmacological

origins. Serotonin selective reuptake

inhibitors (SSRI) antidepressants are a

common pharmaceutical cause, as they

can delay orgasm or eliminate it

entirely.

Post-orgasmic diseases

Definition
Post-coital tristesse (PCT) is a feeling of

melancholy (A feeling of thoughtful

sadness) and anxiety after sexual

intercourse that lasts for up to two

hours. Post-orgasmic diseases cause

symptoms shortly after orgasm or

ejaculation.

Sexual headaches occur in the skull and

neck during sexual activity, including

masturbation or orgasm.

In men, postorgasmic illness syndrome

(POIS) causes severe muscle pain

throughout the body and other

symptoms immediately following

ejaculation. The symptoms last for up to

a week.

SEXUAL PAIN DISORERS

Dyspareunia ,painful intercourse due to

an involuntary spasm of the muscles of

the vaginal wall that interferes with

intercourse ,it affect women almost

exclusively and are also known as

vaginismus

Causes

 Insufficient lubrication (vaginal

dryness) in women. Poor lubrication

may result from insufficient

excitement and stimulation, or from

hormonal changes caused by

menopause, pregnancy, or breast-

feeding.
  Irritation from contraceptive

creams and foams can also cause

dryness, as can fear and anxiety

about sex.

 Sexual trauma (such as rape or

abuse) may play a role.

Priapism is a painful erection that

occurs for several hours and occurs in

the absence of sexual stimulation.

This condition develops when blood gets

trapped in the penis and is unable to

drain out. If the condition is not

promptly treated, it can lead to severe

scarring and permanent loss of erectile

function.

The disorder occurs in young men and

children. Individuals with sickle-cell

disease and those who abuse certain

medications can often develop this

disorder.

Vulvodynia or vulvar vestibulitis.

In this condition, women experience

burning pain during sex which seems to

be related to problems with the skin in

the vulvar and vaginal areas. The cause

is unknown

Management of sexual dysfunctions

Althorough sexual history and

assessment of general health and other

sexual problems (if any) are very

important. Assessing (performance)

anxiety, guilt, stress and worry are

integral to the optimal management of

sexual dysfunction.

Males

 Psychotherapy can help.

 Marriage counseling sessions are

recommended in this situation.

 Lifestyle changes such as

discontinuing smoking, drug or

alcohol abuse can also help in some

types of erectile dysfunction.

 Several oral medications like

Viagra, Cialis and Levitra have

become available to help people with

erectile dysfunction. These

medications provide an easy, safe,

and effective treatment solution for

approximately 60% of men.

  Intracavernous pharmacotherapy

and involves injecting a vasodilator

drug directly into the penis in order

to stimulate an erection. This method

has an increased risk of priapism if

used in conjunction with other

treatments, and localized pain.

Females

Although there are no approved

pharmaceuticals for addressing female

sexual disorders, several are under

investigation for their effectiveness.

 A vacuum device is the only

approved medical device for arousal

and orgasm disorders. It is designed

to increase blood flow to the clitoris

and external genitalia.

 Women experiencing pain with

intercourse are often prescribed pain

relievers

 Lubricants and/or hormone

therapy.

 Psychosocial counseling.
Complications

 Infertility

 Failure of sex satisfaction

 Sometimes, pain

 Psychological disturbance

Other sexual problems

 Sexual aversion disorder

(avoidance of or lack of desire for

sexual intercourse)

 Retrograde ejaculation ,this is the

backwards movement of the semen

due to deformity of ejaculatory

ducts .they are two ejaculatory ducts

leading from the seminal vesicles

through the prostate gland to the

urethra.

 Sexual dissatisfaction (non-

specific)

 Lack of sexual desire

 Sexually transmitted diseases

 Delay or absence of ejaculation,

despite adequate stimulation

 Inability to control timing of

ejaculation
 Inability to relax vaginal muscles

enough to allow intercourse

 Unhappiness or confusion related

to sexual orientation

 Transsexual and transgender

people may have sexual problems

(before or after surgery.

 Sexual addiction

 Hypersexuality

 All forms of Female genital cutting

 Post-orgasmic diseases, such as

Dhat syndrome, post-coital tristesse

 (PCT), postorgasmic illness syndrome

(POIS), and sexual headache.

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Paik, and Raymond C. Rosen. (1999).

"Sexual Dysfunction in the United

States: Prevalence and Predictors."

JAMA: The Journal of the American

Medical Association 281(6):537-44.

29. Jarow J, Nana-Sinkam P, Sabbagh

M. Outcome analysis of goal directed

 therapy for impotence. J Urol 1996;

155: 1609-1612

30. How to Get Rid of Sexual

Disorders and Dysfunction Online

guide against depression. Retrieved

on 2010-02-18

31. Merck Sharpe & Dohme. "Male

genital and sexual disorders" 2010-

02-18.

OBSTETRIC FISTULAE
LEARNING OBJECTIVES
  Explain what an obstetric fistula
is.
 Describe different types of fistulas
 List at least six signs and
symptoms of obstetric fistula.
 Enumerate the causes of obstetric
fistula.
 List the risk factors and
consequences of obstetric fistula.
 Describe the management of
obstetric fistula.

Definition

Afistula is an abnormal communication

between two or more epithelial surfaces.
Fistulas can develop in various parts of
the body .However, this session will only
address obstetric fistulas.

Types of fistulas:

The communication may occur between

the bladder, urethra or ureter and
genital tract.

Accordingly, the following types are

described.

Bladder

 Vesicovaginal (the commonest)-

the bladder communicates with the
vagina
  Vesicourethraovaginal-it involves
the bladder, urethra and vagina
 Vesicouterine –it involves the
bladder and uterus
 Vesicocervica-communication
between the bladder and the cervix
Urethra
 Urethrovaginal-involving the
urethra and vaginal tract
Ureter
 Ureterovaginal-it involves the
ureter and vagina
 Ureterouterine- abnormal
communication between ureter and
the uterus
  Ureterocervical-abnormal
communication between ureter and
cervix
Rectum
Rectovaginal fistula . abnormal
communication between rectum and
vaginal tract
Signs and Symptoms of obstetric
fistulas

 Flatulence, urinary or fecal
incontinence, which may be
continual or only happen at night
 Patient will complain of
continuous dripping of urine from
 anus or stool from vagina sometimes
it is a mixture of urine or stool with
blood.
 Foul-smelling vaginal discharge 
 Repeated vaginal or urinary tract
infections 
 Irritation or pain in the vagina or
surrounding areas 
 Amenorrhea due to worries
 Patient will be miserable and
depressed
 Pain during sexual activity 

Causes of fistulas
 The fistula usually develops as a
result of prolonged labor when
a cesarean section cannot be
accessed. Over the course of the three
to five days of labor, the unborn child
presses against the mother's birth
canal very tightly, cutting off blood
flow to the surrounding tissues
between the vagina and the rectum
and between the vagina and the
bladder, causing the tissues
to disintegrate and rot away.
 Poorly performed abortions
 Pelvic fractures,
 Cancer or radiation therapy
targeted at the pelvic area, 
 Inflammatory bowel disease (such
as Crohn's disease and ulcerative
colitis), or infected episiotomies after
childbirth. 
  Sexual abuse and rape 
 Surgical trauma.

Risk factors for fistulas

 Closely spaced pregnancies and
lack of access to emergency obstetric
care.
 Women affected with Crohn's
disease (A serious chronic and
progressive inflammation of the
ileum producing frequent diarrhea
with abdominal pain and nausea and
fever and weight loss)also have a
higher risk of developing obstetric
fistulas.
 Very young mothers
Examination:
 Thighs are wet of urine s of stool
per vagina and excoriation
 On speculum fistula can be seen
 Vulvitis /vaginitis due to constant
irritation

Investigation
Cystoscopy (an examination of the
bladder using a cystoscope)
Ultra sound scan
Urrinalysis (mid stream specimen)for
culture and sensitivity
Full hemogram

Diagnosis
Through history, examination and
invessstigation
Management of fistulas
Aims of management.

i. Allow fibrosis to take place.

ii. Allow inflammatory response to
take place.
iii. Clear away urinary tract infection.
iv. Fistula may reduce in size.
v. Fistula may close spontaneously.
Hospital care of the fistula
 In hospital the doctor carry out a
gentle vaginal examination with his
fingers, no instrument are used for
fear of enlarging the defect, he passes
catheter at the same time so that the
exact course of urethra may be felt in
relation to any defect in the bladder
neck or urethra.
 The patient is kept on continuous
bladder drainage as the passage of
urine through the defect prevent
healing and is put on appropriate
antibiotics to treat any infection
present.
 She is given a balanced diet, iron
and vitamin supplements and if
necessary is give blood transfusion to
restore her general state of health.
 A significant number of fistulae
will close spontaneously during the
six weeks of the puerperium, provide
that there is continuous bladder
drainage, good general health and all
infection is eradicated
 Antiseptic vaginal douches to treat
the foul-smelling vaginal discharge.
This is caused by the sloughing
necrotic tissue.
 At the end of the puerperium the
patient may be assessed by means of
speculum.
 Surgical repair cannot be done at
this stage as one has to give enough
 time to allow the tissues to heal and
strengthen up sufficiently if repair is
to succeed.
 Therefore woman will have to be
sent home and asked to re-attend for
surgery at a later date.
 Bladder catheterization is stopped
at this time (six weeks from the
delivery date) as continuous bladder
drainage is no longer needed.

PRE OPERATIVE CARE

 Admit as an elective case to
prepare the mother for repair, main
emphasis is put on psychological care
to restore hope and confidence.
 Good diet to correct malnutrition,
plenty of fluids to flush the kidneys,
hygiene especially of the genitalia to
treat / prevent infections.
 Explain to her that she will be
nursed in prone position for 14 days
post operatively to promote healing.
 Counsel her on catheter which
will stay insitu for 14 days or more to
promote healing.
 Prepare her for theatre like other
pre-operative care procedures
(review of the general preoperative
care).
  On the evening before operation
enema is given to decongest the
rectum.
NOTE. Colostomy may be performed in
recto vaginal fistula repair.
POST OPERATIVE CARE
 Mother is nursed in semi prone
position until she gains
consciousness and later nursed in
prone position until 14 days.
 Observe the catheter for drainage,
urine color and side leakage.
 Any abnormality must be
reported.
 Bladder irrigation should be done
by a doctor if required.
  Other routine care is provided.
BLADDER TRAINING
This is commenced after 14 days post
operatively if no leakage has been
observed. Bladder training is done
because bladder loses its muscle tone
and micturition reflex during the period
of continuous bladder drainage (CBD).
1st day – spigot the catheter and remove
the urine bag. Release it hourly during
the day and at night put CBD.
2nd day – remove CBD, spigot the
catheter and release it 2 hourly during
the day, continue with CBD at night.
3rd and 4th day – release the catheter
during the day and continue with CBD at
night.
5th day – remove the catheter, ask the
mother to hold urine as much as
possible so as to see how much the
bladder can hold or tolerate for a period
of time, then ask the mother to pass
urine.
 After passing out urine,
catheterize again to measure the
residue volume of urine remained in
the bladder.
 If the residue urine is less than
100mls, then it means bladder
training has been successful.
Discharge may be considered.
  If residue urine is more than
100mls, this means that bladder
training has not been successful,
therefore, recommence CBD and
bladder training.
NURSING MANAGEMENT
NURSING CONCERNS
 Mother is miserable and
depressed.
 Dripping of urine / feaces.
 Smell of urine
 Urinary tract infections.
NURSING
CARE PLAN

NURS EXPE INTERVE RATION EVALU

ING CTED NTIONS ALE ATION
DIAG OUTC
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ADVICE ON DISCHARGE
 Mother should avoid coitus for 3
months. Counsel both the man and
woman on issue of NO sex so that
they go home when it is properly
resolved.
 To avoid pregnancy for atleast 2-3
years.
  To attend antenatal clinic early
enough when she gets pregnant and
the issue of fistula repair should be
revealed to the attending midwife,
preferably should be seen by a
doctor.
 Delivery should be preferably by
caesarian section.
 Avoid strenuous work and have
enough rest to promote healing.
 Ensure vulva toilet to prevent
infections.
 Have a highly nourishing diet to
promote healing.
 Review in gynecological
department
Prevention
 Access to accurate antenatal care
to screen out at risk mothers likely to
develop obstructed labor. obstetrical
care
 Support from trained health care
professionals throughout pregnancy,
 Providing access to family
planning
 Promoting the practice of spacing
between births, and Supporting
women in education and in
postponing early marriage.
 Fistula prevention also involves
many strategies to educate local
communities about the cultural,
social, and physiological factors that
condition and contribute to the risk
for fistula. One of these strategies
involves
 Prevention of prolonged
obstructed labor and fistula should
preferably begin as early as possible
in each woman's life. For example,
improved nutrition and outreach
programs to raise awareness about
the nutritional needs of children to
prevent malnutrition as well as
improve the physical maturity of
young mothers are important fistula
prevention strategies.
 It is also important to ensure
access to timely and safe delivery
during childbirth: measures include
availability and provision of
emergency obstetric care as well as
quick and safe cesarean sections for
women in obstructed labor.
 Some organizations train local
nurses and midwives to perform
emergency cesarean sections to avoid
vaginal delivery for young mothers
who have under-developed pelvises. 
 Midwives located in the local
communities where fistula is
prevalent can contribute to
promoting health practices that help
prevent future development of
obstetric fistulas.
 Promoting education for girls is also
a key factor to preventing fistula in
the long term.

Complications

 Stillborn babies due to prolonged

labor,
 Severe ulcerations of the vaginal
tract,
 "Foot drop," which is the paralysis
of the lower limbs caused by nerve
damage, making it impossible for
women to walk, infection of the
fistula forming an abscess, and up to
 two-thirds of the women become
amenorrhoeic due to worries.
 Sepsis due to the overspread of
infection

References

1. National Medical Series for

Independent Study (2008) Obstetrics
and Gynaecology, 6th Edition.
2. Thomas J.Bader(2007)OBS/GYN
secrets,3rd Edition.
3. Hacker et al. (2007) Essential of
Obstetrics and Gynaecology, 4th
Edition
VAGINAL DISCHARGE

LEARNING OBJECTIVES

 Define the term vaginal

discharges

 Differentiate between normal and

abnormal vaginal discharges

 Define and describe the

characteristics and functions of

leuchorrhoea, show, liquor amnii,

lochia and its types, and menstrual

flow.
  Describe the characteristics of

abnormal vaginal discharge.

 Manage the patient with

abnormal vaginal discharge

DEFINITION

These are secretions seen per vagina.

They are of two types, that is, normal

and abnormal.

NORMAL VAGINAL DISCHARGE

1. Leucorrhoea

This is the normal discharge and keeps

on changing depending on the

menstrual cycle. It is produced by adult

women in reproductive age by

Doderlien bacilli.

Characteristics

 Should be minimal and moderate

in amount

 Should not be offensive

 Should not be itching or irritating

 Should be acidic in reaction

 It is usually whitish, clear or

creamy in colour and changes

according to the menstrual cycle. It is

egg white and elastic around

 ovulation and should be clear after

peak days.

Functions

It keeps the vagina moist and warm

2. Show

It is a bloody mucoid discharge from the

vagina which appears when a woman is

in her first stage of labour.

Characteristics

 Should not be much in amount

 Should not be nonodorous with

pH around 4.0.
  Microspically, it contains

squamous epithelial cells and a few

bacteria.Lacto-bacilli (Dordelein

bacilli), few gram negative bacteria

and anaerobes are present without

any white or red blood cells.

 Should not be irritating

3. Liquor amnii/ amniotic fluid

It is a clear straw coloured fluid found in

the amniotic membrane in the uterus, in

which the foetus grows.

Characteristics
  It ranges between 1000-1500ml in

amount

 It is clear if not infected

 It pours out during labour which

aids in lubrication of birth canal

during child birth.

 It consists of 99% water, mineral

salts, urea from urine passed by the

foetus.

 It is alkaline in reaction

 It sometimes contains meconeum

especially in obstructed labour

Functions of amniotic fluid

  Protects the fetus

 Free movement of the fetus

 Regulates fetal temperature

 Protects fetal limbs from sticking

together

 Contains nutrients which

nourishes the fetus

Abnormalities associated with amniotic

fluid

 Oligohydromnous-inadequate

amniotic fluid between 300-500mls

 Polyhydromnous-excess amniotic

fluid between 2000-3000mls

  Offensive amniotic fluid-due to

infections

 Blue amniotic fluid-due to drugs

 Brown amniotic fluid-due to fetal

death

 Meconeum stained-due to fetal

distress

4. Lochia

This appears after delivery of the baby

(puerperium)
The amount varies in different women

and is more in quantity than that of

menstrual flow.

Its odour is heavy and unpleasant but

not offensive

It has an alkaline reaction

Types

Rubra (red). Present during the first 3

days. It consists of blood, sheds of

deciduas and pieces of chorion, liquor

amnii vernix caseosa and meconeum

may be present. Appear s red owing to

the presence of erythrocytes.

Serosa (pink). Present from 4th to9th day.

The discharge becomes paler and

pinkish in colour, containing less blood

and more serum, leucocytes (WBC) and

bacteria.

Alba (white or clear). Present from 10th

to 15th day. The discharge becomes

paler; it is yellowish white in colour and

contains cervical mucus, bacteria and

debris from the healing process of the

uterus and the vagina.

5. Menstrual flow

It should be about 60-180mls of blood.

This flow consists of blood from the

endometrium, endometrial tissue, +-

unfertilized ovum and secretions from

the endometrium.

Characteristics

 It should not clot

 It should not be offensive

 It should be dark red

ABNORMAL VAGINAL DISCHARGES

These are discharges which are caused

by sexually transmitted infections of

diseases of the female reproductive

system and require treatment.

These discharges are pathological other

than physiological.

Characteristics of abnormal vaginal

discharges

Colour

Whitish creamy or curdy milky

discharge- usually due to fungal

infection of the vulva and vagina like

candidiasis.

Greenish yellow discharge- is a common

feature of trichomonas vaginalis

Purulent yellow discharge-usually due to

gonococcal infections.

Odour

Any offensive discharge should be

investigated and the cause treated

Amount
Increased amount that tint the nicker is

abnormal and should be investigated

and treated.

Irritant

Any discharge that may cause irritation

and results into inflammation is

abnormal and should be investigated

and treated.

It may be blood –stained or

contaminated with urine or stool

Causes of abnormal vaginal discharges

Cervical causes

Non-infective cervical lesions ,may

produce excessive secretion which

pours out at the vulva.

Such lesions are:

 cervical ectropy,the cervix is

abnormally protruding in the vagina

 Chronic cervitis

 Mucous polyp and ectropion (cervical

glands are exposed to the vagina)

 Sexual transmitted diseases (STDs)

Vaginal causes
 Uterine prolapsed

 Aquired rertroverted uterus

 Chronic pelvic pelvic inflammation

 Pill use

 Vaginal adenosis

Diagnosis

On vulva inspetion;

 obvious white and creamy

discharges

 No evidence of pruritis
 Bimanual including a speculum

examination;

 Either a negative pathology

 Associated pelvic lesions mentioned

earlier causing cervical or vaginal

leucorrhea

Treatment

 Improvement of general health

including local hygiene

 Cervical factors require surgical

treatment like electrocautery

 (Application of a needle heated by an

electric current to destroy tissue)

 Cryosurgery, the use of extreme cold

(usually liquid nitrogen) to destroy

unwanted tissue such as warts or

skin cancers

 Pelvic lesions require appropriate

therapy for the pathology.

 Pill users may have to stop them

temporarily, if the symptoms are

very much annoying

References
1. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

2. Thomas J.Bader(2007)OBS/GYN

secrets,3rd Edition.

3. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.
INFERTILITY

Learning objectives

By the end of this session students

should be able to :

 Define the term infertility.

 List at least eight causes of

infertility in both men and women.

  Mention the investigations carried

out to diagnose infertility.

 Describe the management of

infertility.

Definition.

This is the inability of a couple to

achieve a pregnancy after repeated

intercourse without conception for more

than a year.

Types of infertility
Primary infertility is the inability to

conceive in a couple who have had no

previous pregnancies.

Secondary infertility is the inability in a

couple who have had at least one

previous pregnancy, which may have

ended in a live birth, still birth,

miscarriage, ectopic pregnancy or

induced abortion.

Incidence

1 out of 5 couples in USA are affected.

Causes
The cause can be from male, female or

both.

Male causes

Low sperm count (oligospermia). This

could be due to some drugs like anti-

hypertensives, antidepressants or some

sedatives, or acute / chronic infections of

the male genital tract.

No sperms (azoospermia). This could be

due to bilateral cryptochidism

(undescended testes)
Abnormal sperms ,like those without

tails which makes them difficult to

swim.

Testesterone hormone insufficiency.

Inflamed epididymis. Storage and

maturation of the sperms will not

happen.

High levels of female hormones

(hormonal imbalance)

Blocked vas deferens. Transportation of

sperms will not take place.

Too much exposure of testes to heat.

This affects spermatogenesis

(production of sperms).

Diseases like diabetes mellitus,

hypertension, mumps. These leads to

testicular atrophy.

Auto immune disorder, may result in

production of antisperm antibodies.

Obesity ,may result in testicular atrophy.

Smoking and or alcoholism, affects

spermatogenesis resulting into low

sperm count.
Exposure to chemicals like asbestos,

affects spermatogenesis resulting into

low sperm count.

Exposure to radiations also affects

spermatogenesis.

Premature ejaculation, resulting into

immature and non motile sperms.

Malformations of seminal vesicles and

prostate gland.

Retrograde ejaculation. This when a

man ejaculates sperms into the bladder

instead of the penis.

Congenital abnormalities of the penis

like hypospadias and abnormal urethra.

Varicocele affects the movement of

sperms.

Urethral structure affects the way of the

sperms.

Failure to maintain an erection, a

condition known as erectile dysfunction.

Some medications, like anti-convulsants

and anti-depressants depresses sperm

count and motility.

Causes in females
Pelvic inflammatory diseases (PIDs)

accounts for over 65%. This results into

healing by fibrosis (scar tissue

formation), narrowing or blocking the

fallopian tubes making fertilization

impossible.

Pituitary tumors, leading to production

of high levels of prolactin hence

inhibiting ovulation.

Ovarian cysts ,may hinder ovulation.

Inovulation,this is when ovulation does

not take place.

Absence of ovaries (Turner’s syndrome).

No ova will be produced.

Fibroids,these tend to occupy a greater

part of the uterine cavity making

implantation impossible.

Hormonal imbalance,this may also

hinder ovulation.

Hostile environment to sperms or thick

cervical mucus.
Severe vaginal infection, which

interferes with sperm transport.

Transverse septum in the vagina or

uterus which makes sperms unable to

reach the fallopian tubes where

fertilization takes place.

Uncontrolled diabetes mellitus, active

goiter and hypertension also affects the

fertility rate of a mother.

Severe hypertension and some drugs

like Methyldopa.
Excessive alcohol and smoking,this

affects the production of ova.

Obesity,this also affects the fertility rate.

Increased maternal age, that is, over 35

years. The rate of reproductivity

decreases with an increase in age.

Hypersensitivity to man’s sperms,

whereby man’s sperms get killed by

antibodies in cervical mucus.

Endometriosis, this is the presence of

endometrial tissue outside the uterine

cavity like in fallopian tubes which may

result into implantation in the tubes

resulting into habitual ectopic

pregnancy.

Tub ligation,this is a permanent form of

family planning by which the fallopian

tubes are tied such that the sperms do

not go through to reach the ova for

fertilization.

Adhesions or kinked tubes, these block

the fallopian tubes making it impossible

for the sperm to reach the ova.

Pseudomenorrhoea,This is when a

woman perceives that she is pregnant

yet she is not resulting into absence of

menses.

Causes in both males and females

Poor timing,this when the couple

decides to have intercourse when a

woman is in her safe days.

Lack of relaxation,when a couple have

intercourse while tied, this can result

into production of weak or immature

sperms.
Stress,this can also result into

production of weak sperms.

Excessive alcohol and or smoking,his

affects spermatogenesis and production

of ova.

Incompatibility, that is, woman may

destroy man’s sperms due to variability

in PH(acidity of the vaginal cacity)

Idiopatic causes

Diagnosis/ Investigations
 History taking from both partners.

Personal and family history about

frequency of sex, duration of sex,

infertility in family, alcoholism and

smoking, nature of the job, marital

status whether monogamy or

polygamy, social relationship and

others.

 Examination of the man and

woman to rule out abnormalities like

varicocele and hydrocele in men

which affect fertility, and hirsutism

(excessive facial hair growth in

 women) and obesity in women which

may be suggestive of endocrine

disorders.

Specific investigations in men

Semen analysis. This is the basic test for

male infertility. It should be carried out

before any further investigations on the

couple. Average values are assessed on 3

samples produced over several weeks,

as quality is variable.
Specimen are produced by masturbation

after 2 – 3 days abstinence and

examined in the laboratory within 1

hour.

If satisfactory, the man is assumed to be

potentially fertile.

Normal values

 Volume 2 – 6 mls

 Total sperm count > 40 million per

ml

 Mortility more than 60% moving

forward.
  Morphology > 60% should appear

normal.

Post coital test

A specimen of aspirated cervical mucus

from the female partner is examined at

the fertile time of the cycle within 6

hours of intercourse. The ability of the

sperm to penetrate the mucus can be

observed. This determines whether

sperms can survive in the cervical

mucus.
Specific investigations in women

History of menstruation ,to determine

ovulation.

Hysteresalpingiogram, to rule out

obstruction, abnormal tubes and fibrous

masses in the uterus and adhesions.

Blood for hormones analysis, that is,

prolactin, oestrogen, and progesterone

levels. This will show fluctuations in the

circulating levels.
X-ray of the pituitary gland and

hypothalamus, to rule out tumors and

other abnormalities.

High vaginal swab, to rule out infection.

Ovulation tests ,to confirm if ovulation

occurs or not, and if not more

investigations are carried out to identify

the cause.

Ultra sound scan, to confirm whether

there is growth of ovarian follicles to

20mm and then the release of oocyte at

ovulation.
Endometrial biopsy, to rule out

endometrial change following ovulation.

The presence of secretory endometrium

confirms that ovulation has taken place.

Hysterescopy,this views the uterus to

rule out adhesions and septum in the

uterus and fallopian tubes.

Laparascopy,this views the uterus,

tubes, and ovaries to rule out any

abnormalities.

Crossed hostility test,this observes the

behavior of the partner’s sperm and

fresh donor sperm in the woman’s

cervical mucus.

The sperm penetration test,this

demonstrates the behavior of sperm

alongside a sample of mucus taken at a

fertile time on a glass slide. It

determines whether sperm functions or

mucus hostility is the problem.

Treatment of infertility in men

  Azoospermia is usually

untreatable.

 Reducing high temperatures of

the testicles may encourage sperm

development.

 Oligospermia may be improved by

attention to diet and general health,

particularly reducing smoking and

alcohol intake.

 Administer corticosteroids to any

man who presents with mumps as

soon as there is an idea of infection.

Treatment of infertility in women

 Bromocriptine is used to inhibit

the synthesis and release of prolactin

by the pituitary in case of

hyperprolactinaemia.

 HCG can be used to trigger

ovulation, often in conjunction with

clomiphene or some other forms of

ovulation induction.

 Clomiphene citrate is usually used

to induce ovulation. It stimulates the

hypothalamic – pituitary system,

permitting follicle stimulating

hormone (FSH) and so inducing

ovulation.

 GnRH (gonadotrophin releasing

hormone) drug may be used to

induce ovulation if hypothalamus

has a problem in release of the

hormone.

 In case of hostility, that is , if the

mucus or the woman is producing

antisperm antibodies to her partner’s

sperms, steroids in short courses may

be helpful, or intra- uterine

insemination may be successful.

References

1. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

2. Thomas J.Bader (2007) OBS/GYN

secrets, 3rd Edition.

3. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.

DISORDERS OF MENSTRUATION
By the end of this session students

should be able to:

 Describe the following disorders

of menstruation; amenorrhoea,

dysmenorrhoea, menorrhagia,

metrorrhagia, polymenorrhoea,

dysfunctional uterine bleeding

and endometriosis using their

definition, types, causes, signs and

symptoms, diagnosis/

investigations.

 Describe the management of each

disorder mentioned above.

  Mention the complications of

disorders of menstruation.

DEFINITION

These are abnormalities in

menstruation during reproductive life.

Common disorders associated with

menstruation are as follows;

1. Amenorrhoea

2. Dysmenorrhoea

3. Menorrhagia

4. Metrorrhagia
 5. Polymenorrhoea (epimenorrhoea)

6. Dysfunctional uterine bleeding

7. Endometriosis

AMENORRHOEA

This refers to absence of menstruation

which occurs in female during their

reproductive age.

Types of amenorrhoea

Primary amenorrhoea. This is the

failure of menses to occur by 16 years

of age.It could be due to imperforated

hymen when she has been

menstruating but when blood does not

come out.

Secondary amenorrhoea. This is the

cessation of menses in a woman who

has previously menstruated. It is

regarded as secondary when she takes

a period of 6 month and above without

seeing her menses.

Causes

Physiological like pregnancy and

lactation,during pregnancy the levels

of oestrogen and progesterone remains

high thus ensuring the integrity of the

endometrium resulting into

amenorrhoea.

During lactation- soon after delivery

prolactin is secreted in large quantities

by the anterior pituitary. There is

partial suppression of LH production

so that the ovarian follicles may grow

but ovulation does not occur resulting

into amenorrhoea.

Hypothalamic dysfunction-such kind

of patients have lower levels of follicle

stimulating hormone(FSH) and

leutinising hormone (LH). Several

congenital syndromes associated with

abnormal hypothalamic- gonadal

function have been described and

these conditions present with primary

amenorrhoea and absence of

secondary sex characteristics. It is also

due to failure to the development of

central structures of hypothalamus.

Pituitary disorder,this is associated

with elevated levels of prolactin

(hyperplolactinemia).
Congenital abnormalities ,like

imperforated hymen, vaginal septum,

no uterus, no endometrium but with

uterus, absence of ovaries, cervical

stenosis, and absence of

hypothalamus (kallmann’s syndrome).

This is a congenital hypogonadotrophic

hypogonadism disorder characterized

by absence of secondary sex

characteristics.

Change of environment or occupation.

Fear, anxiety or excitement

Pseudomenorrhoea,pseudo means

false. Here a woman psychologically

thinks that she is pregnant yet she is

not.

After hysterectomy or bilateral

removal of ovaries

Full doses of radiation

Drugs ,like contraceptives especially

hormonal methods

Debilitating diseases like, TB,

HIV/AIDS, DM etc
 Tumours of the pituitary gland,

hypothalamus, ovaries and uterus

Early onset of menopause

Idiopathic

Diagnosis and investigation

 A detailed history taking (history

of change in weight, presence of

stress, questions about excessive

weight, presence of excessive body

or facial hair) and physical

examination.
  Urine for HCG to rule out

pregnancy

 Ultra sound scans of the pelvis to

visualize the contents or organs of

the pelvic cavity.

