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  • 1. THE GYNAECOLOGICAL EXAMINATION By- Jasleen Kaur Luthra
  • 2. Made By: Jasleen kaur luthra 4th year NHMC