 Blood for hormone analysis to

rule out hormonal imbalance.

 Computerised tomography (CT)

scans to visualize the organs.

MANAGEMENT
This will depend on the cause. It may

be medical, surgical, or psychological.

Hyperprolactinaemia is treated by

administration of bromocriptine. This

is an ergot alkaloid which directly

opposes prolactin secretion.

Radiotherapy is reserved for those

patients who fails to respond to

medical therapy.

Imperforated 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.

DYSMENORRHOEA

These are 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.

Cause

This is due to release of a chemical

substance called prostaglandins from

the lining cells of the uterus at the time

 of menstrual period. The prostaglandin

causes contractions of the muscle wall

of the uterus, that are called menstrual

cramps.

Types of dysmenorrhoea

Primary dysmenorrhoea. This refers to

painful menstruation that starts few

years after puberty and usually no

exact cause can be identified.

Pre-disposing factors
  Narrow cervical os

(stenosis) ,which results into

tension during contraction of

muscles.

 Reduced blood supply to the

endometrium (ischaemia)

 Hormonal imbalance

 Retroverted uterus, that is , when

the uterus leans backwards

resulting into tension.

 Psycological or social stress, fear

or anxiety

Signs and symptoms

Dysmenorrhea is cyclic with pain most

often occurring just before or during

the first few days of each period.

 Lower abdominal pain (LAP) that

varies in severity among

individuals, ranging from mild to

colicky or crampy, extending to

the back, thighs and legs.

 Nausea and vomiting

 Constipation or diarrhea

 Fainting, headache, malaise

 Irritability, nervousness,

depression
Diagnosis

It is through history taking,ask about

the nature of pain, duration and when

it occurs. This is often confirmatory.

It is also through physical examination

to rule out pelvic tumours,

endometriosis which is often absent.

Treatment

 Non steroidal anti inflammatory

drugs (NSAIDS) like Iboprufen,

mefenamic acid, diclofenac and

others. These prevent the formation

 of prostaglandins in the uterine

lining cells.They are more effective

if taken before the onset of cramps.

 Antispasmodics like Buscopan

 Antiemetics like Phenegan for

nausea and vomiting

NOTE

 Begin treatment 2 days before

menstruation periods begins and

continue until 2 days after the

period has stopped.

 Avoid additive drugs since this

treatment is for 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.

 Dilatation and Curettage (D&C) may

be of help to remove necrotic tissue

of endometrium, but usually not

encouraged since it increases the

risk of infections.
 Cervical stenosis can be treated by

surgical widening of the canal.

 Effective counseling is important

since pain is usually psychological

to avoid drug dependence and

abuse.

 Delivery or with age will finally

treat pain since there will be

relaxation of uterine muscles and

reduce ischaemia.

 Encourage enough rest and sleep as

well as exercises, hygiene and good

diet.
  Other management options may

include hypnotherapy and

acupuncture.

Secondary dysmenorrhoea

This refers to painful periods which

start many years following normal and

well established menstrual periods. It

is more of pathological occurrence and

on investigations the cause is easily

established.

Causes

 Pelvic inflammatory diseases (PID)

  Uterine fibroids. This results into

the partial contraction of the uterus

resulting into pain.

 Endometriosis.This is the growth of

the endometrial tissue in other area

rather than the uterus.

 Endometritis. This is the

inflammation of the endometrium.

Signs and symptoms

 In addition to signs and symptoms

found in primary dysmenorrhoea,

there is;
  Lower abdominal pain (LAP)

usually happens 3-4 days or even a

week before menstruation and

either pain becomes better or

worsens with menstruation.

 There may be backache

 Signs and symptoms of

menorrhagia

 Painful coitus

 Infertility.This is the inability to

conceive.

Management

 Investigate and treat the cause.

NURSING MANAGEMENT

Nursing concerns

 Acute pain

 Stress

 Nausea and vomiting

Nursing diagnosis

1. Acute pain related to increased

uterine contractility evidenced by

verbalization of the girl or woman.

Nursing interventions
 Warm the abdomen,this causes

vasodilation and reduces the

spasmodic contractions of the

uterus.

 Massage the abdominal area that

feels pain,this reduces pain due to

the stimulus of therapeutic touch.

 Perform light exercises ,to blood

flow to the uterus and improves

muscle tone.

 Perform relaxation techniques to

reduce pressure to get relaxed.

  Administer analgesics as prescribed

to block nociceptive receptors

2. Ineffective individual coping

related to emotional stress evidenced

by patient’s verbalization.

Nursing interventions

 Assess patient’s understanding of

the condition. This is because

patient’s anxiety of the pain is

greatly influenced by knowledge.

  Provide an opportunity to discuss

how the pain is. Help the patient

identify coping mechanisms.

 Provide the patient with periods of

sleep or rest. Ensures relaxation of

the body and mind.

3. Risk for imbalanced nutrition less

than body requirements related to

nausea and vomiting.

Nursing interventions
  Provide the patient with periods of

sleep or rest ,this is to ensure

relaxation of the body.

 Encourage small frequent feeds.

These are easily tolerated by the

patient.

 Administer anti-emetic drugs like

promenzathine. This blocks the

emetic centres.

MENORRHAGIA

This refers to heavy or prolonged

menstrual bleeding or both.

Causes

 Uterine fibroids

 PID (pelvic inflammatory

disease)

 Clotting disorders

 Retroverted uterus

 Functional tumours of ovaries

resulting into hormonal

imbalance

 Cancers like cancer of the

cervix and endometrial cancer

Signs and symptoms

  Heavy bleeding which may be

painful or not, with a prolonged

duration

 Signs and symptoms of anaemia

and shock

Investigations

 Bleeding time to test for

coagulopathy

 Prothrombin time to test for

coagulopathy.

 Clotting time to test for

availability of platelets.
  In the above three tests, results

will be abnormal.

 Full haemoglobin levels and

hormone analysis to rule out

hormonal imbalance.

 Ultra sound scan to rule out

new growth in the uterus

MANAGEMENT

The best management is to investigate

and treat the cause

NURSING MANAGEMENT

Nursing concerns
  Heavy bleeding

 Anxiety

 Self care disturbance

Nursing diagnosis

Ineffective tissue perfusion related to

excessive bleeding evidenced by

pallor.

Nursing interventions

 Assess 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 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.
 METRORRHAGIA

This is defined as cyclic bleeding at

normal intervals,the bleeding is either

excessive in amount (>80 ml) or

duration or both.

This is a symptom of some underlying

pathology which may be organic or

functional.

Causes

 Fibroid uterus
 Adenomyosis (A disorder of the

glands that secrete cervical mucus

and fluids)

 Pelvic endometriosis(The

presence of endometrium

elsewhere than in the lining of the

uterus causing premenstrual pain

and dysmenorrhea)

 Chronic tubo-ovarian mass

 Retroverted uterus-due to

congestion
 Uterine polyp. This is due to vast

blood supply to the polyp which

makes it bleed easily.

 Cervical erosions. This is due to

the presence of a wound and an

increase in blood supply resulting

into bleeding.

 Cancer of the cervix or

endometrial cancer.

 Chronic threatened abortion or

incomplete abortion

 Retained pieces of placenta. This

interferes with contraction of the

 uterus to seal off blood vessels after

birth.

 Mole pregnancy. This is due to an

abnormal uterine mass which

grows after fertilization and is

supplied with a lot of blood

capillaries resulting into bleeding.

 Ovulation bleeding

 Short cycles like polymenorrhoea

Investigations

 Through history taking

  Digital and speculum

examination,to visualize the cervix

for any abnormality.

 Biopsy for histology to rule out

cancer.

 Pelvic scan,to visualize pelvic

organs and rule out any abnormality.

MANAGEMENT

The best management to investigate

and treat the cause

 POLYMENORRHOEA/

EPIMENORRHPEA
This refers to menstruation periods

that occurs at shorter intervals than

usual (14-21 days), but they are

frequent and regular.

Causes

 Ovarian dysfunction

 After abortion or normal delivery

Diagnosis

 History taking

 Physical examination

 Hormone analysis to rule out

hormonal imbalance.
MANAGEMENT

 Investigate and treat the cause.

 If following abortion or delivery,

reassure the mother.

 Administer hormonal therapy to

stabilize the cycle.

 Carry out dilatation and curettage

(D&C) to remove retained products.

DYSFUNCTIONAL UTERINE BLEEDING

This refers to abnormal bleeding

resulting from hormonal changes

rather than from trauma,

inflammation, pregnancy or a tumour.

Incidence

The prevalence varies widely but an

incidence 10% among patients

attending the outpatient seems

logical.The bleeding may be abnormal

in frequency ,amount or duration or

combination of both.

Causes
It is due to sustained levels of

oestrogen leading to thickening of the

endometrium which shed incompletely

and irregularly.

Pathophysiology

In most cases, abnormal bleeding is

caused by local causes in the

endometrium.

However,there is some disturbance of

the endometrial blood vessels and

capillaries and coagulation of blood in

and around these vessels.

These are caused by alteration in the

ratio of endometrial prostaglandins

which are delicately balanced in

hemostasis of menstruation and may

be related to incoordination in the

hypothalamo-pituitary –ovarian axis.

Signs and symptoms

Irregular, prolonged and sometimes

heavy bleeding.

NOTE A diagnosis of dysfunctional

uterine bleeding is made only when all

other possibilities of causes of bleeding

have been excluded.

Investigations

 Ultra sound scan to rule out new

growth

 Blood analysis for hormonal

imbalance

 Biopsy for histology

MANAGEMENT

 Treatment depends on various

factors like age, condition of the

uterine lining and the woman’s

plans regarding pregnancy.

 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.

 When the uterine lining is

thickened but contains normal

cells, heavy bleeding may be

treated with 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 usual manner for

atleast 3 months.

 Women who have lighter

bleeding may be given low doses

from the start.

 If a woman has

contraindications to oestrogen
 containing drug, progestin only

pills may be given by mouth for

10-14 days each month.

 D&C may be used if response

or hormonal therapy proves

ineffective.

 If a woman wants to become

pregnant, clomiphene drug may

be given orally to induce

ovulation.

References
 1. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

2. Thomas J.Bader(2007)OBS/GYN

secrets,3rd Edition.

3. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.

ENDOMETRIOSIS

Objectives

 Define endometiosis
  Causes and predisposing factors

of endometriosis

 Signs and symptoms

 Diaqgnosis

 Management

 Complications

This refers to growth or presence of

endometrial tissue outside the uterus. It

may be referred to as a misplaced

endometrial tissue.

Incidence
10-15%s of women between 25 and 45

years. 25-50% in infertile women.

Common sites that may be affected

Abdominal organs, ovaries, ligaments,

intestines, ureters, urinary

bladder,vagina, vulva, naval, lungs,

nose, conjunctiva and rarely on

normal skin.

Cause

The actual cause is not known

Pre-disposing factors
 Escape of menstrual tissue to the

fallopian tubes and ovaries

(Retrograde menstruation)

 Surgery involving the uterus like

C/S, D&C.

 Too late prime para (over 30 years)

 Genetic makeup (tend to run in

families) especially first degree

relatives like mother, sister,

daughter.

 Race-common in Caucasians

 Abnormal uterus like retroverted

uterus
Signs and symptoms

 Some are asymptomatic

 Lower abdominal pain

 Irregular periods like spotting

before periods

 Infertility

 Painful coitus (dyspareunia)

 Pain during bowel opening

 Rectal bleeding during

menstruation. This is due to the

presence of endometrial tissue in

the rectum.
  Bleeding from the site during

menstruation

 Palpable mass (endometrioma)

 Adhesions

Diagnosis / investigations

 Presence of endometrial tissue in

the site after microscopic

examinations confirms the disease

(biopsy)

 Laparoscopy. To view the tubes and

ovaries for the presence of

endometrial tissue.
  Ultra sound scan. To visualize

pelvic organs for any abnormality.

 Barium enema with x-ray. To locate

the site of the tissue.

 Computerised Tomography (CT )

scan. To visualize the tissue.

 Magnetic Resonance Imaging

(MRI ).

 Blood for marker celle (CA-125 )

and antibodies to endometrial

tissue.

MANAGEMENT
Treatment depends on the symptoms,

pregnancy plans, age of the woman as

well as the extent of the disease.

 Drugs that suppress the activity of

ovaries and slow the growth of

endometrial tissue like COCs,

progestin and GnRH agonists.

 Surgery

 To remove as much of the

misplaced endometrium tissue as

possible

 3.Combination of drugs and surgery

 Total hysterectomy
COMPLICATIONS

 Infertility

 Adhesions leading to intestinal

obstruction

 Chronic lower abdominal pain

References

1. Hiralal Konar(2009)Textbook of

gynecology including contraception

5th Edition.
2. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

3. Thomas J.Bader(2007)OBS/GYN

secrets,3rd Edition.

4. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.
ABORTION

Objectives

 By the end of this session

students should be able to:

 Define abortion

 Describe types of abortion

 Describe causes of abortion

 To list signs and symptoms of

abortion

 Manage abortion
  To explain complications of

abortion

Definition.

Abortion can defined as termination of

pregnancy before 28 weeks of gestation

or viability.

The current WHO definition is

termination of pregnancy before

22weeks or when the fetus weigh 500 g

or less.

This may be spontaneous or

induced.Abortion is important as it
contributes to approximately 50% of

maternal deaths from the haemorrhage

and sepsis which may follow a

mismanaged abortion. It accounts for 95

% of cases of bleeding in early

pregnancy.

Causes of abortion

These are classified as: maternal and

fetal causes

The most common causes are maternal

factors including infections,maternal

illness,and intrauterine anatomic

abnormalities .In some cases

however,the exact cause is no known.

Fetal causes

Fetal abnormalities

Ablighted ovum,this is a pregnany in

which the fetus does not develop ,it is

usually genetic

Abnormal placental attachement in the

uterus Eg.placenta praevia,placenta

abruption.

Maternal causes

Medical Conditions
Hypothyroidism

women with hypothyroidism and

antithyroid antibodies are at risk for

spontaneous abortion. Thyroid

peroxidase autoantibodies are believed

to impair thyroid function during

pregnancy, leading to spontaneous

abortion and premature delivery.

Thyroid peroxidase antibodies are found

in patients with Hashimoto's thyroiditis.

Treatment with levothyroxine lowers

the risk of miscarriage.

Diabetes mellitus,pregnant patients with

diabetes and poor glycemic control

during the period of organogenesis

(within 7 weeks after conception) have

an increased rate of spontaneous

abortion, which is attributed to

hyperglycemia, possible immunologic

factors, and uteroplacental insufficiency

secondary to maternal vascular disease

Polycystic ovary syndrome, women with

polycystic ovary syndrome have a 3-fold

increased risk of early pregnancy loss.

This may be attributable to insulin

resistance with hyperinsulinemia and

high androgen levels

(hyperandrogenemia), which lead to

adverse effects on endometrial

development and embryonic

implantation.

Antiphospholipid antibodies, Nearly

60% of cases of recurrent pregnancy loss

are associated with the presence of

antiphospholipid antibodies.

Antiphospholipid antibodies comprise a

heterogeneous group of

immunoglobulins acting against plasma

proteins. These represent a possible

cause of spontaneous abortion through

promotion of microvascular thrombosis

in the placenta, leading to infarction.

Systemic lupus erythematosus, Women

with systemic lupus erythematosus have

risk of spontaneous abortion, likely due

to abnormal vascular supply to the

placenta and antiphospholipid

antibodies and lupus anticoagulant.

Appendicitis, Spontaneous abortion

occurs in patients with appendicitis

without perforation; the risk increases

to 36% in patients with perforation.

Intrauterine Causes

Asherman syndrome, This syndrome

occurs following curettage of the uterus.

Severe degrees of intrauterine

adhesions lead to obstruction of the

uterine cavity and subsequent

infertility. Mild degrees of adhesions are

associated with pregnancy loss, resulting

from constriction of the uterine cavity,

an insufficient amount of normal

endometrial tissue for implantation and

placental development, and defective

vascularization of the remaining

endometrial tissue caused by fibrosis

Fibroids, Women with submucosal

fibroids have a risk of miscarriage. A

possible mechanism of pregnancy loss

involves projection of the submucosal

fibroids into the uterine cavity, causing

distortion of the blood supply in the

endometrium and possibly interfering

with embryonic implantation.

Uterine malformations, Bicornuate

uterus is the most common

malformation and is the most common

malformation associated with recurrent

pregnancy loss.

Maternal Infections

Bacterial vaginosis, Bacterial vaginosis is

associated with obstetric complications,

including spontaneous abortion.

Treatment of bacterial vaginosis

includes topical or oral preparations of

clindamycin or metronidazole, neither

of which is associated with an increase

in teratogenic risk

Listeria monocytogenes infection,

Maternal infection with L.

monocytogenes affects the fetus in most

cases. Often the woman is exposed to the

bacterium through consumption of

unpasteurized cheese. Infection

occurring during the first 20 weeks of

gestation can result in pregnancy loss. L.

monocytogenes infection is suspected in

patients who develop fever 24 to 48

hours following spontaneous abortion.

Measles, Measles during pregnancy is

associated with a miscarriage rate as

high as 50% if infection occurred in the

first 2 months of gestation and a

miscarriage rate of 20% if infection

occurred in the third month of gestation.

Mumps, Mumps is an acute

paramyxovirus infection that presents

as fever with enlargement of the

salivary glands. There is an association

between maternal mumps and fetal

death or spontaneous abortion.

Toxoplasma

gondii infection( toxoplasmosis),

Toxoplasmosis acquired by the mother

in the first trimester of pregnancy can

results in fetal infection. Fetal infection

with T. gondii at this stage is associated

with miscarriage or fetal death.

Ureaplasma and Mycoplasma infection,

Chronic colonization of the cervix and

vagina
with Ureaplasma orMycoplasma has

been associated with an increased risk

of recurrent abortion.

Obstetric History.

Maternal age at the time of conception,

There is an increased incidence of

pregnancy loss with increasing maternal

age, which is due to an increased

incidence of aneuploidy, resulting in a

decreased implantation rate.

Previous spontaneous abortion, There is

a risk of abortion after a previous

spontaneous abortion. This risk

increases after 2 and 3 cases of

spontaneous abortion, respectively.

Diet and Lifestyle.

Coffee consumption, Coffee

consumption during pregnancy

increases the risk of miscarriage in a

dose-response relationship, showing a

higher risk associated with caffeine

consumption ≥200 mg (approximately

100 mg per 150 mL of caffeinated coffee)

per day

Obesity, In obese patients, insulin

resistance is an independent risk factor

for early pregnancy loss

Smoking, Tobacco smoke interferes with

the normal process of angiogenesis

(formation of new blood vessels),

possibly increasing the risk of

spontaneous abortion in pregnant

women who smoke. There are no exact

data on this risk.

Substance abuse,Cocaine use in the first

trimester of pregnancy is associated

with an increased risk of spontaneous

abortion

Signs and symptoms of abortion

Most abortions occur in the first three

months of pregnancy before the

placenta is mature, the detachment of

the ovum is accompanied by bleeding

which may be profuse. The blood loss is

accompanied by painful contractions of

the uterus, dilation of the cervix and

expulsion of the ovum and its

membranes.

Slight or even moderate bleeding does

not, however, mean that the pregnancy

is no longer alive.

Miscarriages are also caused by a

variety of other factors, including:

 Infection

 Exposure to environmental and

workplace hazards such as high

levels of radiation or toxic agents

 Hormonal problems

 Uterine abnormalities

 Incompetent cervix (the cervix

begins to widen and open too early,

in the middle of pregnancy,

without signs of pain or labor)

 Lifestyle factors such as smoking,

drinking alcohol, or using illegal

drugs

 Disorders of the immune system,

including lupus

 Severe kidney disease

 Congenital heart disease

  Diabetes that is not controlled

 Thyroid disease

 Radiation

 Certain medications, such as the

acne drug Accutane

 Severe malnutrition

Types of abortion

I.Induced abortion: this is an abortion

that is caused intentionally. Reasons for

procuring induced abortions are

typically characterized as either

therapeutic or elective.
An abortion is medically referred to as a

therapeutic abortion when it is

performed to save the life of the

pregnant woman; prevent harm to the

woman's physical or mental health;

terminate a pregnancy where

indications are that the child will have a

significantly increased chance of

premature mobility or mortality or be

otherwise disabled; or to selectively

reduce the number of fetuses to lessen

health risks associated with multiple

pregnancy.
An abortion is referred to as an elective

or voluntary abortion when it is

performed at the request of the woman

for non-medical reasons. 

II.Subgroup of Spontaneous abortion

 Threatened abortion

 Inevitable abortion

 Incomplete abortion

 Complete abortion

 Missed abortion

 Habitual or recurrent abortion

Threatened abortion

This is blood loss from the uterus during

the first 28 weeks of pregnancy; the

patient may have some abdominal

discomfort but does not feel any actual

pain because there are no rhythmic

uterine contractions. If a vaginal

examination is done the cervix is found

to be closed.

Treatment

 Bed rest is the most important

treatment; it increases placental

blood flow and reduces pain. The

patient should remain in bed for five

to seven days or as long as the blood

is bright red.

 Give mild sedatives eg:

phenobarbitone 60 mg t.d.s, to ensure

the patient rests in bed if uterine

contractions become strong then

analgesics such as pethidine 100 mg

intramuscularly or morphine 15 mg

may be needed.

 Save the pads that have been used

in order to help to assess the amount

 of blood loss. Report any increase in

bleeding or pain.

Inevitable abortion:

The abortion becomes inevitable if, in

addition to the signs prescribed for

threatened abortion the Uterine

contraction becomes strong, painful and

lead to dilation of the cervix.

Incomplete abortion:

In this condition some the products of

conception remain in the uterus when

the fetus is passed. A vaginal

examination will show that cervix os is

open. Bleeding may either be severe or

slight but is continuous

Treatment

 If the patient has bled a great deal

and she is in shock, start a plasma-

expender drip after taking blood for

grouping and cross matching.

 Do a sterile vaginal examination

and remove any placental tissue

distending the cervix with a finger or

spongy forceps.
  If the patient is in pain, give 100

mg of pethidine or morphine 15 mg.

 Give ergometrine 0.5 mg

intramuscularly. Once these steps

have been taken the condition

usually improves and the patient can

be safely transferred to hospital.

 The uterus should be evacuated

surgically under general anaesthesia

in hospital.

Do not transfer shocked patient to

hospital resuscitate first.

Complete abortion:
This means that all products of

conception have been passed and the

uterus is empty. Treat an abortion as

incomplete if you have not examined the

uterus and made sure that the products

passed were completed. Does not

require medical attention.

Missed abortion:

In some cases of threatened abortion the

bleeding stops and everything seems to

be all right the signs of pregnancy begin

to disappear, however, breast activity

stops and the uterus does not get bigger.

After a time a brownish discharge

begins from the uterus.

This show that the fetus is dead but still

in the uterus. The dead fetus may turn

into a solid and hard mass, mostly of

organized blood clot, called a carneous

mole, in time this will be expelled with

little or no blood loss.

Refer cases of missed abortion to

hospital for management, as surgical

evacuation and checking of the uterus

may be necessary.

Habitual or recurrent abortion

A woman who has had three more

successive abortions is called habitual

aborter. In the majority of patients no

obvious causes can be found, some of

the known causes are chronic illness

such as diabetes mellitus and

abnormalities such as a septate uterus

and cervical incompetence. A pregnant

habitual aborter should always be

referred to hospital for management of

pregnancy and delivery.

Septic abortion

Infection of the uterus may follow any

abortion especially an incomplete or

induced abortion. This is usually caused

by Gram negative E.coli, but sometimes

gram positive streptococci and

staphylococci are involved.

In most cases infection is mild and

limited to the uterus, but in severe cases

it spreads to the fallopian tubes and may

spill into the peritoneal cavity to cause

peritonitis. Severe E coli infection may

lead to septicaemic shock caused by

endotoxins released from the organisms

Clinical feature

These include fever, fast pulse rate,

offensive vaginal discharge and

tenderness on palpation in the lower

abdomen

Treatment
The treatment of patient with a septic

abortion is an emergency as delay may

result in severe complications or death.

The patient should be managed in

hospital if possible but in most

situations there will be an inevitable

delay in the transfer to hospital, in such

cases treatment should be started as

soon as diagnosis is made.

The principles of management include:

 Resuscitation with intravenous

fluids
  Parenteral broad-spectrum

antibiotics

 Evacuation of infected products of

conception as soon as possible.

Fluid replacement

Most patients will have fluid deficit from

blood loss during abortion, or from poor

fluid intake due to ill health. Blood

transfusion should be done in hospital,

you should give two liters of normal

saline or dextrose/ saline in the first six

hours, the rest of fluid intake should

depend on urine output.

Antibiotic treatment

Where possible a cervical swab for

bacteriological culture and sensitivity

should be taken before starting

antibiotic treatment. The best antibiotics

are:

 Crystalline penicillin 4 mu

intravenously 6-hourly in

combination with streptomycin 0.5

mg intramuscularly every 12 hours,

or

 Crystalline penicillin 4 mu

intravenously 6-hourly in
 combination with chloramphenicol

or tetracycline 500 mg intravenously

6-hourly.

These antibiotics are continued for one

week, or as directed by results of

bacterial sensitivity. Where tetanus is a

high risk, add tetanus toxoid or anti

tetanus serum to the treatment.

Evacuation of the uterus

As soon as resuscitation is completed

and antibiotic treatment has been

started, the products of conception

should be evacuated from the uterus,

most patients who do not improve after

the above treatment have complications

which need the attention of more

qualified doctor.

Prevention of abortion.

 Emphasis on good antenatal

services for early detection of risk

factors

 Good nutrition

 Prevent vaginal infections

 Family planning

 Promote safe motherhood

  Prevent environmental hazards

Complications of abortion.

 Severe bleeding-anemia-shock-

renal failure

 Sepsis-septicaemia-PID-infertility-

ectopic pregnancy.

 Depression-marital disharmony

 Blood transfusion may

predispose patients to HIV, hepatitis

 Perforation of pelvic organs-

peritonitis. Etc.

References
 Poala Aghajarian, MD.et al. (2007)

current diagnosis and treatment in

Obstetrics and Gynecology 10th

Edition.

 Samantha M.Pfeifer (2008) NMS

Obstetrics and Gynecology 16th

Edition

 Hiralal Karar (2008) Textbook of

Gynecology including conception 5th

Edition
FIBROIDS

Learning objectives

Define the term fibroids

Describe the types of fibroids

List at least five signs and symptoms of

fibroids.

Describe the management of fibroids

State the complications of fibroids

Definition

A uterine fibroid is

a leiomyoma (benign, non-cancerous tu

mor from smooth muscle tissue) that

originates from the smooth muscle layer

(myometrium) of the uterus.

Fibroids are often multiple and if the

uterus contains too many leiomyoma to

count, it is referred to as diffuse uterine

leiomyomatosis. The malignant version

of a fibroid is extremely uncommon and

termed a leiomyosarcoma

Other common names are :uterine

leiomyoma, myoma, fibromyoma, fibrol

eiomyoma.
Fibroids are the most common benign

tumors in females and typically found

during the middle and later

reproductive years.

While most fibroids are asymptomatic,

they can grow and cause heavy and

painful menstruation, painful sexual

intercourse, and urinary frequency and

urgency. Some fibroids may interfere

with pregnancy although this appears to

be very rare.

  
Signs and symptoms

Fibroids, particularly when small, may

be entirely asymptomatic.

Symptoms depend on the location of the

lesion and its size. Important symptoms

include;

 Heavy or painful periods,

 Abdominal discomfort or bloating,

 Painful defecation,

 Back ache,

 Urinary frequency or retention,

  And in some cases, infertility. 

There may also be pain during

intercourse, depending on the location

of the fibroid. During pregnancy they

may also be the cause of  abortion,

bleeding, premature labor, or

interference with the position of the

fetus.

While fibroids are common, they are not

a typical cause for infertility accounting

for about 3% of reasons why a woman

may not have a child.

 Typically in such cases a fibroid is

located in a submucosal position and it

is thought that this location may

interfere with the function of the lining

and the ability of the embryo

to implant. Also larger fibroids may

distort or block the fallopian tubes.

Location and classification

Schematic drawing of various types of

uterine fibroids:

A: subserous fibroids

B: interstitial fibroids

C: submucous fibroid

D: pedunculated submucosal fibroid

E: fibroid in the cervix

F: fibroid of the broad ligament

Growth and location are the main

factors that determine if a fibroid leads

to symptoms and problems. A small

lesion can be symptomatic if located

within the uterine cavity while a large

lesion on the outside of the uterus may

go unnoticed. Different locations are

classified as follows:

Interstitial fibroids are located within

the wall of the uterus and are the most

common type; unless large, they may be

asymptomatic. Interstitial fibroids begin

as small nodules in the muscular wall of

the uterus. With time, interstitial

(intramural) fibroids may expand

inwards, causing distortion and

elongation of the uterine cavity.

Subserous fibroids are located

underneath the mucosal (peritoneal)

surface of the uterus and can become

very large. They can also grow out in a

papillary manner to become

pedunculated fibroids. These

pedunculated growths can actually

detach from the uterus to become a

parasitic leiomyoma.

Submucous fibroids are located in the

muscle beneath the endometrium of the

uterus and distort the uterine cavity;

even small lesions in this location may

lead to bleeding and infertility. A

pedunculated lesion within the cavity is

termed an intra-cavitary fibroid and can

be passed through the cervix.

Cervical fibroids are located in the wall

of the cervix (neck of the uterus). Rarely

fibroids are found in the supporting

structures (round ligament, broad

ligament, or uterosacral ligament) of the

uterus that also contain smooth muscle

tissue.

Fibroids may be single or multiple. Most

fibroids start in an intramural location

that is the layer of the muscle of the

uterus. With further growth, some

lesions may develop towards the outside

of the uterus or towards the internal

cavity. Secondary changes that may

develop within fibroids are hemorrhage,

necrosis, calcification, and cystic

changes.

. Diagnosis

 While a bimanual examination

typically can identify the presence of

larger fibroids, gynecologic
ultrasonography (ultrasound) has

evolved as the standard tool to

evaluate the uterus for fibroids.

 Sonography will depict the

fibroids as focal masses with a

heterogeneous texture, which usually

cause shadowing of the ultrasound

beam.

 The location can be determined

and dimensions of the lesion

measured. Also magnetic resonance

imaging (MRI) can be used to define

the depiction of the size and location

of the fibroids within the uterus.

 Imaging modalities cannot clearly

distinguish between the benign

uterine leiomyoma and the

malignant uterine leiomyosarcoma,

however, the latter is quite rare. Fast

growth or unexpected growth, such

as enlargement of a lesion after

menopause; raise the level of

suspicion that the lesion might be a

sarcoma. Also, with advanced

malignant lesions there may be

evidence of local invasion.

 Lesions biopsy is rarely

performed and if performed, is

rarely diagnostic. Should there be an

uncertain diagnosis after ultrasounds

and MRI imaging, surgery is

generally indicated.

 Other imaging techniques that

may be helpful specifically in the

evaluation of lesions that affect the

uterine cavity
 are hysterosalpingography or sonohy

sterography.

Treatment

Most fibroids do not require treatment

unless they are causing symptoms. After

menopause fibroids shrink and it is

unusual for fibroids to cause problems.

Symptomatic uterine fibroids can be

treated by:

 Medication to control symptoms

  Medication aimed at shrinking

tumours.

 Ultrasound fibroid destruction

 Myomectomy or radio frequency

ablation

 Hysterectomy

Medication

A number of medications are in use to

control symptoms caused by fibroids.

 Non-steroid anti-inflammatory

drugs( NSAIDs) can be used to reduce

painful menses.
 Oral contraceptive pills are

prescribed to reduce uterine bleeding

and cramps. 

 Anemia may have to be treated

with iron supplementation.

 Levonorgestrel intrauterine

devices are highly effective in

limiting menstrual blood flow and

improving other symptoms. Side

effects are typically very moderate

because

the levonorgestrel (aprogestin) is

released in low concentration locally.

 Danazol is an effective treatment

to shrink fibroids and control

symptoms. Its use is limited by

unpleasant side effects. Mechanism

of action is thought to be

antiestrogenic effects.

 Gonadotropin-releasing hormone

analogs cause temporary regression

of fibroids by decreasing estrogen

levels. Because of the limitations and

side effects of this medication it is

rarely recommended other than for

preoperative use to shrink the size of

the fibroids and uterus before

surgery. It is typically used for a

maximum of 6 months or less

because after longer use they could

cause osteoporosis and other

typically postmenopausal

complications. The main side effects

are transient postmenopausal

symptoms. In many cases the fibroids

will re-grow after cessation of

treatment, however significant

benefits may persist for much longer

in some cases. Several variations are

 possible, such as GnRH agonists with

add-back regimens intended to

decrease the adverse effects of

estrogen deficiency. Several add-back

regimes are

possible, tibolone, raloxifene, progest

ogens alone, estrogen alone, and

combined estrogens and

progestogens.

Radio frequency ablation

Radiofrequency ablation is one of the

newest minimally invasive treatments

for fibroids. In this technique the fibroid

is shrunk by inserting a needle-like

device into the fibroid through the

abdomen and heating it with radio-

frequency (RF) electrical energy to

cause necrosis of cells.

The treatment is a potential option for

women who have fibroids, have

completed child-bearing and want to

avoid a hysterectomy
Myomectomy

is a surgery to remove one or more

fibroids. It is usually recommended

when more conservative treatment

options fail for women who want

fertility preserving surgery or who want

to retain the uterus.

There are three types of myomectomy:

1. In a hysteroscopic myomectomy

(also called transcervical resection),

the fibroid can be removed by

either the use of a resectoscope,

an endoscopic instrument inserted

 through the vagina and cervix that

can use high-frequency electrical

energy to cut tissue, or a similar

device.

2. A laparoscopic myomectomy is

done through a small incision near

the navel. The physician uses a

laparoscope and surgical

instruments to remove the fibroids.

Studies have suggested that

laparoscopic myomectomy leads to

lower morbidity rates and faster

 recovery than does laparotomic

myomectomy.

3. A laparotomic myomectomy (also

known as

an open or abdominal myomectom

y) is the most invasive surgical

procedure to remove fibroids. The

physician makes an incision in the

abdominal wall and removes the

fibroids from the uterus.

Hysterectomy

Hysterectomy was the classical method

of treating fibroids. Although it is now

recommended only as last option,

Endometrial ablation

Endometrial ablation can be used if the

fibroids are only within the uterus and

not intramural and relatively small.

High failure and recurrence rates are

expected in the presence of larger or

intramural fibroids.
You should refer the patient to hospital,

further management is based on:

 The age of the patient

 Parity

 Size of the tumour

 Signs and symptoms caused by

the tumour

The treatment may therefore be the

removal of the tumour alone

(myomectomy) in a woman who wants

or expects more babies, or removal of

the whole uterus (total hysterectomy) in

woman who doesn’t expect more

deliveries.

NURSING MANAGEMENT

Nursing diagnosis

1. Acute pain related to inflammation

process in the uterine cavity due to

additional mass evidenced by mother’s

verbalization.

Nursing interventions

 Assess pain for intensity and

frequency. This helps in provision of

appropriate interventions for the

mother.

 Position the mother in sitting up

position. This improves muscle tone

and relieves pain.

 Encourage the mother to carry out

deep breathing exercises. This

increases comfort and reduces pain.

 Encourage the mother to use

warm compress. This increases

vasodilation of blood vessels at the

site of pain.
  Administer analgesics as

prescribed. This blocks pain

receptors.

2. Ineffective tissue perfusion related to

excessive bleeding evidenced by

pallor.

Nursing interventions

 Assess 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 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.

Complications

 Fibroids that lead to heavy

vaginal bleeding lead

to anemia and iron deficiency.

 Due to pressure effects

gastrointestinal problems such

as constipation and bloatedness are

possible.
  Compression of the ureter may

lead to hydronephrosis.

 Fibroids may also present

alongside endometriosis, which itself

may cause

infertility. Adenomyosis may be

mistaken for or coexist with fibroids.

 In very rare cases, malignant

(cancerous)

growths, leiomyosarcoma, of the

myometrium can develop.

References
 Poala Aghajarian, MD.et al. (2007)

current diagnosis and treatment in

Obstetrics and Gynecology 10th

Edition.

 Samantha M.Pfeifer (2008) NMS

Obstetrics and Gynecology 16th

Edition

 Hiralal Karar (2008) Textbook of

Gynecology including conception 5th

Edition

.
SEXUALLY TRANSMITTED INFECTIONS

(STIs)

Objectives

By the end of this session students

should be able to:

 Define sexually transmitted

infections

 Classify transmitted infections

  Explain the reasons of increase in

incidence of sexually transmitted

infections

 Describe some examples of

sexually transmitted infections

including their signs and

symptoms ,diagnosis and treatments

 Prevent sexually transmitted

infections

 List complications of sexually

transmitted infections

Definition
Sexually transmitted infections are

those infections which are

predominantly transmitted through

sexual contact from an infected partner.

However, although, sexually transmitted

infections are mostly due to sexual

contact, other modes of transmission

include :

 Placental(HIV,syphilis)

 Blood transfusion or infected

needles (HIV,Hepatitis B or Syphilis)

 Inoculation on to infant’s mucosa

when it passes through the birth

 canal (Gonococcal ,Chlamydial or

Herpes )

Incidence

There is rising trend of STIs throughout

the globe.The reasons of this are:

Rising prevalence of viral infections like

HIV,Hepatitis B and C,HPV,so that many

STIs come as result of immune system

incompetence.They are called

opportunistic infections
 Development of antibiotic

resistance by gonococcal infection

and other microbial organisms

 Increased promiscuity and

permissiveness (A disposition to

allow freedom of choice and

behavior)

 Increased use of family planning

techniques which do not protect

against STIs.

 Increased rate of oversea travel

 Lack of sex education and

inadequate practice of safer sex.

  Inclusion of more diseases mostly

of viral origin

Important sexually transmitted

infections are classified in the following

table

CLASS AND DISEASES

CAUSATIVE AGENT

Bacterial 1. Gonorrhoea

1. Neisseria 2. Non – gonococcal

gonorrhea urethritis

2. Chlamydia 3. Syphilis
 trachomatis(D-K 4. Lymphogranulo

serotypes) ma venereum

3. Treponema 5. Chancroid

pallidum 6. Granuloma

4. Chlamydia inguinale

trachomatis (L 7. Non specific

serotypes) vaginitis

5. Haemophilus 8. Mychoplasma

ducreyi infection

6. Donovania

granulomatis

7. Haemophilus

vaginalis
8. Mychoplasma

hominis

Viral 1. AIDS

1.Human 2. Genital herpes

immunodeficie 3. Condyloma

ncy virus (HIV acuminata

1or HIV2) 4. Mollusccum

2.Herpes contagiosum

simplex virus 5. Viral hepetitis

(HSV 2) 6.CIN

3.Human

papilloma

virus(HPV)
 4.Pox virus

5.Hepatitis B

and C virus

6.HPV-16,18 or

31

Protozoal 1.Bacterial

1. Gardenerella vaginosis (BV)

vaginalis 2.Trichomonas

2. Trichomonas vaginitis

vaginalis
Fungal 1.Monilial vaginitis

1.Candida

albicans

Ectoparasites 1. Scabies

1. Sarcoptes 2. Pediculosis pubis

scabiei

2. Crab

louse(phthitu

s pubis)
In this session few of the major sexual

transmitted infections are described.

GONORRHOEA

It is a gram negative diplococcus

bacteria affecting the epithelium of

genitourinary tract and the incubation

period is 3-7 days.

Clinical features in adults

About 50% of patients are asymptomatic

and even when the symptoms are

present are not specific.

The clinical features of gonoccoccaal

infection is described as follows:

 Local

 Distant or metastasis

 Pelvic inflammatory diseases(PID)

Local

Symptoms

 Dysuria

 Increased frequency of

micturition

 Excessive irritants vaginal

discharge
  Acute unilateral pain and swelling

over the labia due to involvement of

Bartholin’s gland

 There may be rectal discomfort

due to associated

proctitis(Inflammation of the rectum;

marked by bloody stools and a

frequent urge to defecate; frequently

associated with Crohn's disease or

ulcerative colitis) from genital

contamination

Signs
 Labia may be swollen and look

inflamed

 Purulent vaginal discharge

 The external urethral meatus and

the opening of the bartholin’s ducts

look congested .On squizing the

urethra and giving pressure on the

bartholin’s glands ,purulent exudate

escapes out through the openings.

 Bartholin’s glands may be

probably enlarged,tender with

fluctuation ,suggestive of formation

of abcess.
Distant or metastasis

 There may be features of

perihepatitis due to spread of the

infection to the liver capsule and

septicemia.Septicemia is

characterized by:

o low grade fever,

o Polyarthralgia

o Septic arthritis

o Meningitis,

o Endicarditis and

o Skin rash.
  Formation of adhesions with

abdominal wall

Diagnosis

 Gram stain and Culture of

secretion from the urethra, cervix

and bartholin’s gland

 Drug sensitivity

Treatment

Preventive

 Treat adequately the male sexual

partner simultaneously

 To avoid multiple sexual partners

  Adequate therapy for gonococcal

infection and meticulous follow up to

be done till complete cure

 When taking medications ,use of

condom till both partners are free

from a disease

Curative

Asingle dose is adequate of any of the

following ;

 Ceftriaxone-125 mg IM

 Ciprofloxacin-500mg orally

 Ofloxacin-400mg orally
  Cefixim-400mg orally

 Levofloxacin-250mg orally.

It should be borne in mind that the

patient with gonorrhea must be

suspected of having syphilis or

Chlamydial infection.As

such ,treatment should cover all the

three.

Follow up

Culture should be made 7 days after

treatment .Repeat cultures are made

monthly intervals following mens for 3

months.If reports are persistently

negative, then the person is declared

cured.

SYPHILIS

Syphilitic lesion of the genital tract is

acquired by direct contact with another

person who has an open primary or

secondary syphilitic

lesion .Transmission occurs through the

abraded skin or mucosal surface.

The incubation period ranges from 9-90

days.

There are 5 clinical stages of syphilis

The primary lesion (chancre)

 It may be a single or multiple

lesions located in the

labia,fourchette,anus,cervix,and

nipples.

 A small papule is formed which is

quickly eroded to form an ulcer.

 Enlargement of inguinal glands

with discrete pain or painless

 The primary chancre heals

spontaneously in 1-8 weeks with scar

formation.

 The tubes are not affected and

infertility does not occur unless

associated with gonorrhea.

Secondary syphilis
 Within 6 weeks to 6 months from

the onset of primary chancre ,the

secondary syphilis may be evidenced

in the vulva in the form of

condyloma lata

 Patient may present with systemic

symptoms like;fever,headache and

sore throat.

 Maculopapular skin rashes are

seen in the palms and soles.

 Generalised

lymphadenopathy ,mucosal ulcers

and alopecia
  The primary and secondary stages

can last up to 2 years and the woman

is a source of infection.

Latent syphilis

It is the dormant phase after the

primary and secondary syphilis has

resolved .It may be early(less than 2

years from the onset of a disease) or late

(duration more than 2 years from the

onset of a disease)

Tertiary syphilis
 This is an advanced stage from

untreated latent syphilis.

 The risks are the development of

neurosyphilis and cardiovascular

syphilis.

 There is endarteritis and

periarteritis of small and medium

sized vessels.

 There is formation gumma. A

gummatous ulcer is a deep punched

ulcer with rolled out margins.It is

painless with a moist leather base.

 Ophthalmic and auditory lesions.

Gongenital syphilis

Acquired during intrauterine life

through placental

circulation(transplacental

hematogenous inoculation) or during

birth through contact with maternal

genital tract. Newborns with congenital

syphilis may appear healthy at birth but

often develop symptoms weeks or

months later.

Clinical features of syphilis

 Hepatosplenomegaly and

lymphadenitis

 Osteochondritis

 Jaundice and anemia

 Skin lesions

 Rhinitis

 Lymphadenopathy

 Nervous system involvement

 Symptoms may develop weeks or

months later.

 The bones usually reveal signs of

osteochondritis and an irregular

epiphyseal juncture on x-ray.

  The eyes, central nervous system

structures, and other organs may

reveal abnormalities at birth, or

defects may develop later in

untreated cases.

Diagnosis

 Through history taking

 Laboratory tests eg.VDRL(positive

after 6 weeks of infection)

Differential Diagnosis

Primary syphilis must be differentiated

from chancroid, granuloma inguinale,

lymphogranuloma venereum, herpes

genitalis, carcinoma, scabies, trauma,

lichen planus, psoriasis, drug eruption,

aphthosis, mycotic infections, Reiter's

syndrome, and Bowen's disease.

Secondary syphilis must be

differentiated from , psoriasis, drug

eruption, parasitic infections, iritis,

neuroretinitis, condyloma acuminatum,

acute exanthems, infectious

mononucleosis, alopecia, and

sarcoidosis.
Treatment

 Benzathine penicillin G2.4 million

units is given IM weekly for 3

weeks

 Alternative regimen: Doxycycline

100mg orally twice daily or

Tetracycline 500mg orally 4 times a

day for 4 weeks.

 Follow up test very crucial

Prevention

 Early diagnosis and treatment

 Heath education about STIs

 Teach about condom use

CHLAMYDIAL INFECTTIONS

It is an obligatory intracellular gram

negative bacteria.Its prevalence is more

than N.gonorrhea as causative agent for

STIs in developed countries.

It has longer incubation period of 6-14

days compared to gonorrhea (3-

7days).The organisms affects mostly the

superficial surface of genitourinary tract

.The infection is localized in the

urethra,Bartholin’s gland and

cervix.Like gonococcaal infection ,it can

also ascend upstairs to produce acute

pelvic inflammatory disease.

Clinical features

They are non-specific and asymptomatic

in 75%.

Presenting symptoms are:

 Dysuria
  Dyspareunia

 Postcoital bleeding

 Intermenstrual bleeding

 Mucopurulent cervical discharge

 Cervical oedema

 Cervical ectopy

 Cervical friability

Diagnosis

 Endocervical smear laboratory

test

 Tissue culture
  Urine test(first void urine

specimen is most effective and

specific)

Treatment

 Azithromycin-1 gm orally single

dose or

 Doxycycline-100mg orally bid for

7 days or

 Ofloxacin-200mg orally bid for

7days

 Erythromycin-500mg orally bid

for 7 days
The sexual partner should also be

treated with the he same regimen

Complications

 Urethritis and bartholinitis which

are manifested by dysuria and

vaginal dishacharge

 Pelvic inflammatory diseases

 Tubal scarring resulting to

infertility and ectopic pregnancy

 Perihepatitis via lymphatics and

peritoneal cavity

Prevention
  Like in gonococcal infections

Chancroid(soft sore)

 It is a STI caused by a gram

negative streptobacillus –

Haemophilus ducreyi.

 The incubation period is 3-5 days

or less.

Signs and symptoms

 The lesion starts as multiple

vesicopustulesover the vulva, vagina

or cervix
  Circumscribed ulcers formation

on inflammatory zone

 The lesion is very tender with foul

purulent and haemorrhagic

discharge

 There may be cluster on ulcers

 Inguinal lymphadenitis

Diagnosis

 Syphilis must be ruled out first

 Discharge from ulcer pus from

lymph glands is taken for culture

Treatment
 Ceftriaxone 250 mg IM single dose

is effective

 Both sexual partners to be treated

 Azithromycin 1 g orally single

dose

 Erythromycin 500 mg orally every

6 hours for 7 days

 Longer course therapy is needed

in HIV positive patients

BACTERIAL VAGINOSIS (BV)

(BACTERIAL VAGINITIS)

This is a STI caused by bacterial

infections such as Gardenella vaginalis

(haemophilus vaginalis) and

trichomonas vaginalis .

Gardenella vaginalis may be with

anaerobic organisms such as bacteroids

species,peptococcus species ,mobiluncus

and mycoplasma hominis ,acting

synergistically to cause vaginal

infection.
Signs and symptoms

 Creamy vaginal discharge with

fishy smell without evidence of

inflammattion

 Bacterial vaginosis is

characterized by malodorous

vagianal discharge

 The discharge is

homogeneous ,grayish-white and

adherent to the vaginal wall

Diagnosis

 Through signs and symptoms

  Litmus paper test-vaginal pH is

alkaline(pH>4.7)

 Microscopic test with a smear of

vaginal discharge

Treatment

 Mitronidazole-200mg orally three

time s a day for 7 days

 Clindamycin cream (2%) and

metronidazole gel are recommended

for vaginal application to prevent

obstetric complications.

 The patuent’s sexual partner

should be treated simultaneously

Complications

 Preterm ruoture of membranes in

pregnant women ,preterm labour

and chorioamnionitis

 Recurrent infectttion leading to

PID

 Pregnancy complication-second

trimester miscarriage,preterm birth

and endometritis.

GENITAL WARTS (CONDYLOMA

ACUMINATA)
Condylomata are papillary lesions

caused by Human Papilloma Virus(HPV)

usually type 6 and 11.

These are usually multiple and can be

contaminated from other parts of the

body.

Transmission is majorly through sexual

contact.Associated vaginal discharge

favours their growth and so does

pregnancy.

Typically,they grow in clusters along a

narrow stalk giving it a appearance

cauliflower but at time the stalk may be

broad and thick.

It may spread to the vagina or even the

cervix .Very rarely, it becomes

malignant

Anatomic distribution of anogenital

HPV infection

 Cervix :70%

 Vulva:25%

 Vagina:10%

 Anus :20%

Predisposing factors
  Immunosupression

 Diabetes

 Pregnancy and local trauma

 Multiple sexual partners

Treatment

 Podophylin liquid and cream

preparations are used locally two

times daily for 3 days then repeated

after after a break of 4 days

 Trichloroacetic acid (90-

100%)solution is used for isolated

warts that respond poorly to

podophylin
Destructive methods such as

cryotherapy, electrodiathermy ,laser

therapy or surgical removal are used for

resistant cases .

PELVIC INFLAMMATORY DISEASES

(PID)

Objectives

 By the end of this session

stundents should be able to

 Define pelvic inflammatory

diseases
 Outline risk factors for pelvic

inflammatory diseases

 Expain the pathophyssilogy of PID

 List signs and symptoms

 Diagnose

 List differential diagnosis of PID

 To prevent pelvic inflammatory

diseases

 List the common causative agents

of PID

 Manage the patient with pelvic

inflammatory diseases
  List ccomplications of pelvic

inflammatory diseases

Definition:Is a disease of upper genital

tract.It is a spectrum of infection and

inflammation of the upper genital tract

organs typically involving the

endometrium,fallopian

tubes,ovaries,pelvic peritoneum and

surrounding structures.

Thus the better terminology should be

either endometritis ,salpingitits,pelvic

peritonitis or tubo-ovarian abcess.the

cervicitis is not included in the list.

Epidemiology

Despite advanced medical knowledge ,

pelvic inflammatory disease constitutes

a health hazard both in the developed

and more so in the developing countries.

The incidence of pelvic infection is on

the rise due to the rise in sexually

transmitted diseases.

The ready availability of contraception

together with increased permissive

sexual attitude has resulted in increased

incidence of STDs
and,correspondingly,acute PID. The

incidence varies from 1-2 % per year

among sexually active women.About

85% of cases are spontaneous infection

in sexually active women.The

remaining 15% follow unsafe

procedures such as endometrial

biopsy,uterine curettage,insertion of IUD

and hysterosalpingography.2/3 are

restricted to young women of less

than25 years and the remaining 1/3 is

limited among 30years or older.

Risk factors
 Menstruating teenagers, due to

low hormonal and cell mediated

immune defence response to genital

tract infection(Chlamydia

trachomatis and N.gonorrhea)

 Previous history of PID

 Absence of contraceptive pill use

 IUD users

 Area of high prevalence of STDs.

 Multiple sexual partners

 Pathophysilogy
The pathological process is primarily in

the endosalpinx.The involvement of

tubes is always bilateral and usually

following mens due to loss of genital

defence.

All layers of the tube are invaded by

microorganisms which produce an

inflammatory reactions ;they become

oedematous and hyeraemic . There is

gross destruction of the epithelial

cells,cilia,and microvilli.The products of

destruction from layers (exfoliated

cells)along with exudates accumulate

on the mucosal folds of the tube lumen.

The tubal space is closed by the

indrawing of the edematous fimbriae

and by inflammatory adhesions causing

the accumulation of exudates in the

tube.Depending on the virulence of

microorganism ,the exudates may be

watery or purulent.

The congestion of the tube with

purulent exudates together with

exfoliated tissues favours growth of

other pyogenic and anaerobic organisms

resulting in deeper penetration and

more tissue destruction so the damage

may extend beyond causing pelvic

peritonitis and pelvic abcess or may

affect ovaries producing ovarian

abcess.Tubo-ovarian abcess is thus

formed.The infection also may extend to

the endometrium.

Signs and symptoms

 Bilateral lower abdominal pain

and pelvic pain which is dull in

nature.The onset of pain is more

rapid and acute in gonococcaal

infection(3 days) and Chlamydial

infection(5-7days)

 Fever, lassitude and headache

 Irregular and excessive vagianal

bleeding is usually associated wit

endometritis.

 Abnormal vaginal discharge

which becomes purulent and or

copius

 Nausea and vomiting

 Dyspareunia
  Pain and discomfort in right

hypochondrium due to liver

involvement.

 Adnexal mass

 Temperature is beyond 38oC

 Te nderness on both the

quadrants of lower abdomen.The

liver may be enlarged or tender.

 Speculum shows congested cervix

with purulent discharge from the

canal

Diagnosis
  Laboratory doccumantation of

positive cervical infection with

gonorrhea or Chlamydia trachomatis

 Histopathogic evidence of

endometritis on biopsy

 Sonographic evidence of tubo-

ovarian complex

 Laparoscopic evidedence of PID

Differential diagnosis

 Appendicitis

 Disturbed ectopic pregnancy

 Hemorrhage or rupture of

ovarian cyst
  Urinary tract infection

Treatment

Treatment is made of antibiotics and

surgical operation if the damage is

severe.

Out-patient antibiotics

Patients should take oral therapy for 7-

14 days

 Doxycycline100mg two times a day

 Erythromycin 500 mg four times a

day

 Tetracycline 500 mg four times a day

For anaerobic

microorganisms,Metronidazole 400 mg

orally twice a day

Specific therapy for Gonococcal and

chlamydial infections

Chlamydia trachomatis infection

 Doxycycline 100mg orally twice a day

for 7 days

 Azithromycin 1 g orally single dose

 Ofloxacin 400mg orally twice a day

for 7 days
Neisseria gonorrhea infection

 Ceftriaxone 250mg deep IM single

dose

 Ciprofloxacin 500mg orally single

dose

All out- patients are evaluated after 48

hours of therapy and if no response ,are

to be hospitalized.

In-patient antibiotics

Indication of in-patient antibiotic

therapy
  Suspected pelvis abscess

 Severe illness, temperature >38 oC .

 Uncertaain diagnosis –where

surgical emergencies like ectopic

pregnancy cannot be ruled out

 Unresponsiveness to out-patient

antibiotics for 48 hours

 Intolerence to oral antibiotics

 Co-existing pregnancy

 Known HIV patients

In-patient therapy

 Bed rest is imposed

 Oral feeding id restricetsd

  Dehydration and acidosis are

corrected by intravenous fluid

 Ceftriaxitin 2mg IV 4 times a day for

2-4 days

 Gentamycin 2mg/kg IV (loading

dose)followed by 1.5 mg /kg

(maintainance dose) every 8 hours

and Metronidazole 500mg IV every 8

hours.

Improvement of the patient is marked

by improvement of signs and symptoms.

Surgery
  Indication for surgery

 Generalised peritonitis

 Pelvic abscess

 Tubo-ovarian abscess which does

not respond to antimicrobial therapy.

Follow up

 Repeat laboratory tests are to be

done after 7 days of full course of

treatment

 The tests are to be done after three

consecutive menstrual periods before

the patient is declared cured.

  The patient is prohibited intercourse

during treatment

Remember to treat the partner

effectively

Preventive measures

 Barrier method of

contraception,specially condom

along with spermcidals

 Oral steroidal contraception ,they

have got two mechanisms of action:

 Produce thick mucus preventing

the ascending sperms and

microorganisms.

 Decrease in duration of

menstruation hence creates a shorter

interval of bacterial colonization of

the upper tract.

 Avoid multiple partners

 Routine screening in high risk

population Pregnancy

 Menopause

 Husbands who are azoospermic

Microbiology

Acute PID is usually a polymicrobial

infection caused by ascending upstairs

from downstairs.

 The primary organisms

are :Neisseria gonorrhea which

accounts for 30%,Chlamydia

trachomatis-30% and mycoplasma

homonis in 10%.

 The secondary organisms are :

  Aerobic organisms –non-

hemolytic

streptococcus,Escherchia

coli(E.coli),group B streptococcus

and staphylococcus.

 Anaerobic organisms –

Bacteroids species,fragilis and

bivius,peptostreptococcus and

peptococcus.

Complications

Immediate complications
  Pelvic peritonitis or even generalized

peritonitis

 Septicemia-producing arthritis or

myocarditis

Late complications

 Dyspareunia

 Infertility due to tubal damage or

tubo-ovarian mass

 Chronic pelvic inflammation due to

recurrent or associated pyogenic

infection

 Adhesions

 Chronic pelvic pain and ill health

  Increased risk of ectopic pregnany

References

 Samantha M.Pfeifer (2008) NMS

Obstetrics and Gynecology 16th

Edition

 Hiralal Karar (2008) Textbook of

Gynecology including conception 5th

Edition

PELVIC INFLAMMATORY DISEASES

(PID)
Objectives
  By the end of this session
stundents should be able to
 Define pelvic inflammatory
diseases
 Outline risk factors for pelvic
inflammatory diseases
 Expain the pathophyssilogy of PID
 List signs and symptoms
 Diagnose
 List differential diagnosis of PID
 List the common causative agents
of PID
 Manage the patient with pelvic
inflammatory diseases To prevent
pelvic inflammatory diseases
 List ccomplications of pelvic
inflammatory diseases
Definition:Is a disease of upper genital
tract.It is a spectrum of infection and
inflammation of the upper genital tract
organs typically involving the
endometrium,fallopian
tubes,ovaries,pelvic peritoneum and
surrounding structures.
Thus the better terminology should be
either endometritis ,salpingitits,pelvic
peritonitis or tubo-ovarian abcess.the
cervicitis is not included in the list.
Epidemiology
Despite advanced medical knowledge ,
pelvic inflammatory disease constitutes
a health hazard both in the developed
and more so in the developing countries.
The incidence of pelvic infection is on
the rise due to the rise in sexually
transmitted diseases.
The ready availability of contraception
together with increased permissive
sexual attitude has resulted in increased
incidence of STDs
and,correspondingly,acute PID. The
incidence varies from 1-2 % per year
among sexually active women.About
85% of cases are spontaneous infection
in sexually active women.The
remaining 15% follow unsafe
procedures such as endometrial
biopsy,uterine curettage,insertion of IUD
and hysterosalpingography.2/3 are
restricted to young women of less
than25 years and the remaining 1/3 is
limited among 30years or older.
Risk factors
 Menstruating teenagers, due to
low hormonal and cell mediated
 immune defence response to genital
tract infection(Chlamydia
trachomatis and N.gonorrhea)
 Previous history of PID
 Absence of contraceptive pill use
 IUD users
 Area of high prevalence of STDs.
 Multiple sexual partners

Pathophysilogy

The pathological process is primarily in

the endosalpinx.The involvement of
tubes is always bilateral and usually
following mens due to loss of genital
defence.
All layers of the tube are invaded by
microorganisms which produce an
inflammatory reactions ;they become
oedematous and hyeraemic .
There is gross destruction of the
epithelial cells,cilia,and microvilli.
The products of destruction from layers
(exfoliated cells)along with exudates
accumulate on the mucosal folds of the
tube lumen.
The tubal space is closed by the
indrawing of the edematous fimbriae
and by inflammatory adhesions causing
the accumulation of exudates in the
tube.
Depending on the virulence of
microorganism ,the exudates may be
watery or purulent.
The congestion of the tube with
purulent exudates together with
exfoliated tissues favours growth of
other pyogenic and anaerobic organisms
resulting in deeper penetration and
more tissue destruction so the damage
may extend beyond causing pelvic
peritonitis and pelvic abcess or may
affect ovaries producing ovarian
abcess.Tubo-ovarian abcess is thus
formed.The infection also may extend to
the endometrium.
Signs and symptoms
 Bilateral lower abdominal pain
and pelvic pain which is dull in
nature.The onset of pain is more
rapid and acute in gonococcaal
 infection(3 days) and Chlamydial
infection(5-7days)
 Fever, lassitude and headache
 Irregular and excessive vagianal
bleeding is usually associated wit
endometritis.
 Abnormal vaginal discharge
which becomes purulent and or
copius
 Nausea and vomiting
 Dyspareunia
 Pain and discomfort in right
hypochondrium due to liver
involvement.
 Adnexal mass

 Temperature is beyond 38oC
  Te nderness on both the
quadrants of lower abdomen.The
liver may be enlarged or tender.
 Speculum shows congested cervix
with purulent discharge from the
canal
Diagnosis
 Laboratory doccumantation of
positive cervical infection with
gonorrhea or Chlamydia trachomatis
 Histopathogic evidence of
endometritis on biopsy
 Sonographic evidence of tubo-
ovarian complex
 Laparoscopic evidedence of PID
Differential diagnosis
 Appendicitis
 Disturbed ectopic pregnancy
  Hemorrhage or rupture of
ovarian cyst
 Urinary tract infection
Treatment
Treatment is made of antibiotics and
surgical operation if the damage is
severe.
Out-patient antibiotics
Patients should take oral therapy for 7-
14 days
 Doxycycline100mg two times a day
 Erythromycin 500 mg four times a
day
 Tetracycline 500 mg four times a day
For anaerobic
microorganisms,Metronidazole 400 mg
orally twice a day
Specific therapy for Gonococcal and
chlamydial infections
Chlamydia trachomatis infection
 Doxycycline 100mg orally twice a day
for 7 days
 Azithromycin 1 g orally single dose
 Ofloxacin 400mg orally twice a day
for 7 days
Neisseria gonorrhea infection
 Ceftriaxone 250mg deep IM single
dose
 Ciprofloxacin 500mg orally single
dose
All out- patients are evaluated after 48
hours of therapy and if no response ,are
to be hospitalized.
In-patient antibiotics
Indication of in-patient antibiotic
therapy
 Suspected pelvis abscess
 Severe illness, temperature >38 oC .
 Uncertaain diagnosis –where
surgical emergencies like ectopic
pregnancy cannot be ruled out
 Unresponsiveness to out-patient
antibiotics for 48 hours
 Intolerence to oral antibiotics
 Co-existing pregnancy
 Known HIV patients
In-patient therapy
 Bed rest is imposed
 Oral feeding id restricetsd
 Dehydration and acidosis are
corrected by intravenous fluid
  Ceftriaxitin 2mg IV 4 times a day for
2-4 days
 Gentamycin 2mg/kg IV (loading
dose)followed by 1.5 mg /kg
(maintainance dose) every 8 hours
and Metronidazole 500mg IV every 8
hours.
Improvement of the patient is marked
by improvement of signs and symptoms.
Surgery
 Indication for surgery
 Generalised peritonitis
 Pelvic abscess
 Tubo-ovarian abscess which does
not respond to antimicrobial therapy.
Follow up
  Repeat laboratory tests are to be
done after 7 days of full course of
treatment
 The tests are to be done after three
consecutive menstrual periods before
the patient is declared cured.
 The patient is prohibited intercourse
during treatment
Remember to treat the partner
effectively

Preventive measures
 Barrier method of
contraception,specially condom
along with spermcidals
 Oral steroidal contraception ,they
have got two mechanisms of action:
  Produce thick mucus preventing
the ascending sperms and
microorganisms.
 Decrease in duration of
menstruation hence creates a shorter
interval of bacterial colonization of
the upper tract.
 Avoid multiple partners
 Routine screening in high risk
population Pregnancy
 Menopause
 Husbands who are azoospermic
Microbiology
Acute PID is usually a polymicrobial
infection caused by ascending upstairs
from downstairs.
 The primary organisms
are :Neisseria gonorrhea which
 accounts for 30%,Chlamydia
trachomatis-30% and mycoplasma
homonis in 10%.
 The secondary organisms are :
 Aerobic organisms –non-
hemolytic
streptococcus,Escherchia
coli(E.coli),group B streptococcus
and staphylococcus.
 Anaerobic organisms –
Bacteroids species,fragilis and
bivius,peptostreptococcus and
peptococcus.
Complications
Immediate complications
 Pelvic peritonitis or even generalized
peritonitis
  Septicemia-producing arthritis or
myocarditis
Late complications
 Dyspareunia
 Infertility due to tubal damage or
tubo-ovarian mass
 Chronic pelvic inflammation due to
recurrent or associated pyogenic
infection
 Adhesions
 Chronic pelvic pain and ill health
 Increased risk of ectopic pregnany

References
 4. National Medical Series for
Independent Study (2008) Obstetrics
and Gynaecology, 6th Edition.
5. Thomas J.Bader(2007)OBS/GYN
secrets,3rd Edition.
Hacker et al. (2007) Essential of
Obstetrics and Gynaecology, 4th Edition.
SEXUALLY TRANSMITTED
INFECTIONS (STIs)

Definition
Sexually transmitted infections are
those infections which are
predominantly transmitted through
sexual contact from an infected partner.
However, although, sexually transmitted
infections are mostly due to sexual
contact, other modes of transmission
include :
 Placental(HIV,syphilis)
 Blood transfusion or infected
needles (HIV,Hepatitis B or Syphilis)
 Inoculation on to infant’s mucosa
when it passes through the birth
canal (Gonococcal ,Chlamydial or
Herpes )
Complications of sexually transmitted
infections
Gynecological morbidities and
mortalities associated with sexually
transmitted diseases are high:
 Infertility
 Chronic pelvic infections such as
endometritis, salpingitis.etc.
  Pain resulting to an STI disease
process
 Ectopic Pregnancy like in the
uterine fibroids
 Vulval and cervical neoplasia

Incidence
There is rising trend of STIs throughout
the globe.The reasons of this are:
Rising prevalence of viral infections like
HIV,Hepatitis B and C,HPV,so that many
STIs come as result of immune system
incompetence.They are called
opportunistic infections
 Development of antibiotic
resistance by gonococcal infection
and other microbial organisms
  Increased promiscuity and
permissiveness (A disposition to
allow freedom of choice and
behavior)
 Increased use of family planning
techniques which do not protect
against STIs.
 Increased rate of oversea travel
 Lack of sex education and
inadequate practice of safer sex.
 Inclusion of more diseases mostly
of viral origin

Important sexually transmitted

infections are classified in the following
table
CLASS AND DISEASES
CAUSATIVE AGENT

Bacterial 9. Gonorrhoea
9. Neisseria 10. Non – gonococcal
gonorrhea urethritis
10. Chlamydia 11. Syphilis
trachomatis(D-K 12. Lymphogranulo
serotypes) ma venereum
11. Treponema 13. Chancroid
pallidum 14. Granuloma
12. Chlamydia inguinale
trachomatis (L 15. Non specific
serotypes) vaginitis
13. Haemophilus 16. Mychoplasma
ducreyi infection
14. Donovania
 granulomatis
15. Haemophilus
vaginalis
16. Mychoplasma
hominis
Viral 6. AIDS
7.Human 7. Genital herpes
immunodeficie 8. Condyloma
ncy virus (HIV acuminata
1or HIV2) 9. Mollusccum
8.Herpes contagiosum
simplex virus 10. Viral hepetitis
(HSV 2) 6.CIN
9.Human
papilloma
virus(HPV)
10. Pox virus
11. Hepatitis B
 and C virus
12. HPV-16,18
or 31

Protozoal 3.Bacterial
3. Gardenerella vaginosis (BV)
vaginalis 4.Trichomonas
4. Trichomonas vaginitis
vaginalis

Fungal 1.Monilial vaginitis

2.Candida
albicans

Ectoparasites 3. Scabies
3. Sarcoptes 4. Pediculosis pubis
 scabiei
4. Crab
louse(phthitu
s pubis)

In this session few of the major sexual

transmitted infections are described.
GONORRHOEA
It is a gram negative diplococcus
bacteria affecting the epithelium of
genitourinary tract and the incubation
period is 3-7 days.
Clinical features in adults
About 50% of patients are asymptomatic
and even when the symptoms are
present are not specific.
The clinical fatures of gonoccoccaal
infection is described as follows:
 Local
 Distant or metastasis
 Pelvic inflammatory diseases(PID)
Local
Symptoms
 Dysuria
 ncreased frequency of micturition
 Excessive irritants vaginal
discharge
 Acute unilateral pain and swelling
over the labiadue to involvement of
Bartholin’s gland
  There may be rectal discomfort
due to associated
proctitis(Inflammation of the rectum;
marked by bloody stools and a
frequent urge to defecate; frequently
associated with Crohn's disease or
ulcerative colitis) from genital
contamination
Signs
 Labia may be swollen and look
inflamed
 Purulent vaginal discharge
 The external urethral meatus and
the opening of the bartholin’s ducts
look congested .On squizing the
urethra and giving pressure on the
bartholin’s glands ,purulent exudate
escapes out through the openings.
  Bartholin’s glands may be
probably enlarged,tender with
fluctuation ,suggestive of formation
of abcess.
Distant or metastasis
 There may be features of
perihepatitis due to spread of the
infection to the liver capsule and
septicemia.Septicemia is
characterized by:
o low grade fever,
o Polyarthralgia
o Septic arthritis
o Meningitis,
o Endicarditis and
o Skin rash.
 Formation of adhesions with
abdominal wall
Diagnosis
 Gram stain and Culture of
secretion from the urethra, cervix
and bartholin’s gland
 Drug sensitivity
Treatment
Preventive
 Treat adequately the male sexual
partner simultaneously
 To avoid multiple sexual partners
 Adequate therapy for gonococcal
infection and meticulous follow up to
be done till complete cure
 When taking medications ,use of
condom till both partners are free
from a disease
Curative
Asingle dose is adequate of any of the
following ;
 Ceftriaxone-125 mg IM
 Ciprofloxacin-500mg orally
 Ofloxacin-400mg orally
 Cefixim-400mg orally
 Levofloxacin-250mg orally.
It should be borne in mind that the
patient with gonorrhea must be
suspected of having syphilis or
Chlamydial infection.As
such ,treatment should cover all the
three.

Follow up
Culture should be made 7 days after
treatment .Repeat cultures are made
monthly intervals following mens for 3
months.If reports are persistently
negative, then the person is declared
cured.
SYPHILIS
Syphilitic lesion of the genital tract is
acquired by direct contact with another
person who has an open primary or
secondary syphilitic
lesion .Transmission occurs through the
abraded skin or mucosal surface.
The incubation period ranges from 9-90
days.

There are 5 clinical stages of syphilis

The primary lesion (chancre)
 It may be a single or multiple
lesions located in the
labia,fourchette,anus,cervix,and
nipples.
 A small papule is formed which is
quickly eroded to form an ulcer.
 Enlargement of inguinal glands
with discrete pain or painless
 The primary chancre heals
spontaneously in 1-8 weeks with scar
formation.
 The tubes are not affected and
infertility does not occur unless
associated with gonorrhea.

Secondary syphilis
 Within 6 weeks to 6 months from
the onset of primary chancre ,the
 secondary syphilis may be evidenced
in the vulva in the form of
condyloma lata
 Patient may present with systemic
symptoms like;fever,headache and
sore throat.
 Maculopapular skin rashes are
seen in the palms and soles.
 Generalised
lymphadenopathy ,mucosal ulcers
and alopecia
 The primary and secondary stages
can last up to 2 years and the woman
is a source of infection.
Latent syphilis
It is the dormant phase after the
primary and secondary syphilis has
resolved .It may be early(less than 2
years from the onset of a disease) or late
(duration more than 2 years from the
onset of a disease)
Tertiary syphilis
 This is an advanced stage from
untreated latent syphilis.
 The risks are the development of
neurosyphilis and cardiovascular
syphilis.
 There is endarteritis and
periarteritis of small and medium
sized vessels.
 There is formation gumma. A
gummatous ulcer is a deep punched
ulcer with rolled out margins.It is
painless with a moist leather base.
 Ophthalmic and auditory lesions.
Gongenital syphilis
Acquired during intrauterine life
through placental
circulation(transplacental
hematogenous inoculation) or during
birth through contact with maternal
genital tract. Newborns with congenital
syphilis may appear healthy at birth but
often develop symptoms weeks or
months later.

Clinical features of syphilis

 Hepatosplenomegaly and
lymphadenitis
 Osteochondritis
 Jaundice and anemia
 Skin lesions
 Rhinitis
 Lymphadenopathy
  Nervous system involvement
 Symptoms may develop weeks or
months later.
 The bones usually reveal signs of
osteochondritis and an irregular
epiphyseal juncture on x-ray.
 The eyes, central nervous system
structures, and other organs may
reveal abnormalities at birth, or
defects may develop later in
untreated cases.
Diagnosis
 Through history taking
 Laboratory tests eg.VDRL(positive
after 6 weeks of infection)
Differential Diagnosis
Primary syphilis must be differentiated
from chancroid, granuloma inguinale,
lymphogranuloma venereum, herpes
genitalis, carcinoma, scabies, trauma,
lichen planus, psoriasis, drug eruption,
aphthosis, mycotic infections, Reiter's
syndrome, and Bowen's disease.
Secondary syphilis must be
differentiated from , psoriasis, drug
eruption, parasitic infections, iritis,
neuroretinitis, condyloma acuminatum,
acute exanthems, infectious
mononucleosis, alopecia, and
sarcoidosis.
Treatment
 Benzathine penicillin G2.4 million
units is given IM weekly for 3
weeks
 Alternative regimen: Doxycycline
100mg orally twice daily or
 Tetracycline 500mg orally 4 times a
day for 4 weeks.
 Follow up test very crucial
Prevention
 Early diagnosis and treatment
 Heath education about STIs
 Teach about condom use

CHLAMYDIAL INFECTTIONS
It is an obligatory intracellular gram
negative bacteria.Its prevalence is more
than N.gonorrhea as causative agent for
STIs in developed countries.
It has longer incubation period of 6-14
days compared to gonorrhea (3-
7days).The organisms affects mostly the
superficial surface of genitourinary tract
.The infection is localized in the
urethra,Bartholin’s gland and
cervix.Like gonococcaal infection ,it can
also ascend upstairs to produce acute
pelvic inflammatory disease.
Clinical features
They are non-specific and asymptomatic
in 75%.
Presenting symptoms are:
 Dysuria
 Dyspareunia
 Postcoital bleeding
 Intermenstrual bleeding
 Mucopurulent cervical discharge
 Cervical oedema
 Cervical ectopy
 Cervical friability
Diagnosis
  Endocervical smear laboratory
test
 Tissue culture
 Urine test(first void urine
specimen is most effective and
specific)
Treatment
 Azithromycin-1 gm orally single
dose or
 Doxycycline-100mg orally bid for
7 days or
 Ofloxacin-200mg orally bid for
7days
 Erythromycin-500mg orally bid
for 7 days
The sexual partner should also be
treated with the he same regimen
Complications
 Urethritis and bartholinitis which
are manifested by dysuria and
vaginal dishacharge
 Pelvic inflammatory diseases
 Tubal scarring resulting to
infertility and ectopic pregnancy
 Perihepatitis via lymphatics and
peritoneal cavity
Prevention
 Like in gonococcal infections
Chancroid(soft sore)
 It is a STI caused by a gram
negative streptobacillus –
Haemophilus ducreyi.
 The incubation period is 3-5 days
or less.
Signs and symptoms
  The lesion starts as multiple
vesicopustulesover the vulva, vagina
or cervix
 Circumscribed ulcers formation
on inflammatory zone
 The lesion is very tender with foul
purulent and haemorrhagic
discharge
 There may be cluster on ulcers
 Inguinal lymphadenitis
Diagnosis
 Syphilis must be ruled out first
 Discharge from ulcer pus from
lymph glands is taken for culture
Treatment
 Ceftriaxone 250 mg IM single dose
is effective
 Both sexual partners to be treated
  Azithromycin 1 g orally single
dose
 Erythromycin 500 mg orally every
6 hours for 7 days
 Longer course therapy is needed
in HIV positive patients

BACTERIAL VAGINOSIS (BV)

(BACTERIAL VAGINITIS)

This is a STI caused by bacterial

infections such as Gardenella vaginalis
(haemophilus vaginalis) and
trichomonas vaginalis .
Gardenella vaginalis may be with
anaerobic organisms such as bacteroids
species,peptococcus species ,mobiluncus
and mycoplasma hominis ,acting
synergistically to cause vaginal
infection.
Signs and symptoms
 Creamy vaginal discharge with
fishy smell without evidence of
inflammattion
 Bacterial vaginosis is
characterized by malodorous
vagianal discharge
 The discharge is
homogeneous ,grayish-white and
adherent to the vaginal wall
Diagnosis
 Through signs and symptoms
 Litmus paper test-vaginal pH is
alkaline(pH>4.7)
 Microscopic test with a smear of
vaginal discharge
Treatment
 Mitronidazole-200mg orally three
time s a day for 7 days
 Clindamycin cream (2%) and
metronidazole gel are recommended
for vaginal application to prevent
obstetric complications.
 The patuent’s sexual partner
should be treated simultaneously
Complications
 Preterm ruoture of membranes in
pregnant women ,preterm labour
and chorioamnionitis
 Recurrent infectttion leading to
PID
 Pregnancy complication-second
trimester miscarriage,preterm birth
and endometritis.
GENITAL WARTS (CONDYLOMA
ACUMINATA)
Condylomata are papillary lesions
caused by Human Papilloma Virus(HPV)
usually type 6 and 11.
These are usually multiple and can be
contaminated from other parts of the
body.
Transmission is majorly through sexual
contact.Associated vaginal discharge
favours their growth and so does
pregnancy.
Typically,they grow in clusters along a
narrow stalk giving it a appearance
cauliflower but at time the stalk may be
broad and thick.
It may spread to the vagina or even the
cervix .Very rarely, it becomes
malignant
Anatomic distribution of anogenital
HPV infection
 Cervix :70%
 Vulva:25%
 Vagina:10%
 Anus :20%
Predisposing factors
 Immunosupression
 Diabetes
 Pregnancy and local trauma
 Multiple sexual partners
Treatment
 Podophylin liquid and cream
preparations are used locally two
 times daily for 3 days then repeated
after after a break of 4 days
 Trichloroacetic acid (90-
100%)solution is used for isolated
warts that respond poorly to
podophylin
Destructive methods such as
cryotherapy, electrodiathermy ,laser
therapy or surgical removal are used for
resistant cases .

MENOPAUSE

Objectives

By the end of this session student should

be able to ;
  Define the term menopause

 Mention risk factors for early

menopause

 Explain the physiology of

menopause

 Explain various organ changes

during menopause

 Diagnose menopause

 Describe the management,

treatment and prevent of symptoms

of menopause where applicable.

Definition: Menopause means

permanent cessation menstruation at

the end of reproductive life due to loss

of ovarian follicular activity. It usually

occurs from 45-55 years, average being

50 years.

SOME IMPORTANT TERMS

Premenopause:the period prior to

menopause ,during this time the

menstrual cycle begins to be irregular.

Perimenopause:the period around

menopause 40-55 years.

Post menopause : the period after

menopause
Climacteric:the phase of aging process

during which a woman passes from the

reproductive to non reproductive

stages .this phase covers 5-10 years on

either side of menopause.

Premature menopause: when

menopause occurs belloe 40

years.Often ,there is a familial link and

treatment by substitution therapy is of

value.

Delayed menopaouse:If menopause fails

to occur even beyond 55 years

The common causes are constitutional,

uterine fibroids,diabetes mellitus and

oestrogenic tumors of the ovaries.

Artificial menopause:Permanent

cessation of ovarian function done by

artificial means e.g.Surgical removal of

ovaries or by radiation

Factors contributing to early menopause

Tinner women have early menopause

Cigarette smoking

Severe malnutrition

PHSIOLOGY OF NORMAL MENOPAUSE

Hypothalmopituitary gonadal axis

Few years prior to menopause , along

with depletion of the ovarian

follicles ,the follicles become more

resistant to pituitary

gonadotrophins .As a result ,effective

folliculogenesis is impaired with

diminished oestradiol production .There

is a significant fall in the level of serum

estradiol from 50-300 pg/ml before

menopause to 10-20 pg/ml after

menopause leading to

anovulation ,oligo-ovulation ,premature

corpus luteum or corpus luteal

insufficiency.Disturbence in

folliculogenesis also cause sustained

level of oestrogens causing endometrial

hyperplesia and clinical manifestation

of menstrual abnormalities prior to

menopause.

The mean cycle length is significantly

shorter .This is due to shortening of the

ffollicular phase of cycle .Luteal phase

length remaining

constant .Ultimately ,no more follicles

are available and even some exist ,they

are resistant to gonadotophins.

Oestradiol production drops down to the

optimal level of 20 pg/ml no

endometrialgrowth

Absence of menstruation.

ORGAN CHANGES DURING MENOPAUSE

Ovaries

They shrink in size, become wrinkled

and white .
There is thinning of the cortex with

increase in modularly

components .There is abundance of

stromal cells which have got secretory

activity

Fallopian tubes

They show features of atrophy

The muscle coat becomes thinner, the

cilia disappear and the plicae become

less prominent

The uterus
It becomes smaller and the ratio

between the body and the cervix reverts

to 1:1 ratio.

The endometrium becomes thin and

atrophic. In some women, however,

with high endogenous oestrogen, the

endometrium may be proliferative or

even hyperplastic.

The cervical secretion becomes scanty.

The vagina

It becomes narrower due to gradual loss

of elasticity.
The vaginal epithelium becomes thin.

The rugae progressively flatten.

There is no glycogen leading to reduced

glucose level.

Dodrelin’s bacillus is absent.

The vaginal pH becomes alkaline which

exposes the woman to infections

The vulva

 It show features of atrophy

  The labia become flattened and

the pubic hair is scantier.

 The end result is narrowing of the

introitus

Breast fat

 The breast fat is reabsorbed and

the glands atrophy.

 The nipples dicrease in size

 Ultimately,the breasts become flat

and pendulous

Bladder and urethra

  They undergo similar changes

those of vagina .The epithelium

becomes thin and is more prone to

damage and infection.

 There may be dysuria, increased

frequency of micturition, urge or

even stress incontinence.

Loss of muscle tone

This leads to pelvic relaxation, uterine

descent and anatomic changes in the

urethra and neck of the bladder. The

pelvic cellular tissues become scanty

and the ligaments supporting the uterus

and vagina lose their tone.

BONE METABOLISM

Normally,bone formation (osteoblastic

activity) and bone resorption

(osteoclastic activity) are in balance

depending on many factors such

as ;age,endocrine,nutrition and

genetic.Following menopause there is

loss of bone mass by about 3-5 per cent

per year due to deficiency of

oestrogen.This process is termed as

osteoporosis but in this condition the

bone mineral to matrix ratio is

normal.This condition exposes the

postmenopausal women to bone

fractures .Parathyoid hormone and IL-1

also involve in osteoporosis.

Oestrogen prevents osteoporosis by

many mechanisms;It inhibits

oesteoclastic activity and inhibit the

release of IL-1 by monocytes. It also

increases the absorption of calcium

from the gut ,stimulates calcitonin

secretion from C cells of the thyroid and

increases 1,25 dihydroxy vitamin D .All

these lead to bone mineralization.

CARDIOVASCULAR SYSTEM

Risk of cardiovascular diseases is high in

menopause due to deficiency of

oestrogen . Oestrogen prevents

cardiovascular diseases by many ways;it

increases the high density lipoproteins

(HDL) particularly HDL2 and decreases

low density lipoprotein(LDL) and total

ccholestetol . It inhibits platelet and

macrophages aggregation at the

vascular intima(The innermost

membrane of an organ (especially the

inner lining of an artery, vein or

lymphatic vessel)).

It stimulates the release of nitric oxide

and prostacycline from vascular

endothelium to dilate the blood vessel.It

prevents artherosclerosis by it

antioxidant property

MENSTRUATION PATTERNS PRIOR TO

MENOPAUSE

Any of the following symptoms are

observed:
  Abrupt cessation of menstruation

(rare)

 Gradual decrease in both amount

and duration .It may be spotting or

delayed and ultimately lead to

cessation

 Irregular with or without

excessive bleeding.

SIGNS AND SIMPTOMS OF MENOPAUSE

In majority of women, apart from

cessation of menstruation,no more

symptoms are evident.However,in some

women symptoms appear.These include:

Vasomotor symptoms,which present

as;hot flush(a sudden feeling of heat

followed by profuse sweating) there may

be also ,palpitations,fatigue and

weakness.The physiologic changes of hot

flushes are perspiration,and cutaneous

vasodilatation.Both these two functions

are under thermoregulatory centre in

the hypothalamus in association with

gonadotropin releasing

hormone(GnRH)centre in the
hypothalamus is involved in the

aetiology of hot flush

Genital and urinary system( Urogenital

atrophy),steroid receptors have been

identified in the mucous membrane of

urethra,bladder,vagina and the pelvic

floor muscles.So, oestrogen deficiency

produces atrophic epithelial changes in

these organs .Vaginal bleeding resulting

to a minimal

trauma,dyspareunia ,vaginal

infections,dryness,pruritus and

leucorrhea are very common here.The

urinary symptoms

are ;urgency,dysuria,and recurrent

urinary tract infection and stress

incontinence.

Sexual dysfunction;oestrogen deficiency

is often associated with decreased

sexual desire.This may be due to

psychological changes(depression and

anxiety)as well as atrophic changes of

the genitor-urinary system.

Skin and hair;there is thinning ,loss of

elasticity and wrinkling of the skin

Sychological changes;there is increased

frequency of

anxiety,headache,insomnia,irritability

dysphasia and depression. They also

suffer from dementia,alzheimer’s

diseases mood swing and inability to

concentrate.Oestrogen inceases opioid

(neurotransmitter ) activity in the brain

and is known to be important for

memory.

Osteoporosis and fractures,bone mass

loss and microarchitectural

deterioration of bone tissue occurs

primarily

intrabecularbone(vertebra,distal redius)

and in cortical(cortexof the cerebrum)

bones .Bone loss increases 5% per year

during menopause .

Osteoporosis may be primary(type

1),due to oestrogen loss,age,deficient

nutrition(VitD and Calcium) or heredity.

It may be secondary(type 2) ,due to

endocrine abnormalities

(parathyroid,diabetes)or medications
Oteoporosis may lead to back pain ,loss

of height,and kyphosis(An abnormal

backward curve to the vertebral

column).Fractures of bones is a major

health problem ;it may involve vertebral

body,femoral neck,or distal

forearm(colle’s fracture).Morbidity and

mortality following fractures in high in

elderly women.

DIAGNOSIS OF MENOPAUSE
Cessation of menstruation for 12 months

during without a significant underlying

cause.

Hot flushes and night sweats

Vaginal cytology shows maturation

index of at least 10/85/5(features of low

oestrogen)

Serum oestradiol :< 20 pg/ml

Serum FSH and LH :> 40 mIU/ml (three

values at weeks interval required)

MANAGEMENT OF MENOPAUSE
Spontaneous menopause is unavoidable.

However, artificial menopause induced

by surgery e.g. bilateral (oophorectomy-

Surgical removal of one of both ovaries)

or by radiation (gonadal) during

reproductive period can to some extent

be prevented or delayed.

Counseling; Every woman with

postmenopausal symptoms should be

adequately explained about the

physiologic events .This will remove her

fears, anxiety, depression, and insomnia.

Reassurance is essential
TREATMENT

 Non-hormonal treatment

Nutrition diet-balanced with calcium

and protein is helpful

Supplimentary calcium-daily intake of 1-

1.5 gm can reduce osteoporosis and risk

of fractures

Exercise-weight bearing

excercises,walking,jogging(run for

exercises)
Vitamin D-supplimentation of vitamin D3

((cholecalciferol) ;400-800 IU/day) along

with calcium

Exposure to sunlight (enhances

synthesis of cholecaciferol(Vit D3) in the

skin).

Cessation of smoking and alcohol

Biphosphorus ,prevents osteoclatic bone

resorption

Fluoride,prevents osteoporosis and

increases bone matrix

Calcitonin,inhibits bone resorption

Clonidine,alphaadrenergic agonist may

be used to reduce the severityand

duration of hot flushes .Itis helpful

where oestrogen is contraindicated in

hypertension.

Thiazides,reduce urinary calcium

excretion therefore increasing bone

density specially when combined with

oestrogen

Paroxetine,a selective serotonin

reuptake inhibitor ,is effective to reduce

hot flushes both the frequency and

severity.
Gabapentine,a gamma amino butyric

acid(GABA) analogue,also found to be

effective

Etc.

 Hormone replacement therapy(HRT)

The HRT is indicated in menopausal

women to overcome the short-term and

long-term consequences of oestrogen

deficiency.

Goals of HRT

 Relief of menopausal symptoms

  Prevention of osteoroporosis

 To maintain the quality of life in

menopausal years

Special groups of women to whom HRT

should be prescribed

 Premature ovarian failure

 Gonadal dysgenesis

 Surgical or radiation menopause

Available preparations

The principle hormone used in HRT is

oetrogen.This is ideal for a woman who

had her uterus removed already. But a

woman with an intact uterus, only

oestrogen therapy leads to endometrial

hyperplasia and even endometrial

carcinoma.Therefore, addition of

progestins for at least 12-14 days each

month can prevent this

problem.Generally,the use of HRT for a

short period of 3-5 years have been

advised.Reduction of dosage should be

done as soon as possible.

This includes:
 Conjugated oestrogen( 0.625 – 1.25

mg/day) or micronized oestradiol (1-2

mg /day )

 Progestins used are

medroxyprogesterone acetate( 2.5-5

mg/day )or

 Micrinised progesterone100-

300mg/day dydrogesterone 5-10

mg /day. With this regimen.

 Subdermal implants,implants are

inserted subcutaneously over the

anterior abdominal wall using

anesthesia.
 Percutaneous oestrogen gel;1 mg

application of gel ,delivering 1 mg of

oestradiol daily,is to be applied onto

the skin over the anterior wall of the

abdominal wall or thighs.

 Transdermal patch and vaginal

cream are also available.

 Oral oestrogen –conjugated

equine estrogen 0.3mg or 0.625mg is

given daily for a woman who had

hysterectomy

 Oestrogen and cyclic progestin is

given continuously for 25 days the

 progestin is added for at least 12-14

days.

 Continuous estrogen and

progestin therapy, can prevent

endometrial hyperplasia .There may

be irregular bleeding

Containdications to HRT

 Undiagnosed genital tract

bleeding

 Oetrogen dependent neoplasm in

the body

 History of venous

thromboembolism
  Active liver diseases

 Gallbladder disease

Side effects of HRT

Endometrial cancer,when oestrogen is

given alone to woman with intact uterus

,it causes endometrial

proliferation,hyperplasia and carcinoma

.It is therefore advised to combine in

with progestogen to counter balance

such risks.

Breast cancer,cccombined oestrogen and

progestin replacement therapy increases

risks of breast cancer slightly.Abverse

effects are related to dose and duration

of therapy.

Venous thromboembolic (VTE) diseases,

has been found to be increased with the

use of oestrogen combined with

progestin

Coronary heart diseases

(CHD),Combined HRT therapy shows

relative hazard of CHD .Hypertension

has not been observed to be a risk of

hormonal replacement therapy(HRT)

Lipid metabolism,an increased

incidence of gallbladder disease has

been observed following oestrogen

replacement therapy.

Dementia, Alzheimer’s disease is

increase

REFERENCES

1. D C Dutta (2009) Textbook of

Gynecology including Contraception

5th Edition.
 2. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

3. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.

ECTOPIC PRGNANCY

Objectives
 By the end of this session students

should be able to :

 Define ectopic pregnancy

 Outline different sites of ectopic

pregnancy

 Describe causes and risk factors

of ectopic pregnancy

 Diagnose ectopic pregnancy

 List signs and symptoms of

ectopic pregnancy

 List complications of ectopic

pregnancy
  Manage a patient with ectopic

pregnancy

DEFINITION: An ectopic pregnancy is a

gestation that implants outside of the

endometrial cavity.

It represents a serious hazard to a

woman's health and her reproductive

potential, and it requires prompt

recognition and early appropriate

intervention.
 An ectopic pregnancy is estimated to

occur in 1 of every 80 spontaneously

conceived pregnancies.

ANATOMICAL LOCATTION OF ECTOPIC

PREGNANCYS

Tubal (99%): anywhere in the

fallopian tube

o The most common site is the

ampulla.

o Interstitial (cornual) pregnancies

occur in the most proximal tubal

segment, which runs through the

 uterine cornua. This type of

ectopic pregnancy can grow to be

quite large, and rupture may

cause massive hemorrhage.

Ovarian (0.5%): on the ovary

Abdominal (less than 0.1%): in the

abdomen, with possible adherence to

the peritoneum, visceral surfaces, or

omentum

Cervical (0.1%): in the cervix

Heterotopic
 o Both intrauterine and ectopic

pregnancies may occur

concomitantly.

o This type of ectopic pregnancy is

extremely rare (1 in 4000 in the

general population and 1 in 100 in

those who conceived with in vitro

fertilization [IVF]).

Other less common sites of ectopic

implantation are the ovary, uterine

cervix, or a rudimentary uterine horn.

Rarely, an ectopic may be

intraligamentous or in the peritoneal

cavity.

WHY AN ECTOPIC PREGNACY

HAPPENS?

In a normal pregnancy, an egg is

fortified by sperm in one of the fallopian

tube which connect the ovaries to the

womb .The fortified egg moves into the

womb and implants itself into the womb

lining endometrial ,where it grows and

develops
So for an ectopic pregnancy, occurs

when a fertilized egg implants itself

outside the womb.

Epidemiology

From the early 1970s to the early 1990s,

the incidence of ectopic pregnancy in

the United States tripled. Currently, this

condition causes 6% of maternal deaths

in the United States and is the most

common cause of maternal mortality in

the 1st trimester. Several factors

contributed to this increased incidence:

5. Improved technology, which has

allowed for earlier and more

complete recognition of ectopic

pregnancies that would previously

have gone undetected.

6. The rising incidence of acute and

chronic salpingitis, especially related

 to Chlamydia trachomatis.

7. An increasing number of tubal

surgeries, such as tubal ligation and

tubal reconstruction, resulting in

histologic and structural damage to

the tubes.

8. Increasing use of conservative

management of tubal pregnancy,

which does not remove damaged

 tissue.

The key to the successful management

of ectopic pregnancy is early diagnosis.

Today, fewer women are seen in a state

of hemorrhagic shock after tubal

rupture. As a result, mortality from

ectopic pregnancies has steadily

declined for the past 10 years. This

decrease is evidence that a high index of

suspicion and vigorous efforts at early

diagnosis are effective.

CAUSES AND RISK FACTORS FOR

ECTOPIC PREGNANCY

The occurrence of ectopic pregnancy has

been associated with abnormal function

of the fallopian tubes. Normally, the

tubes facilitate collection and transport

of the oocyte and embryo into the

uterus. The integrity of the fimbria,

lumen, and ciliated mucosa appears to

be important for transport. Conditions

thought to prevent or retard migration

of the fertilized ovum to the uterus

increase the risk for an ectopic

pregnancy.

Pelvic inflammatory disease (PID), the

inflammation and scarring of intra and

extra luminal structures resulting from

PID impair normal tubal function and

foster implantation in the tube. Severe

damage may lead to complete tubal

blockage and infertility

Tubal surgery, bilateral tubal ligation

and tubal reanastomosis may lead to

scarring and narrowing of the tube or

false passage formation. Other pelvic

and abdominal surgeries may also result

in peritubal adhesions but have not

been directly associated with ectopic

pregnancy.

Chlamydia and gonorrhea infection, the

typical cause of pelvic inflammatory

diseases, endometriosis and salpingitis

Artificial reproductive techniques

 Studies have documented increased

risk of ectopic pregnancy with in

vitro fertilization, gamete

 intrafallopian transfer. Up to 2% of

ectopic pregnancies in this

population are heterotopic.

Retrograde embryo migration maybe

a possible mechanism

 Delayed fertilization, possible

transmigration of the oocyte (A

female gametocyte that develops into

an ovum after two meiotic

divisions)to the contralateral tube,

and slowed tubal transport, which

delays passage of the

 morula(fertilized egg) to the

endometrial cavity.

Cigarette smoking Studies have shown

that cigarette smoking causes tubal

ciliary dysfunction.

Endometriosis,this makes the uterus not

suitable for implantation

Having a history of previous ectopic

pregnancy, In subsequent pregnancies

there is a 15% to 20% risk of recurrence,

in either the same or opposite tube

History of infertility, Infertile couples

have an increased proportion of ectopic

pregnancies compared to the total

number of pregnancies, regardless of

the etiology of the infertility.

Chromosomal and structural anomalies

of the conceptus, may predispose to

ectopic pregnancy

Contraceptive methods

Contraceptive Risk factors of

method ectopic pregnancy

None 1%
 Oral 1%

contraceptives

Diaphragm 1%

Intrauterine 5%

devices(IUD)

Progestasert 15%

IUD

 Intra uterine devices (IUD),

Intrauterine devices (IUDs) are

highly effective at preventing

intrauterine pregnancy. Thus, any

 pregnancy in an IUD user is more

likely to be tubal

Progestin-only contraceptives,Users of

progestin-only oral contraceptives as

well as injectable progestins are at

increased risk of ectopic pregnancy if

pregnancy occurs, possibly because of

altered tubal motility.

Peritubal adhesions, following

postabortal or puerperal infections,

appendicitis, or endometriosis.
Developmental abnormalities of the

tube, such as diverticula, accessory ostia,

and hypoplasia. Women who have been

exposed to diethylstilbestrol have a four

to five times greater risk of ectopic

pregnancy.

Increased maternal age.

CLINICAL PRESENTATTION OF ECTOPIC

PREGNANCY

Occasionally, an ectopic pregnancy does

not cause noticeable symptoms and is

only detected during routine pregnancy

testing.

However, most women do have

symptoms and these usually become

apparent between 5 to 14 weeks of

gestation.

The classic triad of symptoms of ectopic

pregnancy consists of amenorrhea,

vaginal bleeding, and lower abdominal

pain.

For any individual woman, there are

three possible clinical presentations:

(1) Acutely ruptured ectopic pregnancy

(2) Probable ectopic pregnancy in a

symptomatic woman

(3) Possible ectopic pregnancy

Acutely ruptured ectopic pregnancy.

This clinical scenario represents a

surgical emergency.

The patient who has experienced

rupture of her ectopic pregnancy will

most likely have:

 Intraperitoneal hemorrhage and

will present with severe abdominal

pain and dizziness.

 She may also complain of

ipsilateral shoulder pain from

phrenic nerve irritation due to

hemoper itoneum from the blood in

her abdomen and it occurs in up to

25% of patients

 There may be signs of

hemodynamic instability with

tachycardia, diaphoresis,

hypotension, and even loss of

consciousness.

 Her entire abdomen may be

distended and acutely tender with

guarding and rebound tenderness.

 The patient will usually have

cervical motion tenderness and a

slightly enlarged, globular uterus.

 However, she may not have a

palpable adnexal (Accessory or

adjoining anatomical parts or

appendages to an organ) mass.

Probable ectopic pregnancy

Women who present with lower pelvic

pain and vaginal spotting or bleeding,

with or without amenorrhea, can be

rapidly tested for pregnancy. There are

generally other clinical signs

presentsuch as tenderness of the

abdomen along with adnexal or cervical

motion tenderness.

Possible ectopic pregnancy

This is characterized by:

 Lower abdominal pain is present

in most cases.

 Amenorrhea or a history of an

abnormal last menstrual period is

obtained in 75% to 90% of ectopic

pregnancies.

 Abnormal vaginal bleeding is seen

in over half the patients, ranging

from spotting to the equivalent of a

normal menstrual period, this

spotting or bleeding results from an

abnormally low production of HCG

by the ectopic trophoblastic tissue

DIAGNOSIS OF ECTTOPIC PREGNANCY

 An ultrasound would reveal an

empty uterus and free fluid (blood) in

the peritoneal cavity

 The diagnosis of ectopic

pregnancy may be confirmed by the

absence of intrauterine pregnancy

(IUP) on ultrasound in a woman with

a level of hCG sufficient to normal

pregnancy,the bsence of intrauterine

pregnancy on ultrasound

examination is diagnostic for ectopic

pregnancy if the gestational age is

 known for certain or if the hCG level

is >2500 IU per ml

 Culdocentesis ,is a technique by

which a needle attached to a syringe

is inserted transvaginally through the

posterior vaginal fornix into the

pouch of Douglas to detect any fluid

within the peritoneal cavity

DIFFERENTAL DIAGNOSIS OFECTOPIC

PREGNANCY.

Gynecologic problems

 Threatened or incomplete abortion

  Ruptured corpus luteum cyst

 Indometriosis

 Gestational trophoblastic diseases

 Ruptured corpus luteal cyst

 Dysfunctional uterine bleeding

 Acute pelvic inflammatory disease

 Adnexal torsion

 Degenerating leiomyoma (especially

in pregnancy)

 Salpingitis

NONGYNECOLOGIC PROBLEMS

 Acute appendicitis
  Pyelonephritis

 Pancreatitis

MANAGEMENT

Management has two modalities:

 Surgical approach

 Medical approach

SURGICAL APPROACH

Surgical treatment of ectopic pregnancy

has the advantage of taking care of the

ectopic immediately. It is suitable for

emergency care of ectopic pregnancy.

It is critical to establish large-bore

intravenous lines and to start fluid

resuscitation.

Salpingectomy, the removal of the

fallopian tube containing the ectopic

pregnancy, is the treatment of choice in

the following situations:

 Future childbearing is not

desired.

 The tube is severely damaged.

 Bleeding cannot be controlled.

  The ectopic is in a fallopian tube

where an ectopic occurred

previously.

Linear salpingotomy, the removal of the

gestation through a linear incision in the

fallopian tube, may be performed if

future fertility is desired.

 This procedure is associated

with a persistent ectopic

pregnancy rate of 3% to 20%.

  Therefore, serial quantitative

hCG values must be followed to

ensure resolution.

Operative laparoscopy ,may be

performed to confirm the diagnosis of

ectopic pregnancy and to remove the

abnormal gestation via salpingectomy or

salpingostomy.

This method is typically used in

hemodynamically stable patients.

Advantages of this technique over

laparotomy include:
  Shorter hospital stay

 Faster postoperative recovery

 Better cosmetic result

 Potentially shorter operative

time

Laparotomy, is typically reserved for

hemodynamically unstable patients who

require emergent surgery for a ruptured

ectopic pregnancy. This method may

also be appropriate when laparoscopy is

contraindicated or technically

challenging because of extensive

adhesive disease from prior surgery.

Cornual resection, may be performed

when an interstitial pregnancy occurs.

The interstitial portion of the tube is

removed via wedge resection into the

uterine cornu.

Cornual ectopic pregnancies have a

higher failure rate with methotrexate

and a surgical approach may be more

effective.

Oophorectomy is indicated only when

an ovarian ectopic pregnancy occurs

and salvage of the affected ovary is not

possible.

MEDICAL APPROACH

Methotrexate, a chemotherapeutic

agent, has been used successfully to

treat small, unruptured ectopic

pregnancies. This approach has the

advantage that it avoids surgery, but the

patient must be counseled that it may

take 3 to 4 weeks for the ectopic to

resolve with methotrexate therapy.Early

diagnosis is very paramount for

successful management.

Mechanism of action

 Methotrexate is a folic acid

antagonist that interferes with DNA

synthesis. Its action is principally

directed at rapidly dividing cells,

such as trophoblastic cells.

 Once an ectopic pregnancy has

been confirmed, 50 mg/m2 is

administered intramuscularly in a
single or multiple doses with folic

acid.

 Serial hCG levels are followed

every 2 to 4 days after treatment

until the hCG level starts to decrease.

This is to ensure resolution of the

pregnancy

 If a 15% reduction is not achieved

during the first week, or in

subsequent weeks a plateau occurs,

then an additional injection of MTX is

given or surgical exploration is

advocated.

 Decreased success has been noted

with ectopic pregnancies of greater

than 3.5 cm, with fetal cardiac

activity, or with high hCG levels

(greater than 5000).

 After treatment failures, surgical

management is usually necessary.

 After an ectopic gestation,

pregnancy should be avoided for at

least 3 months to allow for the

 fallopian tube architecture to

normalize.

 Contraception should be provided

Side effects (approximately 5% of

patients).

Mild gastrointestinal symptoms such as

nausea, vomiting, diarrhea, and

stomatitis are typical.

Potential life-threatening complications

include pneumonitis, thrombocytopenia,

neutropenia, elevated liver function

tests, and renal failure.

Contraindications,

Women who are breastfeeding

Immunodeficiency,

Liver disease, renal disease,

Blood disorders,

Peptic ulcer disease,

Active pulmonary disease should not

receive methotrexate .
Criteria for medical management of

ectopic pregnancy

Criteria for Contraindications

receiving to medical therapy

methotrexate(MT

X)

Absolute Absolute

indications contraindications

6. Hemodyna 8. Breastfeedi

mically stable ng

without active 9. Overt or

 bleeding or laboratory

signs of evidence of

hemoperitone immunodeficie

um ncy

7. Nonlaparos 10. Alcoholism,

copic diagnosis alcoholic liver

8. Patient disease, or

desires future other chronic

fertility liver disease

9. General 11. Preexisting

anesthesia blood

poses a dyscrasias,

significant risk such as bone

 10. Patient is marrow

able to return hypoplasia,

for follow-up leukopenia,

care thrombocytope

nia or
No
significant
contraindications
anemia
to MTX
12. Known

sensitivity to

MTX

13. Active

pulmonary

disease
 14. Peptic ulcer

disease

Hepatic, renal, or

hematologic

dysfunction

Relative Relative

indications contraindications

3. Unruptured 3. Gestational

mass ≤3.5 cm sac =3.5 cm

at its greatest 4. Embryonic

dimension cardiac motion

4. No fetal
 cardiac motion

detected

Patients whose

hCG level does not

exceed a

predetermined

value (6000-

15,000 mIU/Ml

COMPLICATTIONS OF ECTOPIC

PREGNANCY
The most common complication is
rupture with internal haemorrhage
which may lead to hypovolemic shock.
Death from rupture is rare in women
who have access to modern medical
facilities.
 Infertility
 Recurrence
 Severe hemorrhage leading to
shock
 Anaemia due to bleeding.
 Infections following operation.
 Adhesions due to scar formation
during healing process.
 Re-occurance of another ectopic
pregnancy.
 Infertility if both tubes are
affected.
References

4. National Medical Series for

Independent Study (2008) Obstetrics

and Gynaecology, 6th Edition.

5. Thomas J.Bader(2007)OBS/GYN

secrets,3rd Edition.

6. Hacker et al. (2007) Essential of

Obstetrics and Gynaecology, 4th

Edition.
OBSTETRIC FISTULAE
LEARNING OBJECTIVES
 Explain what an obstetric fistula
is.
 Describe different types of fistulas
 List at least six signs and
symptoms of obstetric fistula.
 Enumerate the causes of obstetric
fistula.
  List the risk factors and
consequences of obstetric fistula.
 Describe the management of
obstetric fistula.

Definition
Afistula is an abnormal communication
between two or more epithelial surfaces.
Fistulas can develop in various parts of
the body .However, this session will only
address obstetric fistulas.
Types of fistulas:
The communication may occur between
the bladder, urethra or ureter and
genital tract.
Accordingly, the following types are
described .
Bladder
 Vesicovaginal (the commonest)-the
bladder communicates with the
vagina
 Vesicourethraovaginal-it involves the
bladder, urethra and vagina
 Vesicouterine –it involves the bladder
and uterus
 Vesicocervica-communication
between the bladder and the cervix
Urethra
 Urethrovaginal-involving the urethra
and vaginal tract
Ureter
 Ureterovaginal-it involves the ureter
and vagina
  Ureterouterine- abnormal
communication between ureter and
the uterus
 Ureterocervical-abnormal
communication between ureter and
cervix
Tectum
Rectovaginal fistula . abnormal
communication between rectum and
vaginal tract

Signs and Symptoms of obstetric fistulas

 Flatulence, urinary or fecal
incontinence, which may be
continual or only happen at night
  Patient will complain of
continuous dripping of urine from
anus or stool from vagina sometimes
it is a mixture of urine or stool with
blood.
 Foul-smelling vaginal discharge 
 Repeated vaginal or urinary tract
infections 
 Irritation or pain in the vagina or
surrounding areas 
 Amenorrhea due to worries
 Patient will be miserable and
depressed
 Pain during sexual activity 

Causes of fistulas
 The fistula usually develops as a
result of prolonged labor when
a cesarean section cannot be
 accessed. Over the course of the three
to five days of labor, the unborn child
presses against the mother's birth
canal very tightly, cutting off blood
flow to the surrounding tissues
between the vagina and the rectum
and between the vagina and the
bladder, causing the tissues
to disintegrate and rot away.
 Poorly performed abortions
 Pelvic fractures,
 Cancer or radiation therapy
targeted at the pelvic area, 
 Inflammatory bowel disease (such
as Crohn's disease and ulcerative
colitis), or infected episiotomies after
childbirth. 
 Sexual abuse and rape 
 Surgical trauma.
Risk factors for fistulas
 Closely spaced pregnancies and
lack of access to emergency obstetric
care.
 Women affected with Crohn's
disease (A serious chronic and
progressive inflammation of the
ileum producing frequent diarrhea
with abdominal pain and nausea and
fever and weight loss)also have a
higher risk of developing obstetric
fistulas.
 Very young mothers
Examination:
 Thighs are wet of urine s of stool
per vagina and excoriation
 On speculum fistula can be seen
  Vulvitis /vaginitis due to constant
irritation

Investigation
Cystoscopy(an examination of the
bladder using a cystoscope)
Ultra sound scan
Urrinalysis (mid stream specimen)for
culture and sensitivity
Full hemogram

Diagnosis
Through history,examination and
invessstigation
Management of fistulas
 vi. Allow fibrosis to take place.
vii. Allow inflammatory response to
take place.
viii. Clear away urinary tract infection.
ix. Fistula may reduce in size.
x. Fistula may close spontaneously.
Hospital care of the fistula
 In hospital the doctor carry out a
gentle vaginal examination with his
fingers, no instrument are used for
fear of enlarging the defect, he passes
catheter at the same time so that the
exact course of urethra may be felt in
relation to any defect in the bladder
neck or urethra.
 The patient is kept on continuous
bladder drainage as the passage of
urine through the defect prevent
healing and is put on appropriate
 antibiotics to treat any infection
present.
 She is given a balanced diet, iron
and vitamin supplements and if
necessary is give blood transfusion to
restore her general state of health.
 A significant number of fistulae
will close spontaneously during the
six weeks of the puerperium, provide
that there is continuous bladder
drainage, good general health and all
infection is eradicated
 Antiseptic vaginal douches to treat
the foul-smelling vaginal discharge.
This is caused by the sloughing
necrotic tissue.
 At the end of the puerperium the
patient may be assessed by means of
speculum.
 Surgical repair cannot be done at
this stage as one has to give enough
time to allow the tissues to heal and
strengthen up sufficiently if repair is
to succeed.
 Therefore woman will have to be
sent home and asked to re-attend for
surgery at a later date.
 Bladder catheterization is stopped
at this time (six weeks from the
delivery date) as continuous bladder
drainage is no longer needed.

PRE OPERATIVE CARE

 Admit as an elective case to
prepare the mother for repair, main
emphasis is put on psychological care
to restore hope and confidence.
  Good diet to correct malnutrition,
plenty of fluids to flush the kidneys,
hygiene especially of the genitalia to
treat / prevent infections.
 Explain to her that she will be
nursed in prone position for 14 days
post operatively to promote healing.
 Counsel her on catheter which
will stay insitu for 14 days or more to
promote healing.
 Prepare her for theatre like other
pre-operative care procedures
(review of the general preoperative
care).
 On the evening before operation
enema is given to decongest the
rectum.
NOTE. Colostomy may be performed in
recto vaginal fistula repair.
POST OPERATIVE CARE
 Mother is nursed in semi prone
position until she gains
consciousness and later nursed in
prone position until 14 days.
 Observe the catheter for drainage,
urine color and side leakage.
 Any abnormality must be
reported.
 Bladder irrigation should be done
by a doctor if required.
 Other routine care is provided.
BLADDER TRAINING
This is commenced after 14 days post
operatively if no leakage has been
observed. Bladder training is done
because bladder loses its muscle tone
and micturition reflex during the period
of continuous bladder drainage (CBD).
1st day – spigot the catheter and remove
the urine bag. Release it hourly during
the day and at night put CBD.
2nd day – remove CBD, spigot the
catheter and release it 2 hourly during
the day, continue with CBD at night.
3rd and 4th day – release the catheter
during the day and continue with CBD at
night.
5th day – remove the catheter, ask the
mother to hold urine as much as
possible so as to see how much the
bladder can hold or tolerate for a period
of time, then ask the mother to pass
urine.
 After passing out urine,
catheterize again to measure the
residue volume of urine remained in
the bladder.
  If the residue urine is less than
100mls, then it means bladder
training has been successful.
Discharge may be considered.
 If residue urine is more than
100mls, this means that bladder
training has not been successful,
therefore, recommence CBD and
bladder training.

NURSING MANAGEMENT
NURSING CONCERNS
Mother is miserable and depressed.
Dripping of urine / feaces.
Smell of urine
Wet thighs
Urinary tract infections.
NURSING CARE PLAN
NURS EXPEC INTERVE RATIO EVALU
ING TED NTIONS NALE ATION
DIAG OUTC
NOSIS OME
Ineffe Mothe Re- Promot Mother
ctive r assure es verbali
indivi shoul the coping zes
dual d mother attaina
copin verbal continuo nce of
g ise usly. coping
Mother
relate attain by the
apprec rd
d to ance 3 day.
Explain iates
conti of the the
nuous coping cause of reason
drippi mecha fistula to for
ng of nism the surger
urine by the mother. y.
evide 3rd day
nced of Promot
by admis
Explain es
moth sion.
each cooper
er’s
procedur ation.
verba
e to the
lizatio
mother.
n.
Allays
Orient anxiet
the y.
mother
in the
hospital.
Promot
es
Answer coping
every
question
 asked by
the Mother
mother. apprec
iates
the
Explain reason
for
each
treatm
step
achieved ent.
.

Know Mothe Answer PromotMother

ledge r every es verbali
defici shoul question comforzes
t d be the t. attaina
relate knowl mother nce of
d to edgea asks. Mothe knowle
the ble Explain r dge
cause about the apprec about
of the the cause of iates the
condi cause fistula to the cause
tion of the the reason of
evide fistula mother. for fistula
nced by the surger by 5th
by 5th day y day of
moth of admiss
er admis ion.
askin sion. Explain
each Mother
g so
step apprec
many
achieved iates
questi
. the
ons.
reason
for
treatm
ent
Risk Mothe Encoura Skin Mother
for r’s ge the remain ’s skin
impai skin mother s dry. remain
red shoul to bath ed
skin d and dry intact
interg remai the skin all the
rity n frequent time.
relate intact ly. Skin
d to all the remain
conti time. s dry.
Encoura
nuous ge the
drippi Promot
mother
ng of es skin
to
urine. integri
change
pads ty.
frequent
ly. Kills
microo
rganis
 Give a ms.
high
nourishi
ng diet.

Treat
urinary
tract
infection
s with
antibioti
cs.

ADVICE ON DISCHARGE
 Mother should avoid coitus for 3
months. Counsel both the man and
woman on issue of NO sex so that
 they go home when it is properly
resolved.
 To avoid pregnancy for atleast 2-3
years.
 To attend antenatal clinic early
enough when she gets pregnant and
the issue of fistula repair should be
revealed to the attending midwife,
preferably should be seen by a
doctor.
 Delivery should be preferably by
caesarian section.
 Avoid strenuous work and have
enough rest to promote healing.
 Ensure vulva toilet to prevent
infections.
 Have a highly nourishing diet to
promote healing.
  Review in gynecological
department.

PREVENTION

 Access to accurate antenatal care

to screen out at risk mothers likely to
develop obstructed labor. obstetrical
care
 Support from trained health care
professionals throughout pregnancy,
 Providing access to family
planning
 Promoting the practice of spacing
between births, and Supporting
women in education and in
postponing early marriage.
 Fistula prevention also involves
many strategies to educate local
communities about the cultural,
social, and physiological factors that
condition and contribute to the risk
for fistula. One of these strategies
involves
 Prevention of prolonged
obstructed labor and fistula should
preferably begin as early as possible
in each woman's life. For example,
improved nutrition and outreach
programs to raise awareness about
 the nutritional needs of children to
prevent malnutrition as well as
improve the physical maturity of
young mothers are important fistula
prevention strategies.
 It is also important to ensure
access to timely and safe delivery
during childbirth: measures include
availability and provision of
emergency obstetric care as well as
quick and safe cesarean sections for
women in obstructed labor.
 Some organizations train local
nurses and midwives to perform
emergency cesarean sections to avoid
vaginal delivery for young mothers
who have under-developed pelvises. 
 Midwives located in the local
communities where fistula is
 prevalent can contribute to
promoting health practices that help
prevent future development of
obstetric fistulas.
Promoting education for girls is also
a key factor to preventing fistula in
the long term.

Complications

 Stillborn babies due to prolonged

labor,
 Severe ulcerations of the vaginal
tract,
 "Foot drop," which is the paralysis
of the lower limbs caused by nerve
damage, making it impossible for
women to walk, infection of the
fistula forming an abscess, and up to
 two-thirds of the women become
amenorrhoeic due to worries.
 Sepsis due to the overspread of
infection
VAGINAL DISCHARGE
LEARNING OBJECTIVES
 Define the term vaginal
discharges
 Differentiate between normal and
abnormal vaginal discharges
  Define and describe the
characteristics and functions of
leuchorrhoea, show, liquor amnii,
lochia and its types, and menstrual
flow.
 Describe the characteristics of
abnormal vaginal discharge.
 Manage the patient with
abnormal vaginal discharge
DEFINITION
These are secretions seen per vagina.
They are of two types, that is, normal
and abnormal.
NORMAL VAGINAL DISCHARGE
1. Leucorrhoea
This is the normal discharge and keeps
on changing depending on the
menstrual cycle. It is produced by adult
women in reproductive age by
Doderlien bacilli.
Characteristics
 Should be minimal and moderate
in amount
 Should not be offensive
 Should not be itching or irritating
 Should be acidic in reaction
 It is usually whitish, clear or
creamy in colour and changes
according to the menstrual cycle. It is
egg white and elastic around
 ovulation and should be clear after
peak days.
Functions
It keeps the vagina moist and warm
2. Show
It is a bloody mucoid discharge from the
vagina which appears when a woman is
in her first stage of labour.
Characteristics

 Should not be much in amount

 Should not be nonodorous with
pH around 4.0.
 Microspically ,it contains
squamous epithelial cells and a few
 bacteria.Lacto-bacilli(Dordelein
bacilli) ,few gram negative bacteria
and anaerobes are present without
any white or red blood cells.
 Should not be irritating
3. Liquor amnii/ amniotic fluid
It is a clear straw coloured fluid found in
the amniotic membrane in the uterus, in
which the foetus grows.
Characteristics
 It ranges between 1000-1500ml in
amount
 It is clear if not infected
 It pours out during labour which
aids in lubrication of birth canal
during child birth.
  It consists of 99% water, mineral
salts, urea from urine passed by the
foetus.
 It is alkaline in reaction
 It sometimes contains meconeum
especially in obstructed labour
Functions of amniotic fluid
 Protects the fetus
 Free movement of the fetus
 Regulates fetal temperature
 Protects fetal limbs from sticking
together
 Contains nutrients which
nourishes the fetus
Abnormalities associated with amniotic
fluid
  Oligohydromnous-inadequate
amniotic fluid between 300-500mls
 Polyhydromnous-excess amniotic
fluid between 2000-3000mls
 Offensive amniotic fluid-due to
infections
 Blue amniotic fluid-due to drugs
 Brown amniotic fluid-due to fetal
death
 Meconeum stained-due to fetal
distress

4.Lochia
This appears after delivery of the baby
(puerperium)
The amount varies in different women
and is more in quantity than that of
menstrual flow.
Its odour is heavy and unpleasant but
not offensive
It has an alkaline reaction

Types
Rubra (red). Present during the first 3
days. It consists of blood, sheds of
deciduas and pieces of chorion, liquor
amnii vernix caseosa and meconeum
may be present. Appear s red owing to
the presence of erythrocytes.
Serosa (pink). Present from 4th to9th day.
The discharge becomes paler and
pinkish in colour, containing less blood
and more serum, leucocytes(WBC) and
bacteria.
Alba(white or clear). Present from 10th to
15th day. The discharge becomes paler, it
is yellowish white in colour and contains
cervical mucus, bacteria and debris
from the healing process of the uterus
and the vagina.

5.Menstrual flow
It should be about 60-180mls of blood.
This flow consists of blood from the
endometrium, endometrial tissue, +-
unfertilized ovum and secretions from
the endometrium.
Characteristics
 It should not clot
 It should not be offensive
 It should be dark red

ABNORMAL VAGINAL DISCHARGES

These are discharges which are caused
by sexually transmitted infections of
diseases of the female reproductive
system and require treatment.
These discharges are pathological other
than physiological.
Characteristics of abnormal vaginal
discharges
Colour
Whitish creamy or curdy milky
discharge- usually due to fungal
infection of the vulva and vagina like
candidiasis.
Greenish yellow discharge- is a common
feature of trichomonas vaginalis
Purulent yellow discharge-usually due to
gonococcal infections.
Odour
Any offensive discharge should be
investigated and the cause treated
Amount
Increased amount that tint the nicker is
abnormal and should be investigated
and treated.
Irritant
Any discharge that may cause irritation
and results into inflammation is
abnormal and should be investigated
and treated.
It may be blood –stained or
contaminated with urine or stool

Causes of abnormal vaginal discharges

Cervical causes
Non-infective cervical lesions ,may
produce excessive secretion which
pours out at the vulva.
Such lesions are:
 cervical ectropy,the cervix is
abnormally protruding in the vagina
 Chronic cervitis
 Mucous polyp and ectropion (cervical
glands are exposed to the vagina)
 Sexual transmitted diseases (STDs)
Vaginal causes
 Uterine prolapsed
 Aquired rertroverted uterus
 Chronic pelvic pelvic inflammation
 Pill use
 Vaginal adenosis
Diagnosis
On vulva inspetion;
  obvious white and creamy
discharges
 No evidence of pruritis
Bimanual including a speculum
examination;
 Either a negative pathology
 Associated pelvic lesions mentioned
earlier causing cervical or vaginal
leucorrhea
Treatment
 Improvement of general health
including local hygiene
 Cervical factors require surgical
treatment like electrocautery
(Application of a needle heated by an
electric current to destroy tissue)
  Cryosurgery, the use of extreme cold
(usually liquid nitrogen) to destroy
unwanted tissue such as warts or
skin cancers
 Pelvic lesions require appropriate
therapy for the pathology.
 Pill users may have to stop them
temporarily, if the symptoms are
very much annoying

INFERTILITY
Learning objectives
By the end of this session students
should be able to :
 Define the term infertility.
  List at least eight causes of
infertility in both men and women.
 Mention the investigations carried
out to diagnose infertility.
 Describe the management of
infertility.
Definition.
This is the inability of a couple to
achieve a pregnancy after repeated
intercourse without contraception for
more than a year.
Types of infertility
Primary infertility is the inability to
conceive in a couple who have had no
previous pregnancies.
Secondary infertility is the inability in a
couple who have had at least one
previous pregnancy, which may have
ended in a live birth, still birth,
miscarriage, ectopic pregnancy or
induced abortion.
Incidence
1 out of 5 couples in USA are affected.
Causes
The cause can be from male, female or
both.
Male causes
Low sperm count (oligospermia). This
could be due to some drugs like anti-
hypertensives, antidepressants or some
sedatives, or acute / chronic infections of
the male genital tract.
No sperms (azoospermia). This could be
due to bilateral cryptochidism
(undescended testes)
Abnormal sperms ,like those without
tails which makes them difficult to
swim.
Testesterone hormone insufficiency.
Inflamed epididymis. Storage and
maturation of the sperms will not
happen.
High levels of female hormones
(hormonal imbalance)
Blocked vas deferens. Transportation of
sperms will not take place.
Too much exposure of testes to heat.
This affects spermatogenesis
(production of sperms).
Diseases like diabetes mellitus,
hypertension, mumps. These leads to
testicular atrophy.
Auto immune disorder, may result in
production of antisperm antibodies.
Obesity ,may result in testicular atrophy.
Smoking and or alcoholism, affects
spermatogenesis resulting into low
sperm count.
Exposure to chemicals like asbestos,
affects spermatogenesis resulting into
low sperm count.
Exposure to radiations also affects
spermatogenesis.
Premature ejaculation, resulting into
immature and non motile sperms.
Malformations of seminal vesicles and
prostate gland.
Retrograde ejaculation. This when a
man ejaculates sperms into the bladder
instead of the penis.
Congenital abnormalities of the penis
like hypospadias and abnormal urethra.
Varicocele affects the movement of
sperms.
Urethral structure affects the way of the
sperms.
Failure to maintain an erection, a
condition known as erectile dysfunction.
Some medications, like anti-convulsants
and anti-depressants depresses sperm
count and motility.

Causes in females

Pelvic inflammatory diseases (PIDs)

accounts for over 65%. This results into
healing by fibrosis (scar tissue
formation), narrowing or blocking the
fallopian tubes making fertilization
impossible.
Pituitary tumors, leading to production
of high levels of prolactin hence
inhibiting ovulation.
Ovarian cysts ,may hinder ovulation.
Inovulation,this is when ovulation does
not take place.
Absence of ovaries (Turner’s syndrome).
No ova will be produced.
Fibroids,these tend to occupy a greater
part of the uterine cavity making
implantation impossible.
Hormonal imbalance,this may also
hinder ovulation.
Hostile environment to sperms or thick
cervical mucus.
Severe vaginal infection, which
interferes with sperm transport.
Transverse septum in the vagina or
uterus which makes sperms unable to
reach the fallopian tubes where
fertilization takes place.
Uncontrolled diabetes mellitus, active
goiter and hypertension also affects the
fertility rate of a mother.
Severe hypertension and some drugs
like Methyldopa.
Excessive alcohol and smoking,this
affects the production of ova.
Obesity,this also affects the fertility rate.
Increased maternal age, that is, over 35
years. The rate of reproductivity
decreases with an increase in age.
Hypersensitivity to man’s sperms,
whereby man’s sperms get killed by
antibodies in cervical mucus.
Endometriosis, this is the presence of
endometrial tissue outside the uterine
cavity like in fallopian tubes which may
result into implantation in the tubes
resulting into habitual ectopic
pregnancy.
Tub ligation,this is a permanent form of
family planning by which the fallopian
tubes are tied such that the sperms do
not go through to reach the ova for
fertilization.
Adhesions or kinked tubes, these block
the fallopian tubes making it impossible
for the sperm to reach the ova.
Pseudomenorrhoea,This is when a
woman perceives that she is pregnant
yet she is not resulting into absence of
menses.
Causes in both males and females
Poor timing,this when the couple
decides to have intercourse when a
woman is in her safe days.
Lack of relaxation,when a couple have
intercourse while tied, this can result
into production of weak or immature
sperms.
Stress,this can also result into
production of weak sperms.
Excessive alcohol and or smoking,his
affects spermatogenesis and production
of ova.
Incompatibility, that is, woman may
destroy man’s sperms due to variability
in PH(acidity of the vaginal cacity)
Idiopatic causes
Diagnosis/ Investigations
 History taking from both partners.
Personal and family history about
frequency of sex, duration of sex,
infertility in family, alcoholism and
smoking, nature of the job, marital
status whether monogamy or
polygamy, social relationship and
others.
 Examination of the man and
woman to rule out abnormalities like
varicocele and hydrocele in men
which affect fertility, and hirsutism
(excessive facial hair growth in
women) and obesity in women which
may be suggestive of endocrine
disorders.
Specific investigations in men
Semen analysis. This is the basic test for
male infertility. It should be carried out
before any further investigations on the
couple. Average values are assessed on 3
samples produced over several weeks,
as quality is variable.
Specimen are produced by masturbation
after 2 – 3 days abstinence and
examined in the laboratory within 1
hour.
If satisfactory, the man is assumed to be
potentially fertile.
Normal values
Volume 2 – 6 mls
Total sperm count > 40 million per ml
Mortility more than 60% moving
forward.
Morphology > 60% should appear
normal.
Post coital test
A specimen of aspirated cervical mucus
from the female partner is examined at
the fertile time of the cycle within 6
hours of intercourse. The ability of the
sperm to penetrate the mucus can be
observed. This determines whether
sperms can survive in the cervical
mucus.
Specific investigations in women
History of menstruation ,to determine
ovulation.
Hysteresalpingiogram, to rule out
obstruction, abnormal tubes and fibrous
masses in the uterus and adhesions.
Blood for hormones analysis, that is,
prolactin, oestrogen, and progesterone
levels. This will show fluctuations in the
circulating levels.
X-ray of the pituitary gland and
hypothalamus, to rule out tumors and
other abnormalities.
High vaginal swab, to rule out infection.
Ovulation tests ,to confirm if ovulation
occurs or not, and if not more
investigations are carried out to identify
the cause.
Ultra sound scan, to confirm whether
there is growth of ovarian follicles to
20mm and then the release of oocyte at
ovulation.
Endometrial biopsy, to rule out
endometrial change following ovulation.
The presence of secretory endometrium
confirms that ovulation has taken place.
Hysterescopy,this views the uterus to
rule out adhesions and septum in the
uterus and fallopian tubes.
Laparascopy,this views the uterus,
tubes, and ovaries to rule out any
abnormalities.
Crossed hostility test,this observes the
behavior of the partner’s sperm and
fresh donor sperm in the woman’s
cervical mucus.
The sperm penetration test,this
demonstrates the behavior of sperm
alongside a sample of mucus taken at a
fertile time on a glass slide. It
determines whether sperm functions or
mucus hostility is the problem.

TREATMENT OF INFERTILITY IN MEN

  Azoospermia is usually
untreatable.
 Reducing high temperatures of
the testicles may encourage sperm
development.
 Oligospermia may be improved by
attention to diet and general health,
particularly reducing smoking and
alcohol intake.
 Administer corticosteroids to any
man who presents with mumps as
soon as there is an idea of infection.
TREATMENT OF INFERTILITY IN
WOMEN
 Bromocriptine is used to inhibit
the synthesis and release of prolactin
by the pituitary in case of
hyperprolactinaemia.
 HCG can be used to trigger
ovulation, often in conjunction with
clomiphene or some other forms of
ovulation induction.
 Clomiphene citrate is usually used
to induce ovulation. It stimulates the
hypothalamic – pituitary system,
permitting follicle stimulating
hormone (FSH) and so inducing
ovulation.
 GnRH (gonadotrophin releasing
hormone) drug may be used to
induce ovulation if hypothalamus
has a problem in release of the
hormone.
  In case of hostility, that is , if the
mucus or the woman is producing
antisperm antibodies to her partner’s
sperms, steroids in short courses may
be helpful, or intra- uterine
insemination may be successful.

THE MENSTRUAL FLOW

About 60-180mls of blood is lost at
each menstruation.
The flow consists of blood from the
endometrium and the endometrial
tissue, + - unfertilized ovum plus
secretions from the endometrium.
CHARACTERISTICS OF MENSTRUAL
FLOW
 It should not clot.
 It should be dark red.
 It should be non offensive.
 It should be not painful
 Not in excessive amount
 It should be limited within time 3
to 7 days
MILD AIILMENTS OF MENSTRUATION
 Enlargement and tenderness of
breasts and nipples.
 Fluid/secretions from the breasts.
  GIT disturbances like epigastric
discomfort and constipation.
 Inceased frequency of micturition.
 Increased amount of vaginal
discharge.
 Weight gain.
 Mood changes.
 Uneasiness.
HYGIENE DURING MENSTRUATION
 This should be encouraged to
prevent inconviniences to the
individual and community
members, and to prevent infections.
 She is encouraged to change
sanitary pads frequently, use of
clean pads and cotton pants.
  Ensuring hand washing before
and after changing pads by use of
soap and water.

THINGS THAT MAY INTERFERE WITH

THE MENSTRUAL CYCLE
 Malnutrition. This can result in
irregularity of menses.
 Pregnancy. This results in absence
of menses.
 Drugs like family planning pills
 Menopause gradual onset. This
results in inconsistency of
menstrual periods.
 Age-unstable in young girls after
menarche
 Debilitating diseases like
tuberculosis, HIV/AIDS and cancer.
They can result into absence of
menses.
 IUD (intra-uterine device) insitu.
This can result into heavy bleeding.
 Tumours, trauma and diseases of
hypothalamus, pituitary gland,
ovaries and uterus
 Stress
 Dysfunctional uterine action.
DISORDERS OF MENSTRUATION
By the end of this session students
should be able to:
  Describe the following disorders of
menstruation; amenorrhoea,
dysmenorrhoea, menorrhagia,
metrorrhagia, polymenorrhoea,
dysfunctional uterine bleeding and
endometriosis using their
definition, types, causes, signs and
symptoms, diagnosis/
investigations.
 Describe the management of each
disorder mentioned above.
 Mention the complications of
disorders of menstruation.
DEFINITION
These are abnormalities in
menstruation during reproductive life.
Common disorders associated with
menstruation are as follows;
3. Amenorrhoea
2. Dysmenorrhoea
3. Menorrhagia
4. Metrorrhagia
5. Polymenorrhoea (epimenorrhoea)
6. Dysfunctional uterine bleeding
7. Endometriosis
AMENORRHOEA
This refers to absence of menstruation
which occurs in female during their
reproductive age.
Types of amenorrhoea
Primary amenorrhoea. This is the
failure of menarche to occur by 16
years of age.It could be due to
imperforated hymen when she has
been menstruating but when blood
does not come out.
Secondary amenorrhoea. This is the
cessation of menses in a woman who
has previously menstruated. It is
regarded as secondary when she takes
a period of 6 month and above without
seeing her menses.
Causes
Physiological like pregnancy and
lactation,during pregnancy the levels
of oestrogen and progesterone remains
high thus ensuring the integrity of the
endometrium resulting into
amenorrhoea.
During lactation- soon after delivery
prolactin is secreted in large quantities
by the anterior pituitary. There is
partial suppression of LH production
so that the ovarian follicles may grow
but ovulation does not occur resulting
into amenorrhoea.
Hypothalamic dysfunction-such kind
of patients have lower levels of follicle
stimulating hormone(FSH) and
leutinising hormone (LH). Several
congenital syndromes associated with
abnormal hypothalamic- gonadal
function have been described and
these conditions present with primary
amenorrhoea and absence of
secondary sex characteristics. It is also
due to failure to the development of
central structures of hypothalamus.
Pituitary disorder,this is associated
with elevated levels of prolactin
(hyperplolactinemia).
Congenital abnormalities ,like
imperforated hymen, vaginal septum,
no uterus, no endometrium but with
uterus, absence of ovaries, cervical
stenosis, and absence of
hypothalamus (kallmann’s syndrome).
This is a congenital hypogonadotrophic
hypogonadism disorder characterized
by absence of secondary sex
characteristics.
Change of environment or occupation.
Fear, anxiety or excitement
Pseudomenorrhoea,pseudo means
false. Here a woman psychologically
thinks that she is pregnant yet she is
not.
After hysterectomy or bilateral
removal of ovaries
Full doses of radiation
Drugs ,like contraceptives especially
hormonal methods
Debilitating diseases like, TB,
HIV/AIDS, DM etc
Tumours of the pituitary gland,
hypothalamus, ovaries and uterus
Early onset of menopause
Idiopathic
DIAGNOSIS/INVESTIGATIONS
A detailed history taking (history of
change in weight, presence of stress,
questions about excessive weight,
presence of excessive body or facial
hair) and physical examination.
Urine for HCG to rule out pregnancy
Ultra sound scan of the pelvis to
visualize the contents or organs of the
pelvic cavity.
Blood for hormone analysis to rule out
hormonal imbalance.
Computerised tomography (CT) scan to
visualize the organs.

MANAGEMENT
This will depend on the cause. It may
be medical, surgical, or psychological.
Hyperprolactinaemia is treated by
administration of bromocriptine. This
is an ergot alkaloid which directly
opposes prolactin secretion.
Radiotherapy is reserved for those
patients who fails to respond to
medical therapy.
Imperforated 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.

DYSMENORRHOEA
These are 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.
Cause
This is due to release of a chemical
substance called prostaglandins from
the lining cells of the uterus at the time
of menstrual period. The prostaglandin
causes contractions of the muscle wall
of the uterus, that are called menstrual
cramps.
Types of dysmenorrhoea
Primary dysmenorrhoea. This refers to
painful menstruation that starts few
years after puberty and usually no
exact cause can be identified.

Pre-disposing factors
 Narrow cervical os (stenosis) ,which
results into tension during
contraction of muscles.
 Reduced blood supply to the
endometrium (ischaemia)
 Hormonal imbalance
  Retroverted uterus, that is , when
the uterus leans backwards
resulting into tension.
 Psycological or social stress, fear or
anxiety

Signs and symptoms

Dysmenorrhea is cyclic with pain most
often occurring just before or during
the first few days of each period.
 Lower abdominal pain (LAP) that
varies in severity among
individuals, ranging from mild to
 colicky or crampy, extending to the
back, thighs and legs.
 Nausea and vomiting
 Constipation or diarrhea
 Fainting, headache, malaise
 Irritability, nervousness, depression
Diagnosis
It is through history taking,ask about
the nature of pain, duration and when
it occurs. This is often confirmatory.
It is also through physical examination
to rule out pelvic tumours,
endometriosis which is often absent.
Treatment
 Non steroidal anti inflammatory
drugs (NSAIDS) like Iboprufen,
 mefenamic acid, diclofenac and
others. These prevent the formation
of prostaglandins in the uterine
lining cells.They are more effective
if taken before the onset of cramps.
 Antispasmodics like Buscopan
 Antiemetics like Phenegan for
nausea and vomiting
NOTE
 Begin treatment 2 days before
menstruation periods begins and
continue until 2 days after the
period has stopped.
 Avoid additive drugs since this
treatment is for 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.
 Dilatation and Curettage (D&C) may
be of help to remove necrotic tissue
of endometrium, but usually not
encouraged since it increases the
risk of infections.
 Cervical stenosis can be treated by
surgical widening of the canal.
 Effective counseling is important
since pain is usually psychological
to avoid drug dependence and
abuse.
  Delivery or with age will finally
treat pain since there will be
relaxation of uterine muscles and
reduce ischaemia.
 Encourage enough rest and sleep as
well as exercises, hygiene and good
diet.
 Other management options may
include hypnotherapy and
acupuncture.
Secondary dysmenorrhoea
This refers to painful periods which
start many years following normal and
well established menstrual periods. It
is more of pathological occurrence and
on investigations the cause is easily
established.
Causes
 Pelvic inflammatory diseases (PID)
 Uterine fibroids. This results into
the partial contraction of the uterus
resulting into pain.
 Endometriosis.This is the growth of
the endometrial tissue in other area
rather than the uterus.
 Endometritis. This is the
inflammation of the endometrium.
Signs and symptoms
 In addition to signs and symptoms
found in primary dysmenorrhoea,
there is;
  Lower abdominal pain (LAP)
usually happens 3-4 days or even a
week before menstruation and
either pain becomes better or
worsens with menstruation.
 There may be backache
 Signs and symptoms of
menorrhagia
 Painful coitus
 Infertility.This is the inability to
conceive.
Management
 Investigate and treat the cause.

NURSING MANAGEMENT
Nursing concerns
  Acute pain
 Stress
 Nausea and vomiting
Nursing diagnosis
4. Acute pain related to increased
uterine contractility evidenced by
verbalization of the girl or woman.
Nursing interventions
 Warm the abdomen,this causes
vasodilation and reduces the
spasmodic contractions of the
uterus.
 Massage the abdominal area that
feels pain,this reduces pain due to
the stimulus of therapeutic touch.
  Perform light exercises ,to blood
flow to the uterus and improves
muscle tone.
 Perform relaxation techniques to
reduce pressure to get relaxed.
 Administer analgesics as prescribed
to block nociceptive receptors
5. Ineffective individual coping
related to emotional stress evidenced
by patient’s verbalization.
Nursing interventions
 Assess patient’s understanding of
the condition. This is because
patient’s anxiety of the pain is
greatly influenced by knowledge.
  Provide an opportunity to discuss
how the pain is. Help the patient
identify coping mechanisms.
 Provide the patient with periods of
sleep or rest. Ensures relaxation of
the body and mind.
6. Risk for imbalanced nutrition less
than body requirements related to
nausea and vomiting.
Nursing interventions
 Provide the patient with periods of
sleep or rest ,this is to ensure
relaxation of the body.
 Encourage small frequent feeds.
These are easily tolerated by the
patient.
  Administer anti-emetic drugs like
promenzathine. This blocks the
emetic centres.

MENORRHAGIA
This refers to heavy or prolonged
menstrual bleeding or both.
Causes
 Uterine fibroids
 PID (pelvic inflammatory disease)
 Clotting disorders
 Retroverted uterus
 Functional tumours of ovaries
resulting into hormonal imbalance
 Cancers like cancer of the cervix
and endometrial cancer
Signs and symptoms
 Heavy bleeding which may be
painful or not, with a prolonged
duration
 Signs and symptoms of anaemia
and shock

Investigations
 Bleeding time to test for
coagulopathy
 Prothrombin time to test for
coagulopathy.
  Clotting time to test for availability
of platelets.
 In the above three tests, results will
be abnormal.
 Full haemoglobin levels and
hormone analysis to rule out
hormonal imbalance.
 Ultra sound scan to rule out new
growth in the uterus
MANAGEMENT
The best management is to investigate
and treat the cause
NURSING MANAGEMENT
Nursing concerns
 Heavy bleeding
 Anxiety
  Self care disturbance
Nursing diagnosis
Ineffective tissue perfusion related to
excessive bleeding evidenced by
pallor.
Nursing interventions
 Assess 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 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.

METRORRHAGIA
This refers to uterine bleeding ,usually
not excessive, occurring at irregular
intervals.
This is symptom not a disease.
Causes
 Uterine polyp. This is due to vast
blood supply to the polyp which
makes it bleed easily.
 Cervical erosions. This is due to the
presence of a wound and an
increase in blood supply resulting
into bleeding.
 Cancer of the cervix or endometrial
cancer.
 Chronic threatened abortion or
incomplete abortion
 Retained pieces of placenta. This
interferes with contraction of the
uterus to seal off blood vessels after
birth.
 Mole pregnancy. This is due to an
abnormal uterine mass which
 grows after fertilization and is
supplied with a lot of blood
capillaries resulting into bleeding.
 Ovulation bleeding
 Short cycles like polymenorrhoea
Investigations
 Through history taking
 Digital and speculum
examination,to
visualize the cervix for
any abnormality.
 Biopsy for histology to
rule out cancer.
 Pelvic scan,to visualize
pelvic organs and rule
out any abnormality.
MANAGEMENT
 The best management to investigate
and treat the cause

POLYMENORRHOEA/
EPIMENORRHPEA
This refers to menstruation periods
that occurs at shorter intervals than
usual (14-21 days), but they are
frequent and regular.
Causes
 Ovarian dysfunction
 After abortion or normal delivery
Diagnosis
 History taking
 Physical examination
 Hormone analysis to rule out
hormonal imbalance.
MANAGEMENT
 Investigate and treat the cause.
 If following abortion or delivery,
reassure the mother.
 Administer hormonal therapy to
stabilize the cycle.
 Carry out dilatation and curettage
(D&C) to remove retained products.

DYSFUNCTIONAL UTERINE BLEEDING

This refers to abnormal bleeding
resulting from hormonal changes
rather than from trauma,
inflammation, pregnancy or a tumour.
Incidence
Occurs in 20% in adolescents and more
than 50% in women over 45 years.
Causes
It is due to sustained levels of
oestrogen leading to thickening of the
endometrium which shed incompletely
and irregularly.
Signs and symptoms
Irregular, prolonged and sometimes
heavy bleeding.
NOTE A diagnosis of dysfunctional
uterine bleeding is made only when all
other possibilities of causes of bleeding
have been excluded.
Investigations
 Ultra sound scan to rule out new
growth
 Blood analysis for hormonal
imbalance
 Biopsy for histology
MANAGEMENT
 Treatment depends on various
factors like age, condition of the
uterine lining and the woman’s
plans regarding pregnancy.
 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.
 When the uterine lining is
thickened but contains normal
cells, heavy bleeding may be
treated with 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 usual manner for atleast 3
months.
 Women who have lighter bleeding
may be given low doses from the
start.
 If a woman has contraindications to
oestrogen containing drug,
progestin only pills may be given by
mouth for 10-14 days each month.
 D&C may be used if response or
hormonal therapy proves
ineffective.
 If a woman wants to become
pregnant, clomiphene drug may be
given orally to induce ovulation.
ENDOMETRIOSIS
This refers to growth or presence of
endometrial tissue outside the uterus.
It may be referred to as a misplaced
endometrial tissue.
Incidence
10-15%s of women between 25 and 45

years. 25-50% in infertile women.

Common sites that may be affected

Abdominal organs, ovaries, ligaments,

intestines, ureters, urinary

bladder,vagina, vulva, naval, lungs,

nose, conjunctiva and rarely on

normal skin.

Cause

The actual cause is not known

Pre-disposing factors

 Escape of menstrual tissue to the

fallopian tubes and ovaries

(Retrograde menstruation)

 Surgery involving the uterus like

C/S, D&C.

 Too late prime para (over 30 years)

  Genetic makeup (tend to run in

families) especially first degree

relatives like mother, sister,

daughter.

 Race-common in Caucasians

 Abnormal uterus like retroverted

uterus

Signs and symptoms

Some are asymptomatic

Lower abdominal pain

Irregular periods like spotting before

periods
Infertility

Painful coitus (dyspareunia)

Pain during bowel opening

Rectal bleeding during menstruation.

This is due to the presence of

endometrial tissue in the rectum.

Bleeding from the site during

menstruation

Palpable mass (endometrioma)

Adhesions

Diagnosis / investigations
Presence of endometrial tissue in the

site after microscopic examinations

confirms the disease (biopsy)

Laparoscopy. To view the tubes and

ovaries for the presence of

endometrial tissue.

Ultra sound scan. To visualize pelvic

organs for any abnormality.

Barium enema with x-ray. To locate

the site of the tissue.

Computerised Tomography (CT ) scan.

To visualize the tissue.

Magnetic Resonance Imaging (MRI ).

Blood for marker celle (CA-125 ) and

antibodies to endometrial tissue.

MANAGEMENT

Treatment depends on the symptoms,

pregnancy plans, age of the woman as

well as the extent of the disease.

1. Drugs that suppress the activity of

ovaries and slow the growth of

endometrial tissue like COCs, progestin

and GnRH agonists.

2. Surgery
To remove as much of the misplaced

endometrium tissue as possible

3.Combination of drugs and surgery

4. Total hysterectomy

COMPLICATIONS

Infertility

Adhesions leading to intestinal

obstruction

Chronic lower abdominal pain

ABORTION
Objectives
 By the end of this session students
should be able to:
 Define abortion
 Describe types of abortion
 Describe causes of abortion
 To list signs and symptoms of
abortion
 Manage abortion
 To explain complications of abortion

Definition:
Abortion is defined as the expulsion of
the fetus before the 28th week of
pregnancy. Abortion is important not
only because of the loss of wanted
pregnancy, but because it is an
important cause of maternal death from
the haemorrhage and sepsis which may
follow a mismanaged abortion.
Abortion accounts for 95 % of cases of
bleeding in early pregnancy.
Causes of abortion
Causes of abortion are classified into
maternal and fetal causes. Common
causes are maternal factors, including
infections, maternal illness, and
intrauterine anatomic abnormalities. In
some cases, however, the exact cause
remains unknown.
Fetal causes of abortion.
Abnormalities of the fetus are common
causes of early abortion, a blighted
ovum is a pregnancy in which the fetus
does not develop as might happen if it is
genetically abnormal; this is probably
the commonest reason of all
spontaneous abortion.
Another cause is abnormal attachment
of the placenta eg; near the internal os
Maternal causes
Medical Conditions
Hypothyroidism
women with hypothyroidism and
antithyroid antibodies are at risk for
spontaneous abortion. Thyroid
peroxidase autoantibodies are believed
to impair thyroid function during
pregnancy, leading to spontaneous
abortion and premature delivery.

Thyroid peroxidase antibodies are found

in patients with Hashimoto's thyroiditis.
Treatment with levothyroxine lowers
the risk of miscarriage.
Diabetes mellitus,pregnant patients with
diabetes and poor glycemic control
during the period of organogenesis
(within 7 weeks after conception) have
an increased rate of spontaneous
abortion, which is attributed to
hyperglycemia, possible immunologic
factors, and uteroplacental insufficiency
secondary to maternal vascular disease
Polycystic ovary syndrome, women with
polycystic ovary syndrome have a 3-fold
increased risk of early pregnancy loss.
This may be attributable to insulin
resistance with hyperinsulinemia and
high androgen levels
(hyperandrogenemia), which lead to
adverse effects on endometrial
development and embryonic
implantation.

Antiphospholipid antibodies, Nearly

60% of cases of recurrent pregnancy loss
are associated with the presence of
antiphospholipid antibodies.
Antiphospholipid antibodies comprise a
heterogeneous group of
immunoglobulins acting against plasma
proteins. These represent a possible
cause of spontaneous abortion through
promotion of microvascular thrombosis
in the placenta, leading to infarction.

Systemic lupus erythematosus, Women

with systemic lupus erythematosus have
risk of spontaneous abortion, likely due
to abnormal vascular supply to the
placenta and antiphospholipid
antibodies and lupus anticoagulant.
Appendicitis, Spontaneous abortion
occurs in patients with appendicitis
without perforation; the risk increases
to 36% in patients with perforation.
Intrauterine Causes
Asherman syndrome, This syndrome
occurs following curettage of the uterus.
Severe degrees of intrauterine
adhesions lead to obstruction of the
uterine cavity and subsequent
infertility. Mild degrees of adhesions are
associated with pregnancy loss, resulting
from constriction of the uterine cavity,
an insufficient amount of normal
endometrial tissue for implantation and
placental development, and defective
vascularization of the remaining
endometrial tissue caused by fibrosis

Fibroids, Women with submucosal

fibroids have a risk of miscarriage. A
possible mechanism of pregnancy loss
involves projection of the submucosal
fibroids into the uterine cavity, causing
distortion of the blood supply in the
endometrium and possibly interfering
with embryonic implantation.
Uterine malformations, Bicornuate
uterus is the most common
malformation and is the most common
malformation associated with recurrent
pregnancy loss.
Maternal Infections
Bacterial vaginosis, Bacterial vaginosis is
associated with obstetric complications,
including spontaneous abortion.
Treatment of bacterial vaginosis
includes topical or oral preparations of
clindamycin or metronidazole, neither
of which is associated with an increase
in teratogenic risk
Listeria monocytogenes infection,
Maternal infection with L.
monocytogenes affects the fetus in most
cases. Often the woman is exposed to the
bacterium through consumption of
unpasteurized cheese. Infection
occurring during the first 20 weeks of
gestation can result in pregnancy loss. L.
monocytogenes infection is suspected in
patients who develop fever 24 to 48
hours following spontaneous abortion.
Measles, Measles during pregnancy is
associated with a miscarriage rate as
high as 50% if infection occurred in the
first 2 months of gestation and a
miscarriage rate of 20% if infection
occurred in the third month of gestation.
 Mumps, Mumps is an acute
paramyxovirus infection that presents
as fever with enlargement of the
salivary glands. There is an association
between maternal mumps and fetal
death or spontaneous abortion.
Toxoplasma
gondii infection( toxoplasmosis),
Toxoplasmosis acquired by the mother
in the first trimester of pregnancy can
results in fetal infection. Fetal infection
with T. gondii at this stage is associated
with miscarriage or fetal death.

Ureaplasma and Mycoplasma infection,
Chronic colonization of the cervix and
vagina
with Ureaplasma orMycoplasma has
been associated with an increased risk
of recurrent abortion.

Obstetric History
Maternal age at the time of conception,
There is an increased incidence of
pregnancy loss with increasing maternal
age, which is due to an increased
incidence of aneuploidy, resulting in a
decreased implantation rate.

Previous spontaneous abortion, There is

a risk of abortion after a previous
spontaneous abortion. This risk
increases after 2 and 3 cases of
spontaneous abortion, respectively.
Diet and Lifestyle

Caffeine consumption, Coffee

consumption during pregnancy
increases the risk of miscarriage in a
dose-response relationship, showing a
higher risk associated with caffeine
consumption ≥200 mg (approximately
100 mg per 150 mL of caffeinated coffee)
per day

Obesity, In obese patients, insulin

resistance is an independent risk factor
for early pregnancy loss
Smoking, Tobacco smoke interferes with
the normal process of angiogenesis
(formation of new blood vessels),
possibly increasing the risk of
spontaneous abortion in pregnant
women who smoke. There are no exact
data on this risk.

Substance abuse,Cocaine use in the first

trimester of pregnancy is associated
with an increased risk of spontaneous
abortion
Signs and symptoms of abortion
Most abortions occur in the first three
months of pregnancy before the
placenta is mature, the detachment of
the ovum is accompanied by bleeding
which may be profuse. The blood loss is
accompanied by painful contractions of
the uterus, dilation of the cervix and
expulsion of the ovum and its
membranes.
Slight or even moderate bleeding does
not, however, mean that the pregnancy
is no longer alive.

Types of abortion

Spontaneous or miscarriage abortion:

refers to the loss of pregnancy before 28
weeks of gestation without outside
 intervention. It is classified into the
following subgroups based on the
clinical presentation: threatened
abortion, inevitable abortion,
incomplete abortion, complete abortion,
missed abortion, and recurrent abortion
Subgroups of Spontaneous Abortion
Subgroup Comments
Threatened Presents as vaginal bleeding
abortion in the presence of a viable
pregnancy with a closed
cervix
Inevitable Occurs when the cervix has
abortion dilated and the membranes
have ruptured, but the
products of conception
remain in utero
Missed abortion Characterized by
intrauterine fetal death and
 retention of the products of
conception
Complete Refers to the spontaneous
abortion passage of all the products
of conception; does not
require medical treatment
Recurrent A history of 3 or more
abortion spontaneous pregnancy
losses

Induced abortion: this is an abortion

that is caused intentionally. Reasons for
procuring induced abortions are
typically characterized as either
therapeutic or elective.
An abortion is medically referred to as a
therapeutic abortion when it is
performed to save the life of the
pregnant woman; prevent harm to the
woman's physical or mental health;
terminate a pregnancy where
indications are that the child will have a
significantly increased chance of
premature morbidity or mortality or be
otherwise disabled; or to selectively
reduce the number of fetuses to lessen
health risks associated with multiple
pregnancy.
An abortion is referred to as an elective
or voluntary abortion when it is
performed at the request of the woman
for non-medical reasons. 
 Miscarriages are also caused by a
variety of other factors, including:
 Infection
 Exposure to environmental and
workplace hazards such as high levels of
radiation or toxic agents
 Hormonal problems
 Uterine abnormalities
 Incompetent cervix (the cervix begins to
widen and open too early, in the middle
of pregnancy, without signs of pain or
labor)
 Lifestyle factors such as smoking,
drinking alcohol, or using illegal drugs
 Disorders of the immune system,
including lupus
 Severe kidney disease
 Congenital heart disease
 Diabetes that is not controlled
 Thyroid disease
 Radiation
 Certain medications, such as the acne
drug Accutane
 Severe malnutrition
Threatened abortion:
This is blood loss from the uterus during
the first 28 weeks of pregnancy; the
patient may have some abdominal
discomfort but does not feel any actual
pain because there are no rhythmic
uterine contractions. If a vaginal
examination is done the cervix is found
to be closed.
Treatment
 Bed rest is the most important
treatment; it increases placental
blood flow and reduces pain. The
patient should remain in bed for five
to seven days or as long as the blood
is bright red.
 Give mild sedatives eg:
phenobarbitone 60 mg t.d.s, to
ensure the patient rests in bed if
uterine contractions become strong
then analgesics such as pethidine 100
mg intramuscularly or morphia 15
mg may be needed.
 Save the pads that have been used in
order to help to assess the amount of
blood loss. Report any increase in
bleeding or pain.
Inevitable abortion:
The abortion becomes inevitable if, in
addition to the signs prescribed for
threatened abortion the Uterine
contraction becomes strong, painful and
lead to dilation of the cervix, this is
allowed by
 Complete abortion
 Incomplete abortion, this may lead
to heavy bleeding and shock
Complete abortion:
This means that all products of
conception have been passed and the
uterus is empty. Treat an abortion as
incomplete if you have not examined the
uterus and made sure that the products
passed were completed. Does not
require medical attention.
Incomplete abortion:
In this condition some the products of
conception remain in the uterus when
the fetus is passed. A vaginal
examination will show that cervix os is
open. Bleeding may either be severe or
slight but is continuous

Treatment
 If the patient has bled a great deal
and she is in shock, start a plasma-
 expender drip after taking blood for
grouping and cross matching.
 Do a sterile vaginal examination and
remove any placental tissue
distending the cervix with a finger or
spongy forceps.
 If the patient is in pain, give 100 mg
of pethidine or morphia 15 mg.
 Give ergometrine 0.5 mg
intramuscularly. Once these steps
have been taken the condition
usually improves and the patient can
be safely transferred to hospital.
 The uterus should be evacuated
surgically under general anaesthesia
in hospital.
Do not transfer shocked patient to
hospital resuscitate first.
Missed abortion:
In some cases of threatened abortion the
bleeding stops and everything seems to
be all right the signs of pregnancy begin
to disappear, however, breast activity
stops and the uterus does not get bigger.
After a time a brownish discharge
begins from the uterus. This show that
the fetus is dead but still in the uterus.
The dead fetus may turn into a solid and
hard mass, mostly of organized blood
clot, called a carneous mole, in time this
will be expelled with little or no blood
loss.
Refer cases of missed abortion to
hospital for management, as surgical
evacuation and checking of the uterus
may be necessary.
Septic abortion:
Infection of the uterus may follow any
abortion especially an incomplete or
induced abortion. This is usually caused
by Gram negative E.coli, but sometimes
gram positive streptococci and
staphylococci are involved.
In most cases infection is mild and
limited to the uterus, but in severe cases
it spreads to the fallopian tubes and may
spill into the peritoneal cavity to cause
peritonitis. Severe E coli infection may
lead to septicaemic shock caused by
endotoxins released from the organisms
Clinical features
These include fever, fast pulse rate,
offensive vaginal discharge and
tenderness on palpation in the lower
abdomen
Treatment
The treatment of patient with a septic
abortion is an emergency as delay may
result in severe complications or death.
The patient should be managed in
hospital if possible but in most
situations there will be an inevitable
delay in the transfer to hospital, in such
cases treatment should be started as
soon as diagnosis is made. The
principles of management include:
 Resuscitation with intravenous fluids
 Parenteral broad-spectrum
antibiotics
 Evacuation of infected products of
conception as soon as possible.
Fluid replacement
Most patients will have fluid deficit from
blood loss during abortion, or from poor
fluid intake due to ill health. Blood
transfusion should be done in hospital,
you should give two liters of normal
saline or dextrose/ saline in the first six
hours, the rest of fluid intake should
depend on urine output.
Antibiotic treatment
Where possible a cervical swab for
bacteriological culture and sensitivity
should be taken before starting
antibiotic treatment. The best antibiotics
are:
Crystalline penicillin 4 mu intravenously
6-hourly in combination with
streptomycin 0.5 mg intramuscularly
every 12 hours, or
Crystalline penicillin 4 mu intravenously
6-hourly in combination with
chloramphenicol or tetracycline 500 mg
intravenously 6-hourly.
These antibiotics are continued for one
week, or as directed by results of
bacterial sensitivity. Where tetanus is a
high risk, add tetanus toxoid or anti
tetanus serum to the treatment.
Evacuation of the uterus
As soon as resuscitation is completed
and antibiotic treatment has been
started, the products of conception
should be evacuated from the uterus,
most patients who do not improve after
the above treatment have complications
which need the attention of more
qualified doctor.
Habitual or recurrent abortion
A woman who has had three more
successive abortions is called habitual
aborter. In the majority of patients no
obvious causes can be found, some of
the known causes are chronic illness
such as diabetes mellitus and
abnormalities such as a septate uterus
and cervical incompetence. A pregnant
habitual aborter should always be
referred to hospital for management of
pregnancy and delivery.

FIBROIDS
Learning objectives
Define the term fibroids
Describe the types of fibroids
List at least five signs and symptoms of
fibroids.
 Describe the management of fibroids
State the complications of fibroids
Definition:A uterine fibroid is
a leiomyoma (benign, non-cancerous tu
mor from smooth muscle tissue) that
originates from the smooth muscle layer
(myometrium) of the uterus. Fibroids
are often multiple and if the uterus
contains too many leiomyomata to
count, it is referred to as diffuse uterine
leiomyomatosis. The malignant version
of a fibroid is extremely uncommon and
termed a leiomyosarcoma.
Other common names are uterine
leiomyoma, myoma, fibromyoma, fibrol
eiomyoma.
Fibroids are the most common benign
tumors in females and typically found
during the middle and later
reproductive years.
While most fibroids are asymptomatic,
they can grow and cause heavy and
painful menstruation, painful sexual
intercourse, and urinary frequency and
urgency. Some fibroids may interfere
with pregnancy although this appears to
be very rare.
  
Signs and symptoms
Fibroids, particularly when small, may
be entirely asymptomatic.
Symptoms depend on the location of the
lesion and its size. Important symptoms
include;
 Heavy or painful periods,
 Abdominal discomfort or bloating,
  Painful defecation,
 Back ache,
 Urinary frequency or retention,
 And in some cases, infertility. 
There may also be pain during
intercourse, depending on the location
of the fibroid. During pregnancy they
may also be the cause of  abortion,
bleeding, premature labor, or
interference with the position of the
fetus.
While fibroids are common, they are not
a typical cause for infertility accounting
for about 3% of reasons why a woman
may not have a child. Typically in such
cases a fibroid is located in a
submucosal position and it is thought
that this location may interfere with the
function of the lining and the ability of
the embryo to implant. Also larger
fibroids may distort or block the
fallopian tubes.
Location and classification

Schematic drawing of various types of

uterine fibroids:
A: subserous fibroids
B: interstitial fibroids
C: submucous fibroid
D: pedunculated submucosal fibroid
E: fibroid in the cervix
F: fibroid of the broad ligament
Growth and location are the main
factors that determine if a fibroid leads
to symptoms and problems. A small
lesion can be symptomatic if located
within the uterine cavity while a large
lesion on the outside of the uterus may
go unnoticed. Different locations are
classified as follows:
Interstitial fibroids are located within
the wall of the uterus and are the most
common type; unless large, they may be
asymptomatic. Interstitial fibroids begin
as small nodules in the muscular wall of
the uterus. With time, interstitial
(intramural) fibroids may expand
inwards, causing distortion and
elongation of the uterine cavity.
Subserous fibroids are located
underneath the mucosal (peritoneal)
surface of the uterus and can become
very large. They can also grow out in a
papillary manner to become
pedunculated fibroids. These
pedunculated growths can actually
detach from the uterus to become a
parasitic leiomyoma.
Submucous fibroids are located in the
muscle beneath the endometrium of the
uterus and distort the uterine cavity;
even small lesions in this location may
lead to bleeding and infertility. A
pedunculated lesion within the cavity is
termed an intra-cavitary fibroid and can
be passed through the cervix.
Cervical fibroids are located in the wall
of the cervix (neck of the uterus). Rarely
fibroids are found in the supporting
structures (round ligament, broad
ligament, or uterosacral ligament) of the
uterus that also contain smooth muscle
tissue.
Fibroids may be single or multiple. Most
fibroids start in an intramural location
that is the layer of the muscle of the
uterus. With further growth, some
lesions may develop towards the outside
of the uterus or towards the internal
cavity. Secondary changes that may
develop within fibroids are hemorrhage,
necrosis, calcification, and cystic
changes.
. Diagnosis
While a bimanual examination typically
can identify the presence of larger
fibroids, gynecologic
ultrasonography (ultrasound) has
evolved as the standard tool to evaluate
the uterus for fibroids. Sonography will
depict the fibroids as focal masses with a
heterogeneous texture, which usually
cause shadowing of the ultrasound
beam.
The location can be determined and
dimensions of the lesion measured. Also
magnetic resonance imaging (MRI) can
be used to define the depiction of the
size and location of the fibroids within
the uterus.
Imaging modalities cannot clearly
distinguish between the benign uterine
leiomyoma and the malignant uterine
leiomyosarcoma, however, the latter is
quite rare. Fast growth or unexpected
growth, such as enlargement of a lesion
after menopause; raise the level of
suspicion that the lesion might be a
sarcoma. Also, with advanced malignant
lesions there may be evidence of local
invasion.
Lesions biopsy is rarely performed and
if performed, is rarely diagnostic. Should
there be an uncertain diagnosis after
ultrasounds and MRI imaging, surgery is
generally indicated.
Other imaging techniques that may be
helpful specifically in the evaluation of
lesions that affect the uterine cavity
are hysterosalpingography or sonohyste
rography.

Treatment
Most fibroids do not require treatment
unless they are causing symptoms. After
menopause fibroids shrink and it is
unusual for fibroids to cause problems.
Symptomatic uterine fibroids can be
treated by:
 Medication to control symptoms
 Medication aimed at shrinking
tumours.
 Ultrasound fibroid destruction
 Myomectomy or radio frequency
ablation
 Hysterectomy
Medication

A number of medications are in use to

control symptoms caused by fibroids.
Non-steroid anti-inflammatory
drugs( NSAIDs), can be used to reduce
painful menses.
Oral contraceptive pills ,are prescribed
to reduce uterine bleeding and cramps. 
Anemia may have to be treated with
iron supplementation.
Levonorgestrel intrauterine devices are
highly effective in limiting menstrual
blood flow and improving other
symptoms. Side effects are typically very
moderate because
the levonorgestrel (aprogestin) is
released in low concentration locally.
Danazol ,is an effective treatment to
shrink fibroids and control symptoms.
Its use is limited by unpleasant side
effects. Mechanism of action is thought
to be antiestrogenic effects.
Gonadotropin-releasing hormone
analogs ,cause temporary regression of
fibroids by decreasing estrogen levels.
Because of the limitations and side
effects of this medication it is rarely
recommended other than for
preoperative use to shrink the size of the
fibroids and uterus before surgery. It is
typically used for a maximum of 6
months or less because after longer use
they could cause osteoporosis and other
typically postmenopausal complications.
The main side effects are transient
postmenopausal symptoms. In many
cases the fibroids will re-grow after
cessation of treatment, however
significant benefits may persist for much
longer in some cases. Several variations
are possible, such as GnRH agonists with
add-back regimens intended to decrease
the adverse effects of estrogen
deficiency.
Several add-back regimes
arepossible, tibolone, raloxifene, progest
ogens alone, estrogen alone, and
combined estrogens and progestogens.

Radio frequency ablation

Radiofrequency ablation is one of the
newest minimally invasive treatments
for fibroids. In this technique the fibroid
is shrunk by inserting a needle-like
device into the fibroid through the
abdomen and heating it with radio-
frequency (RF) electrical energy to
cause necrosis of cells. The treatment is
a potential option for women who have
fibroids, have completed child-bearing
and want to avoid a hysterectomy.
Myomectomy
is a surgery to remove one or more
fibroids. It is usually recommended
when more conservative treatment
options fail for women who want
fertility preserving surgery or who want
to retain the uterus.
There are three types of myomectomy:
 i. In a hysteroscopic myomectomy
(also called transcervical resection),
the fibroid can be removed by
either the use of a resectoscope,
an endoscopic instrument inserted
through the vagina and cervix that
can use high-frequency electrical
energy to cut tissue, or a similar
device.
ii. A laparoscopic myomectomy is
done through a small incision near
the navel. The physician uses a
laparoscope and surgical
instruments to remove the fibroids.
Studies have suggested that
laparoscopic myomectomy leads to
lower morbidity rates and faster
recovery than does laparotomic
myomectomy.
iii. A laparotomic myomectomy (also
known as
an open or abdominal myomectomy
) is the most invasive surgical
procedure to remove fibroids. The
physician makes an incision in the
abdominal wall and removes the
fibroids from the uterus.

Hysterectomy
Hysterectomy was the classical method
of treating fibroids. Although it is now
recommended only as last option,

Endometrial ablation
Endometrial ablation can be used if the
fibroids are only within the uterus and
not intramural and relatively small.
High failure and recurrence rates are
expected in the presence of larger or
intramural fibroids.

You should refer the patient to hospital,

further management is based on:
 The age of the patient
 Parity
 Size of the tumour
 Signs and symptoms caused by
the tumour
The treatment may therefore be the
removal of the tumour alone
(myomectomy) in a woman who wants
or expects more babies, or removal of
the whole uterus (total hysterectomy) in
woman who doesn’t expect more
deliveries.
Complications

 Fibroids that lead to heavy

vaginal bleeding lead
to anemia and iron deficiency.
 Due to pressure effects
gastrointestinal problems such
as constipation and bloatedness are
possible.
 Compression of the ureter may
lead to hydronephrosis.
 Fibroids may also present
alongside endometriosis, which itself
may cause
infertility. Adenomyosis may be
mistaken for or coexist with fibroids.
 In very rare cases, malignant
(cancerous)
 growths, leiomyosarcoma, of the
myometrium can develop.

NURSING MANAGEMENT
Nursing diagnosis
1. Acute pain related to inflammation
process in the uterine cavity due to
additional mass evidenced by mother’s
verbalization.
Nursing interventions
 Assess pain for intensity and
frequency. This helps in provision of
appropriate interventions for the
mother.
 Position the mother in sitting up
position. This improves muscle tone
and relieves pain.
  Encourage the mother to carry out
deep breathing exercises. This
increases comfort and reduces pain.
 Encourage the mother to use
warm compress. This increases
vasodilation of blood vessels at the
site of pain.
 Administer analgesics as
prescribed. This blocks pain
receptors.

2.Ineffective tissue perfusion related to

excessive bleeding evidenced by pallor.
Nursing interventions
 Assess 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 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.
ECTOPIC PREGNANCY
LEARNING OBJECTIVES
Explain what an ectopic pregnancy is.
List the causes / predisposing factors of
ectopic pregnancy.
Describe different sites of ectopic
pregnancy.
Explain the signs and symptoms of
ectopic pregnancy before and after
rupture.
Describe the outcomes of ectopic
pregnancy.
An ectopic pregnancy refers to a
pregnancy in which the embryo
implants outside the uterine cavity. 
With rare exceptions, ectopic
pregnancies are not viable.
Furthermore, they are dangerous for the
mother, since internal haemorrhage is a
life-threatening complication. Most
ectopic pregnancies occur in
the Fallopian tube  (also-called tubal
pregnancies), but implantation can also
occur in the cervix, ovaries, and
abdomen.
A ruptured ectopic pregnancy is a
potential gynaecologic emergency, and,
if not treated properly, can lead to
death.
In a typical ectopic pregnancy, the
embryo adheres to the lining of the
fallopian tube and burrows into the
tubal lining. Most commonly this
invades vessels and will cause bleeding.
This intratubal
bleeding hematosalpinx expels the
implantation out of the tubal end as a
tubal abortion.
Tubal abortion is a common type
of miscarriage. There is no inflammation
of the tube in ectopic pregnancy. The
pain is caused by prostaglandins
released at the implantation site, and by
free blood in the peritoneal cavity,
which is a local irritant. Sometimes the
bleeding might be heavy enough to
threaten the health or life of the woman.
Usually this degree of bleeding is due to
delay in diagnosis, but sometimes,
especially if the implantation is in the
proximal tube (just before it enters the
uterus), it may invade into the nearby
artery, causing heavy bleeding earlier
than usual.
If left untreated, about half of ectopic
pregnancies will resolve without
treatment. These are the tubal abortions.
The advent of methotrexate treatment
for ectopic pregnancy has reduced the
need for surgery; however, surgical
intervention is still required in cases
where the Fallopian tube has ruptured
or is in danger of doing so.
This intervention may
be laparoscopic or through a larger
incision, known as a laparotomy.
CLASSIFICATION
Tubal pregnancy
The vast majority of ectopic pregnancies
implant in the Fallopian tube.
Pregnancies can grow in the fimbrial
end, in the ampullary section, the
isthmus, the cornual and interstitial part
of the tube. Mortality of a tubal
pregnancy at the isthmus is higher as
there is increased vascularity that may
result more likely in sudden major
internal hemorrhage.
Non tubal ectopic pregnancy
Two percent of ectopic pregnancies
occur in the ovary, cervix, or are intra
abdominal.
Transvaginal ultrasound examination is
usually able to detect a cervical
pregnancy.
While a fetus of ectopic pregnancy is
typically not viable, very rarely, a live
baby has been delivered from
an abdominal pregnancy. In such a
situation the placenta sits on the intra
abdominal organs or
the peritoneum and has found sufficient
blood supply.
The diagnosis is most commonly made
at 16 to 20 weeks gestation. Such a fetus
would have to be delivered
by laparatomy. Maternal morbidity and
mortality from extra uterine pregnancy
are high as attempts to remove the
placenta from the organs to which it is
attached usually lead to uncontrollable
bleeding from the attachment site.
If the organ to which the placenta is
attached is removable, such as a section
of bowel, then the placenta should be
removed together with that organ. This
is such a rare occurrence that true data
are unavailable and reliance must be
made on anecdotal reports. However,
the vast majority of abdominal
pregnancies require intervention well
before fetal viability because of the risk
of hemorrhage.

SIGNS AND SYMPTOMS

Early symptoms are either absent or
subtle. Clinical presentation of ectopic
pregnancy occurs at a mean of 7.2 weeks
after the last normal menstrual period,
with a range of 4 to 8 weeks. Later
presentations are more common in
communities deprived of modern
diagnostic ability.
Early signs and symptoms (before
rapture) include:
Vague lower abdomen pain, (pain may
be confused with a strong stomach pain,
it may also feel like a strong cramp).
Amenorrhea.
Pain while urinating (dysuria)
Pain and discomfort, usually mild.
A corpus luteum on the ovary in a
normal pregnancy may give very
similar symptoms.
Pain while having a bowel movement.
On examination the patient is usually
healthy. You might feel a slight enlarged
uterus or a mass on the side of the
uterus.
Late signs and symptoms (after
rupture):
Patients with a late ectopic pregnancy
typically experience pain and bleeding.
This bleeding will be both vaginal and
internal and has two discrete
pathophysiologic mechanisms:
 External bleeding is due to the falling
progesterone levels.
 Internal bleeding (hematoperitoneum)
is due to hemorrhage from the affected
tube.
The differential diagnosis at this point is
between miscarriage, ectopic pregnancy,
and early normal pregnancy. The
presence of a positive pregnancy test
virtually rules out pelvic infection as it is
rare indeed to find pregnancy with an
active pelvic inflammatory disease (PID).
The most common misdiagnosis
assigned to early ectopic pregnancy is
PID.
 Lower back, abdominal, or pelvic pain.
 Shoulder pain. This is caused by free
blood tracking up the abdominal
cavity and irritating the diaphragm,
and is an ominous sign.
 There may be cramping or even
tenderness on one side of the pelvis.
 The pain is of recent onset, meaning it
must be differentiated from cyclical
pelvic pain, and is often getting worse.
Ectopic pregnancy can mimic symptoms
of other diseases such as appendicitis,
other gastrointestinal disorder,
problems of the urinary system, as well
as pelvic inflammatory disease and
other gynaecologic problems.

CAUSES. The actual cause is unknown

PREDISPOSING FACTORS
There are a number of risk factors for
ectopic pregnancies. However, in as
many as one third to one half no risk
factors can be identified. They include: 
Pelvic inflammatory disease,
Use of an intrauterine device (IUD),
Previous exposure to tubal surgery,
intrauterine surgery 
Smoking,
Previous ectopic pregnancy,
Tubal ligation.
 Previous low grade infection of the
tubes
Infection of the tubes neighboring
structures
Tumors in the pelvis
Congenital abnormalities of the tubes

Cilial damage and tube occlusion

Hair-like cilia located on the internal
surface of the Fallopian tubes carry the
fertilized egg to the uterus. Fallopian
cilia are sometimes seen in reduced
numbers subsequent to an ectopic
pregnancy, leading to a hypothesis that
cilia damage in the Fallopian tubes is
likely to lead to an ectopic pregnancy.
Women with pelvic inflammatory
disease (PID) have a high occurrence of
ectopic pregnancy. This results from the
build-up of scar tissue in the Fallopian
tubes, causing damage to cilia. If
however both tubes were completely
blocked, so that sperm and egg were
physically unable to meet, then
fertilization of the egg would naturally
be impossible, and neither normal
pregnancy nor ectopic pregnancy could
occur.
Tubal surgery for damaged tubes might
remove this protection and increase the
risk of ectopic pregnancy. Intrauterine
adhesions (IUA) present in Asherman's
syndrome can cause ectopic cervical
pregnancy or, if adhesions partially
block access to the tubes via the Ostia,
ectopic tubal pregnancy. Asherman's
syndrome usually occurs from
intrauterine surgery.
Endometrial/pelvic/genital tuberculosis,
another cause of Asherman's syndrome,
can also lead to ectopic pregnancy as
infection may lead to tubal adhesions in
addition to intrauterine adhesions.
Tubal ligation can predispose to ectopic
pregnancy. This is higher if more
destructive methods of tubal ligation
(tubal cautery, partial removal of the
tubes) have been used than less
destructive methods (tubal clipping). A
history of a tubal pregnancy increases
the risk of future occurrences. This risk
is not reduced by removing the affected
tube, even if the other tube appears
normal. The best method for diagnosing
this is to do an early ultrasound.
DIAGNOSIS
An ectopic pregnancy should be
considered as the cause of abdominal
pain or vaginal bleeding in every
woman who has a positive pregnancy
test. An ultrasound showing
a gestational sac with fetal heart in
the fallopian tube is clear evidence of
ectopic pregnancy.
An abnormal rise in blood human
chorionic gonadotropin (HCG) levels
may indicate an ectopic pregnancy.
There is no single threshold for the
human chorionic gonadotropin that
confirms an ectopic pregnancy. Instead,
the best test in a pregnant women is a
high resolution,
Transvaginal ultrasound. The presence
of an adnexal mass in the absence of an
intrauterine pregnancy on transvaginal
sonography increases the likelihood of
an ectopic pregnancy. When there are
no adnexal abnormalities on
transvaginal sonography, the likelihood
of an ectopic pregnancy decreases. An
empty uterus with levels higher than
1500 IU/ml may be evidence of an
ectopic pregnancy, but may also be
consistent with an intrauterine
pregnancy which is simply too small to
be seen on ultrasound.
If the diagnosis is uncertain, it may be
necessary to wait a few days and repeat
the blood work. This can be done by
measuring the HCG level approximately
48 hours later and repeating the
ultrasound. The serum HCG ratios
and logistic regression models appear to
be better than absolute single serum
HCG level. If the HCG falls on repeat
examination, this strongly suggests a
spontaneous abortion or rupture.
A laparoscopy or laparotomy can also be
performed to visually confirm an ectopic
pregnancy. Often if a tubal abortion or
tubal rupture has occurred, it is difficult
to find the pregnancy tissue. A
laparoscopy in very early ectopic
pregnancy rarely shows a normal
looking fallopian tube.
Culdocentesis, in which fluid is retrieved
from the space separating the vagina
and rectum, is a less commonly
performed test that may be used to look
for internal bleeding. In this test, a
needle is inserted into the space at the
very top of the vagina, behind the uterus
and in front of the rectum. Any blood or
fluid found may have been derived from
a ruptured ectopic pregnancy.
Cullen's sign can indicate a ruptured
ectopic pregnancy.
Note: when trying to make a diagnosis
you should consider these other causes
of acute abdominal pain:
Uterine abortion
Salpingitis
Appendicitis
Acute pyelonephritis
Torsion of an ovarian cyst
Rupture of corpus luteum with
intraperitoneal bleeding.
MANAGEMENT
- Refer all cases with definite or
suspected ectopic pregnancy to hospital
urgently as the condition may get worse
very quickly,
- Start an IV drip of normal saline before
transferring the patient to hospital, and
where possible blood donors should go
with the patient to the hospital.
- In hospital the operation should be
performed as soon as the diagnosis is
definite. It may be necessary to start the
operation while the patient is still in
chock as the blood loss may so great that
it cannot be compensated until the
bleeding is stopped.
- It may be possible to give an auto
transfusion to a patient with fresh
rupture of a tubal pregnancy. In this
procedure blood is collected from
peritoneal cavity, filtered through sterile
gauze into bottle with citrate, and then
transfused back into the patient.
At the operation the affected tube is
usually removed.
- Always think of ruptured ectopic
pregnancy if a woman in the child
bearing age present with acute
abdomen.

Medical
Early treatment of an ectopic pregnancy
with methotrexate is a viable alternative
to surgical treatment since at least
1993. If administered early in the
pregnancy, methotrexate terminates the
growth of the developing embryo; this
may cause an abortion, or the
developing embryo may then be either
resorbed by the woman's body or pass
with a menstrual period.
Contraindications include liver, kidney,
or blood disease, as well as an ectopic
embryonic mass > 3.5 cm.

Surgical
If hemorrhage has already occurred,
surgical intervention may be necessary.
However, whether to pursue surgical
intervention is an often difficult decision
in a stable patient with minimal
evidence of blood clot on ultrasound.
Surgeons
use laparoscopy or laparotomy to gain
access to the pelvis and can either incise
the affected Fallopian and remove only
the pregnancy (salpingostomy) or
remove the affected tube with the
pregnancy (salpingectomy). The first
successful surgery for an ectopic
pregnancy was performed by Robert
Lawson Tait in 1883.
NURSING MANAGEMENT
Nursing concerns
Pain
Bleeding
Anxiety
Low blood pressure
Nursing care plan
NURSI EXPEC INTERV RATIO EVALU
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COMPLICATIONS
The most common complication is
rupture with internal haemorrhage
which may lead to hypovolemic shock.
Death from rupture is rare in women
who have access to modern medical
facilities.
Anaemia due to bleeding.
Infections following operation.
Adhesions due to scar formation during
healing process.
Re-occurance of another ectopic
pregnancy.
Infertility if both tubes are affected.
OBSTETRIC FISTULAE
LEARNING OBJECTIVES
Explain what an obstetric fistula is.
list at least six signs and symptoms of
obstetric fistula.
Enumerate the causes of obstetric
fistula.
List the risk factors and consequences of
obstetric fistula.
Describe the management of obstetric
fistula.
Obstetric Fistula: is a medical condition
in which a fistula (hole) develops
between either
the rectum and vagina ( recto-vaginal
fistula) or between the bladder and
vagina ( vesico-vaginal fistula) after
severe or failed childbirth, when
adequate medical care is not available. 
It is considered a disease of
poverty because of its tendency to occur
in women in poor countries who do not
have health resources comparable to
developed nations.

SIGNS AND SYMPTOMS

Symptoms of obstetric fistula include:
 Flatulence, urinary or fecal
incontinence, which may be continual
or only happen at night
 Foul-smelling vaginal discharge 
 Repeated vaginal or urinary tract
infections 
 Irritation or pain in the vagina or
surrounding areas 
 Pain during sexual activity 
Other effects of obstetric fistula include
stillborn babies due to prolonged labor,
severe ulcerations of the vaginal tract,
"foot drop," which is the paralysis of the
lower limbs caused by nerve damage,
making it impossible for women to
walk, infection of the fistula forming
an abscess, and up to two-thirds of the
women become amenorrhoeic due to
worries.
CAUSES
The fistula usually develops as a result
of prolonged labor when a cesarean
section cannot be accessed. Over the
course of the three to five days of labor,
the unborn child presses against the
mother's birth canal very tightly, cutting
off blood flow to the surrounding tissues
between the vagina and the rectum and
between the vagina and the bladder,
causing the tissues to disintegrate and
rot away.
Obstetric fistula can also be caused by
 Poorly performed abortions, 
 Pelvic fractures,
 Cancer or radiation therapy targeted
at the pelvic area, 
 Inflammatory bowel disease (such
as Crohn's disease and ulcerative
colitis), or infected episiotomies after
childbirth. 
 Sexual abuse and rape, , 
 and other surgical trauma.
RISK FACTORS
Primary risk factors include early or
closely spaced pregnancies and lack of
access to emergency obstetric
care.When available at all, cesarean
sections and other medical interventions
are usually not performed until after
tissue damage has already been done.
Women affected with Crohn's
disease also have a higher risk of
developing obstetric fistulas.
INDIRECT CAUSES
Social, political, and economic causes
that indirectly lead to the development
of obstetric fistula concern issues
of poverty, malnutrition, lack of
education, early marriage and
childbirth, the role and status of women
in developing countries, harmful
traditional practices, sexual violence,
and lack of good quality or accessible
maternal and health care. For instance,
one traditional practice in some regions
is encouraging women to drink water to
aid the baby's birth, but a full bladder
during delivery actually increases the
risks of fistula.
Poverty
Poverty is the number one indirect
cause of obstetric fistulas around the
world. As obstructed labor and obstetric
fistulas account for 8% of maternal
deaths worldwide and “a 60-fold
difference in Gross National Product per
person shows up as a 120-fold difference
in maternal mortality ratio,” it is clear
that impoverished countries produce
higher maternal mortality rates and
thus higher obstetric fistula
rates. Furthermore, impoverished
countries not only have low incomes but
also lack adequate infrastructure,
trained and educated professionals,
resources, and a centralized government
that exist in developed nations to
effectively eradicate obstetric fistula.
Malnutrition
One reason that poverty produces such
high rates of fistula cases is
the malnutrition that exists in such
areas. Lack of money and access to
proper nutrition, as well as vulnerability
to diseases that exist in impoverished
areas because of limited basic health
care and disease prevention methods
cause inhabitants of these regions to
experience stunted growth. Sub-Saharan
Africa is one such environment where
the shortest women have on average
lighter babies and more difficulties
during birth when compared with fully-
grown women.
This stunted growth causes expecting
mothers to have skeletons unequipped
for proper birth, such as an
underdeveloped pelvis. This weak and
underdeveloped bone structure
increases the chances that the baby will
get stuck in the pelvis during birth,
cutting off circulation and leading to a
rotting away of tissue. Because of the
correlation between malnutrition,
stunted growth, and birthing difficulties,
maternal height can at times be used as
a measure for expected labor difficulties.
Lack of education
High levels of poverty also lead to low
levels of education among impoverished
women concerning maternal health.
This lack of information in combination
with obstacles preventing rural women
to easily travel to and from hospitals
lead many to arrive at the birthing
process without prenatal care. This can
cause a development of unplanned
complications that may arise during
home-births, in which traditional
techniques are used. These techniques
often fail in the event of unplanned
emergencies leading women to go to
hospital for care too late, desperately ill
and therefore vulnerable to the risks of
anesthesia and surgery that must be
used on them.
Education is associated with lower
desired family size, greater use of
contraceptives, and increased use of
professional medical services. Educated
families are also more likely to be able
to afford health care, especially
maternal healthcare.
Early marriages and early childbirth
Many girls enter into arranged
marriages soon after menarche (usually
between the ages of 9 and 15). Social
factors and economic factors contribute
to this practice of early marriages.
Socially, some grooms want to ensure
their brides are virgins when they get
married, so an earlier marriage is
desirable. Economically, the bride
price received and having one less
person to feed in the family helps
alleviate the financial burdens of the
bride's family. Early marriages lead to
early childbirth, which increases the
risk of obstructed labor, since young
mothers who are poor and
malnourished may have under-
developed pelvises. In fact, obstructed
labor is responsible for 76% to 97% of
obstetric fistulas.
Lack of quality maternal healthcare
Even women who do make it to the
hospital may not get proper treatment.
Countries that suffer from poverty, civil
and political unrest or conflict, and
other dangerous public health issues
such as malaria, HIV/AIDS,
and tuberculosis often suffer from a
severe burden and breakdown within
the healthcare system. This breakdown
puts many people at risk, specifically
women. Many hospitals within these
conditions suffer from shortages of staff,
supplies, and other forms of medical
technology that would be necessary to
perform reconstructive obstetric fistula
repair. There is a shortage of doctors in
rural Africa, and studies find that the
doctors and nurses who do exist in rural
Africa often do not show up for work.
Poverty hinders women from being able
to access normal and emergency
obstetric care because of long distances
and expensive procedures. For some
women, the closest maternal care
facility can be more than 50 kilometers
away. In Kenya, a study by the Ministry
of Health found that the "rugged
landscape, long distances to health
facilities, and societal preferences for
delivery with a traditional birth
attendant contributed to delays in
accessing necessary obstetric
care. Emergency cesarean sections,
which can help avoid vaginal delivery
and consequent fistula, are very
expensive.
Role and status of women
Women who are affected by obstetric
fistula do not necessarily have full
agency over their bodies or their
households. Rather, their husbands and
other family members have control in
determining the healthcare that the
women receive. For example, a woman's
family may refuse medical examinations
for the patient by male doctors, but
female doctors may be unavailable, thus
barring women from prenatal
care. Furthermore, many societies
believe that women are supposed to
suffer in childbirth, thus are less
inclined to support maternal health
efforts.

CONSEQUENCES
Obstetric fistula has far-reaching
physical, social, economic, and
psychological consequences for the
women afflicted.
Physical consequences
The most direct consequence of an
obstetric fistula is the constant leaking
of urine, feces, and blood as a result of a
hole that forms between the vagina and
bladder or rectum. This leaking has both
physical and societal penalties. The acid
in the urine, feces, and blood causes
severe burn wounds on the legs from
the continuous dripping. Nerve damage
that can result from the leaking can
cause women to struggle with walking
and eventually lose mobility.
In an attempt to avoid the dripping,
women limit their intake of water and
liquid which can ultimately lead to
dangerous cases of dehydration.
Ulceration and infections can persist as
well as kidney disease and kidney
failure which can each lead to death.
Further, only a quarter of women who
suffer a fistula in their first birth are
able to have a living baby, and therefore
have minuscule chances of conceiving a
healthy baby later on. Some women, due
to obstetric fistula and other
complications from childbirth, do not
survive.
Social consequences
Physical consequences of obstetric
fistula lead to severe socio-cultural
stigmatization for various reasons. For
example, in Burkina Faso, most citizens
do not believe obstetric fistula to be a
medical condition but as a divine
punishment or a curse for disloyal or
disrespectful behavior. Other sub-
Saharan cultures view offspring as an
indicator of a family's wealth. A woman
who is unable to successfully produce
children as assets for her family is
believed to make her and her family
socially and economically inferior. A
patient's incontinence and pain also
render her unable to perform household
chores and childrearing as a wife and as
a mother, thus devaluing her
worth. Other misconceptions about
obstetric fistula are that it is caused
by venereal diseases or that it is divine
punishment for sexual misconduct.
As a result, many girls are divorced or
abandoned by their husbands and
partners, disowned by family, ridiculed
by friends, and even isolated by health
workers. Now marginalized members of
society, girls are pushed to the brims of
their villages and towns, often to live in
isolation in a hut where they will likely
die from starvation or an infection in
the birth canal.
The unavoidable odor is viewed as
offensive, thus their removal from
society is seen as essential. Accounts of
women who suffer obstetric fistula
proclaim that their lives have been
reduced to the leaking of urine, feces,
and blood because they are no longer
capable or allowed to participate in
traditional activities, including the
duties of wife and mother. Because such
consequences highly stigmatize and
marginalize the woman, the intense
loneliness and shame can lead to clinical
depression and suicidal thoughts. Some
women have formed small groups and
resorted to walking by foot to seek
medical help, where their stench makes
them a target for sub-Saharan wildlife,
further endangering their lives. This trip
can take on average 12 hours to
complete. Moreover, women are
sometimes forced to turn to commercial
sex work as a means of survival because
the extreme poverty and social isolation
that result from obstetric fistula
eliminate all other income
opportunities. The vast majority of
women are forced to suffer the
consequences of obstructed and
prolonged labor simply because options
and access to help is so incredibly
limited.
Psychological consequences
Although there are few sources of
empirical data, studies show that some
common psychological consequences
that fistula patients face are the despair
from losing their child, the humiliation
from their stench and inability to
perform their family roles, and the fear
of developing another fistula in future
pregnancies.

MANAGEMENT
It is a planned repair (elective). Repair is
done after 3-6 months from the time of
injury to;
Allow fibrosis to take place.
Allow inflammatory response to take
place.
Clear away urinary tract infection.
Fistula may reduce in size.
Fistula may close spontaneously.
In hospital the doctor carry out a gentle
vaginal examination with his fingers, no
instrument are used for fear of
enlarging the defect, he passes catheter
at the same time so that the exact course
of urethra may be felt in relation to any
defect in the bladder neck or urethra.
The patient is kept on continuous
bladder drainage as the passage of urine
through the defect prevent healing and
is put on appropriate antibiotics to treat
any infection present. She is given a
balanced diet, iron and vitamin
supplements and if necessary is give
blood transfusion to restore her general
state of health.
A significant number of fistulae will
close spontaneously during the six
weeks of the puerperium, provide that
there is continuous bladder drainage,
good general health and all infection is
eradicated
Some women get foul-smelling vaginal
discharge. This is caused by the
sloughing necrotic tissue. This can be
treated with antiseptic vaginal douches.
At the end of the puerperium the patient
may be assessed by means of speculum.
Surgical repair cannot be done at this
stage as one has to give enough time to
allow the tissues to heal and strengthen
up sufficiently if repair is to succeed.
Therefore woman will have to be sent
home and asked to re-attend for surgery
at a later date. Bladder catheterization is
stopped at this time (six weeks from the
delivery date) as continuous bladder
drainage is no longer needed.
PRE OPERATIVE CARE
Admit as an elective case to prepare the
mother for repair, main emphasis is put
on psychological care to restore hope
and confidence. Good diet to correct
malnutrition, plenty of fluids to flush the
kidneys, hygiene especially of the
genitalia to treat / prevent infections.
Explain to her that she will be nursed in
prone position for 14 days post
operatively to promote healing.
Counsel her on catheter which will stay
insitu for 14 days or more to promote
healing.
Prepare her for theatre like other pre-
operative care procedures (review of the
general preoperative care).
On the evening before operation enema
is given to decongest the rectum.
NOTE. Colostomy may be performed in
recto vaginal fistula repair.
POST OPERATIVE CARE
Mother is nursed in semi prone position
until she gains consciousness and later
nursed in prone position until 14 days.
Observe the catheter for drainage, urine
color and side leakage. Any abnormality
must be reported. Bladder irrigation
should be done by a doctor if required.
Other routine care is provided.
BLADDER TRAINING
This is commenced after 14 days post
operatively if no leakage has been
observed. Bladder training is done
because bladder loses its muscle tone
and micturition reflex during the period
of continuous bladder drainage (CBD).
1st day – spigot the catheter and remove
the urine bag. Release it hourly during
the day and at night put CBD.
2nd day – remove CBD, spigot the
catheter and release it 2 hourly during
the day, continue with CBD at night.
3rd and 4th day – release the catheter
during the day and continue with CBD at
night.
5th day – remove the catheter, ask the
mother to hold urine as much as
possible so as to see how much the
bladder can hold or tolerate for a period
of time, then ask the mother to pass
urine. After passing out urine,
catheterize again to measure the residue
volume of urine remained in the
bladder. If the residue urine is less than
100mls, then it means bladder training
has been successful. Discharge may be
considered.
If residue urine is more than 100mls,
this means that bladder training has not
been successful, therefore, recommence
CBD and bladder training.

NURSING MANAGEMENT
NURSING CONCERNS
Mother is miserable and depressed.
Dripping of urine / feaces.
Smell of urine
Wet thighs
Urinary tract infections.
NURSING CARE PLAN
NURS EXPEC INTERVE RATIO EVALU
ING TED NTIONS NALE ATION
DIAG OUTC
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Explain iates
conti of the
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Explain Promot
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Risk Mothe Encoura Skin Mother
for r’s ge the remain ’s skin
impai skin mother s dry. remain
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skin d and dry intact
interg remai the skin all the
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Encoura
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 frequent
ly. Kills
microo
Give a rganis
high ms.
nourishi
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Treat
urinary
tract
infection
s with
antibioti
cs.

ADVICE ON DISCHARGE
Mother should avoid coitus for 3
months. Counsel both the man and
woman on issue of NO sex so that they
go home when it is properly resolved.
To avoid pregnancy for atleast 2-3 years.
To attend antenatal clinic early enough
when she gets pregnant and the issue of
fistula repair should be revealed to the
attending midwife, preferably should be
seen by a doctor.
Delivery should be preferably by
caesarian section.
Avoid strenuous work and have enough
rest to promote healing.
Ensure vulva toilet to prevent infections.
Have a highly nourishing diet to
promote healing.
Review in gynecological department.
PREVENTION
Prevention comes in the form of
 Access to obstetrical care,
 Support from trained health care
professionals throughout pregnancy,
 Providing access to family planning,
 Promoting the practice of spacing
between births,
 and Supporting women in education
and in postponing early marriage.
Fistula prevention also involves many
strategies to educate local communities
about the cultural, social, and
physiological factors that condition and
contribute to the risk for fistula. One of
these strategies involve
 Organizing community-level
awareness campaigns to educate
women about prevention methods
such as proper hygiene and care
during pregnancy and labor. 
 Prevention of prolonged obstructed
labor and fistula should preferably
begin as early as possible in each
woman's life. For example, improved
nutrition and outreach programs to
raise awareness about the nutritional
needs of children to prevent
malnutrition as well as improve the
physical maturity of young mothers
are important fistula prevention
strategies.
 It is also important to ensure access
to timely and safe delivery during
childbirth: measures include
 availability and provision of
emergency obstetric care as well as
quick and safe cesarean sections for
women in obstructed labor.
 Some organizations train local nurses
and midwives to perform emergency
cesarean sections to avoid vaginal
delivery for young mothers who have
under-developed pelvises. 
 Midwives located in the local
communities where fistula is
prevalent can contribute to
promoting health practices that help
prevent future development of
obstetric fistulas.
 Promoting education for girls is also
a key factor to preventing fistula in
the long term.
VAGINAL DISCHARGE
LEARNING OBJECTIVES
Define the term vaginal discharges
Differentiate between normal and
abnormal vaginal discharges
Define and describe the characteristics
and functions of leuchorrhoea, show,
liquor amnii, lochia and its types, and
menstrual flow.
Describe the characteristics of
abnormal vaginal discharge.
DEFINITION
These are secretions seen per vagina.
They are of two types, that is, normal
and abnormal.
NORMAL VAGINAL DISCHARGE
1.Leucorrhoea
This is the normal discharge and keeps
on changing depending on the
menstrual cycle. It is produced by adult
women in reproductive age by
Doderlien bacilli.
Characteristics
Should be minimal and moderate in
amount
Should not be offensive
Should not be itching or irritating
Should be acidic in reaction
It is usually whitish, clear or creamy in
colour and changes according to the
menstrual cycle. It is egg white and
elastic around ovulation and should be
clear after peak days.
Functions
It keeps the vagina moist and warm
2.Show
It is a bloody mucoid discharge from the
vagina which appears when a woman is
in her first stage of labour.
Characteristics
Should not be much in amount
Should not be offensive
Should not be irritating
3.Liquor amnii/ amniotic fluid
It is a clear straw coloured fluid found in
the amniotic membrane in the uterus, in
which the foetus grows.
It ranges between 1000-1500ml in
amount
It is clear if not infected
It pours out during labour which aids in
lubrication of birth canal during child
birth.
It consists of 99% water, mineral salts,
urea from urine passed by the foetus.
It is alkaline in reaction
It sometimes contains meconeum
especially in obstructed labour
Functions of amniotic fluid
Protects the fetus
Free movement of the fetus
Regulates fetal temperature
Protects fetal limbs from sticking
together
Contains nutrients which nourishes the
fetus
Abnormalities associated with amniotic
fluid
Oligohydromnous-inadequate amniotic
fluid between 300-500mls
Polyhydromnous-excess amniotic fluid
between 2000-3000mls
Offensive amniotic fluid-due to
infections
Blue amniotic fluid-due to drugs
Brown amniotic fluid-due to fetal death
Meconeum stained-due to fetal distress
4.Lochia
This appears after delivery of the baby
(puerperium)
The amount varies in different women
and is more in quantity than that of
menstrual flow.
Its odour is heavy and unpleasant but
not offensive
It has an alkaline reaction
Types
Rubra (red). Present during the first 3
days. It consists of blood, sheds of
deciduas and pieces of chorion, liquor
amnii vernix caseosa and meconeum
may be present. Appear s red owing to
the presence of erythrocytes.
Serosa (pink). Present from 4th to9th day.
The discharge becomes paler and
pinkish in colour, containing less blood
and more serum, leucocytes(WBC) and
bacteria.
Alba(white or clear). Present from 10th to
15th day. The discharge becomes paler, it
is yellowish white in colour and contains
cervical mucus, bacteria and debris
from the healing process of the uterus
and the vagina.

5.Menstrual flow
It should be about 60-180mls of blood.
This flow consists of blood from the
endometrium, endometrial tissue, +-
unfertilized ovum and secretions from
the endometrium.
Characteristics
It should not clot
It should not be offensive
It should be dark red
ABNORMAL VAGINAL DISCHARGES
These are discharges which are caused
by sexually transmitted infections of
diseases of the female reproductive
system and require treatment.
These discharges are pathological other
than physiological.
Characteristics of abnormal vaginal
discharges
Colour
Whitish creamy or curdy milky
discharge- usually due to fungal
infection of the vulva and vagina like
candidiasis.
Greenish yellow discharge- is a common
feature of trichomonas vaginalis
Purulent yellow discharge-usually due to
gonococcal infections.
Odour
Any offensive discharge should be
investigated and the cause treated
Amount
Increased amount that tint the nicker is
abnormal and should be investigated
and treated.
Irritant
Any discharge that may cause irritation
and results into inflammation is
abnormal and should be investigated
and treated.
HUMAN SEXUAL FUNCTIONAL

DISORDERS
Definition:

Sexual dysfunction (or sexual

malfunction or sexual disorder) is

difficulty experienced by an individual

or a couple during any stage of a normal

sexual activity, including physical

pleasure, desire, preference, arousal or

orgasm

General factors and causes of sexual

dysfunctional disorders

There are many factors which may

result in a person experiencing a sexual

dysfunction. These may result from:

Emotional factors:

 Interpersonal or psychological

problems, which can be the result of

depression(A mental state

characterized by a pessimistic sense

of inadequacy and a despondent lack

of activity), sexual fears or guilt, past

sexual trauma, and sexual disorders,

among others.

 Anxiety disorders,ordinary

anxiousness can obviously cause

erectile dysfunction in men without

psychiatric problems, but clinically

diagnosable disorders such as panic

disorder commonly cause avoidance

of intercourse and premature

ejaculation.Pain during intercourse is

often a together with anxiety

disorders among women.

Physical causes:

 They include the use of drugs,

such as alcohol, nicotine, narcotics,

stimulants, antihypertensives,

antihistamines, and some

psychotherapeutic drugs.

 For women, almost any

physiological change that affects the

reproductive system—premenstrual

syndrome, pregnancy and the

postpartum period, menopause—can

have an adverse effect on libido.

 Injuries to the back may also

impact sexual activity

 Problems with an enlarged

prostate gland, problems with blood

supply or nerve damage (as in spinal

cord injuries).

 Diseases such as diabetes,

multiple sclerosis, tumors, and,

rarely, syphilis may also impact the

activity

 Failure of various organ systems

such as the heart and lungs

 Endocrine disorders (thyroid,

pituitary, or adrenal gland problems)

 Hormonal deficiencies (low

testosterone, other androgens, or

estrogen) and some birth defects.

 In aging women, it is natural for

the vagina to narrow and become

atrophied. If a woman has not been

participating in sexual activity

regularly (in particular, activities

involving vaginal penetration) with

her partnern
 Hormone deficiency or hormonal

imbalance e.g:increased amounts of

prolactin in women dysfunctional

sexual disorders

 In individuals with testicular

failure like in Klinefelter syndrome,

or those who have had radiation

therapy, chemotherapy or childhood

exposure to mumps virus, the testes

may fail and not produce

testosterone
FEMALE SEXUAL DYSFUNCTIONAL

DISORDERS

Definition

Female sexual arousal disorder (FSAD)

occurs when a woman is continually

unable to attain or maintain arousal and

lubrication during intercourse, is unable

to reach orgasm, or has no desire for

sexual intercourse

It is also called "frigidity." Other terms

for the disorder include dyspareunia

and vaginismus, both of which involve

pain during intercourse.

Causes

There are numerous causes of this

disorder. They include:

 physical problems, such as

endometriosis, cystitis, or vaginitis

 systemic problems, such as

diabetes, high blood pressure, or

hypothyroidism.

 Even pregnancy or the

postpartum period (time after

delivery of a child) may affect desire.

 Menopause is also known to

reduce sexual desire.

 medications, including oral

contraceptives, antidepressants,

antihypertensives, and tranquilizers

 surgery, such as mastectomy or

hysterectomy which may affect how

a woman feels about her sexual self.

 stress

 depression

 use of alcohol, drugs, or cigarette

smoking
 Symptoms

Symptoms vary.

 A woman may have no desire for

sex, or may not be able to maintain

arousal, or may be unable to reach

orgasm.

 She may also have pain during sex

or orgasm, which interferes with her

desire for intercourse.

Diagnosis

 Through b complete medical

history to determine when the

problem started, how it presents,

how severe it is, and what the patient

thinks may be causing it.

 The doctor will also conduct a

complete physical examination,

looking for any abnormalities in the

genital region

Treatment

The physician should start by providing

education about the disorder and

recommending various nonmedical

treatment strategies. These include:

 Use of erotic materials, such as

vibrators, books, magazines and

videos

 Sensual massage, avoiding the

genitals

 Position changes to reduce pain

 Use of lubricants to moisten the

vagina and genital area

 Kegel exercises to strengthen the

vagina and clitoris

  Kherapy to overcome any

relationship or sexual abuse issues

Medical treatments include:

 Estrogen replacement therapy,

which may help with vaginal

dryness, pain and arousal

 Testosterone therapy in women

who have low levels of this male

hormone (Side effects, however, may

include deepening voice, hair

growth, and acne)

 The EROS clitoral therapy device

(EROS-CTD), recently approved by the

Food and Drug Administration; a

small vacuum pump, placed over the

clitoris and gently activated to

provide a gentle suction designed to

increase blood flow to the region,

which, in turn, helps with arousal

 Using the herb yohimbine

combined with nitric oxide has been

found to increase vaginal blood flow

in postmenopausal women and thus

 help with some forms of female

sexual arousal disorders(FSAD)

Alternative treatment

 Natural estrogens, such as those

found in soy products and flax, may

be effective.

 Herbal remedies include

belladonna, gingko, and motherwort.

However, there is no scientific

evidence to prove these herbs

actually help.

 Some women squirt vitamin E in

their vagina to increase lubrication.

  Women may also want to see a

sexual therapist for additional help.

Prevention

 Maintaining a close and open

relationship with a partner is one

way to avoid the emotional pain and

isolation that can lead to sexual

dysfunction.
  Additionally, women should learn

if any medications they take affect

sexual function, and should refrain

from alcohol and drugs and quit

smoking.

 Women who have anxieties and

fears about sexual intercourse,

whether because of earlier abuse,

rape, or a prudish upbringing, should

deal with those issues through

therapy.

Classification of sexual dysfunction

Sexual dysfunction disorders may be

classified into four categories:

 Sexual desire disorders,

 arousal disorders,

 Orgasm disorders

 Pain disorders.
SEXUAL DESIRE DOSORDES

Hypoactive sexual desire disorder

Sexual desire disorders or decreased

libido which are characterized by a lack

or absence for some period of time of

sexual desire or libido for sexual activity

or of sexual fantasies.

The condition ranges from a general

lack of sexual desire to a lack of sexual

desire for the current partner. The

condition may have started after a

period of normal sexual functioning or

the person may always have had no/low

sexual desire.

Causes

 The decrease in the production of

normal estrogen in women or

testosterone in both men and

women.

 Increased level of prolactin

production

 Aging

 Fatigue

 Pregnancy
  Medications such as the Serotonin

selective reuptake inhibitors (SSRIs)

e.g.Fluoxetine ,Sertraline ,Paroxetine

Fluvoxamine

 Psychiatric conditions, such as

depression and anxiety.

SEXUAL AROUSAL DISORDERS

Definittion

Sexual arousal disorders were

previously known as frigidity in women

and impotence in men. Though these

have now been replaced with less

judgmental terms. Impotence is now

known as erectile dysfunction, and

frigidity has been replaced with a

number of terms describing specific

problems that can be broken down into

four categories: lack of desire, lack of

arousal, pain during intercourse, and

lack of orgasm.
So the clear definition now is an erectile

dysfunction and lack of desire, lack of

arousal, pain during intercourse, and

lack of orgasm during intercourse

For both men and women, these

conditions can manifest themselves as

an aversion to, and avoidance of, sexual

contact with a partner.

In men, there may be partial or

complete failure to attain or maintain an

erection, or a lack of sexual excitement

and pleasure in sexual activity.

Causes

 There may be decreased blood

flow

 Lack of vaginal lubrication.

 Chronic diseases e.g:Diabetes

mellitus ,heart diseases

 Nature of the relationship

between the partners.

ERECTILE DYSFUNTIONS

Definition

Erectile dysfunction or impotence is a

sexual dysfunction characterized by the

inability to develop or maintain an

erection of the penis.

Causes

Damage to the nervi erigentes which

prevents or delays erection

Psychological or physical

causes ,psychological erectile

dysfunction can often be helped by

almost anything that the patient believes

in; there is a very strong placebo effect.

Physical damage is much more severe.

One leading physical cause of erectile

dysfunction is continual or severe

damage taken to the nervi erigentes.

These nerves course beside the prostate

arising from the sacral plexus and can

be damaged in prostatic and colorectal

surgeries.
Diseases, diabetes as well as

cardiovascular disease, which simply

decreases blood flow to the tissue in the

penis, are also common causes of

erectile dysfunctional; especially in men.

There are also multiple sclerosis(A

chronic progressive nervous disorder

involving loss of myelin sheath around

certain nerve fibers), kidney failure,

vascular disease and spinal cord injury

are the source of erectile dysfunction.

Importence
The Latin term impotentia coeundi

describes simple inability to insert the

penis into the vagina. It is now mostly

replaced by more precise terms.

Pharmacological treatment

The first pharmacologically effective

remedy for impotence, sildenafil (trade

name Viagra)

Premature ejaculation

Definition

Premature ejaculation is when

ejaculation occurs before the partner

achieves orgasm, or a mutually

satisfactory length of time has passed

during intercourse.

There is no correct length of time for

intercourse to last, but generally,

premature ejaculation is thought to

occur when ejaculation occurs in under

2 minutes from the time of the insertion

of the penis.

Causes
Premature ejaculation may have an

underlying neurobiological cause which

may lead to rapid ejaculation.

Diagnosis

The patient must have a chronic history

of premature ejaculation

Poor ejaculatory control, and the

problem must cause feelings of

dissatisfaction as well as distress the

patient, the partner or both.

ORGASM DISORDERS

Orgasm disorders are persistent delays

or absence of orgasm following a

normal sexual excitement phase .

Causes
 The disorder can have physical,

psychological, or pharmacological

origins. Serotonin selective reuptake

inhibitors(SSRI) antidepressants are a

common pharmaceutical cause, as they

can delay orgasm or eliminate it

entirely.

Post-orgasmic diseases

Definition

Post-coital tristesse (PCT) is a feeling of

melancholy (A feeling of thoughtful

sadness) and anxiety after sexual

intercourse that lasts for up to two

hours. Post-orgasmic diseases cause

symptoms shortly after orgasm or

ejaculation.

Sexual headaches occur in the skull and

neck during sexual activity, including

masturbation or orgasm.

In men, postorgasmic illness syndrome

(POIS) causes severe muscle pain

throughout the body and other

symptoms immediately following

ejaculation. The symptoms last for up to

a week.

SEXUAL PAIN DISORERS

Dyspareunia ,painful intercourse due to

an involuntary spasm of the muscles of

the vaginal wall that interferes with

intercourse ,it affect women almost

exclusively and are also known as

vaginismus
Causes

 Insufficient lubrication (vaginal

dryness) in women. Poor lubrication

may result from insufficient

excitement and stimulation, or from

hormonal changes caused by

menopause, pregnancy, or breast-

feeding.

 Irritation from contraceptive

creams and foams can also cause

dryness, as can fear and anxiety

about sex.
  Sexual trauma (such as rape or

abuse) may play a role.

Priapism is a painful erection that

occurs for several hours and occurs in

the absence of sexual stimulation.

This condition develops when blood gets

trapped in the penis and is unable to

drain out. If the condition is not

promptly treated, it can lead to severe

scarring and permanent loss of erectile

function.
The disorder occurs in young men and

children. Individuals with sickle-cell

disease and those who abuse certain

medications can often develop this

disorder.

Vulvodynia or vulvar vestibulitis.

In this condition, women experience

burning pain during sex which seems to

be related to problems with the skin in

the vulvar and vaginal areas. The cause

is unknown
Management of sexual dysfunctions

Althorough sexual history and

assessment of general health and other

sexual problems (if any) are very

important. Assessing (performance)

anxiety, guilt, stress and worry are

integral to the optimal management of

sexual dysfunction.

Males

 Psychotherapy can help.

 Marriage counseling sessions are

recommended in this situation.

 Lifestyle changes such as

discontinuing smoking, drug or

alcohol abuse can also help in some

types of erectile dysfunction.

 Several oral medications like

Viagra, Cialis and Levitra have

become available to help people with

erectile dysfunction. These

medications provide an easy, safe,

and effective treatment solution for

approximately 60% of men.

 Intracavernous pharmacotherapy

and involves injecting a vasodilator

 drug directly into the penis in order

to stimulate an erection. This method

has an increased risk of priapism if

used in conjunction with other

treatments, and localized pain.

Females

Although there are no approved

pharmaceuticals for addressing female

sexual disorders, several are under

investigation for their effectiveness.

 A vacuum device is the only

approved medical device for arousal

 and orgasm disorders. It is designed

to increase blood flow to the clitoris

and external genitalia.

 Women experiencing pain with

intercourse are often prescribed pain

relievers

 Lubricants and/or hormone

therapy.

 Psychosocial counseling.

Complications

 Infertility

 Failure of sex satisfaction

  Sometimes, pain

 Psychological disturbance

Other sexual problems

 Sexual aversion disorder

(avoidance of or lack of desire for

sexual intercourse)
 Retrograde ejaculation ,this is the
backwards movement of the semen
due to deformity of ejaculatory
ducts .they are two ejaculatory ducts
leading from the seminal vesicles
through the prostate gland to the
urethra.

 Sexual dissatisfaction (non-

specific)

 Lack of sexual desire

 Sexually transmitted diseases

 Delay or absence of ejaculation,

despite adequate stimulation

 Inability to control timing of

ejaculation
 Inability to relax vaginal muscles

enough to allow intercourse

 Unhappiness or confusion related

to sexual orientation

 Transsexual and transgender

people may have sexual problems

(before or after surgery.

 Sexual addiction

 Hypersexuality

 All forms of Female genital cutting

 Post-orgasmic diseases, such as

Dhat syndrome, post-coital tristesse

 (PCT), postorgasmic illness syndrome

(POIS), and sexual headache.

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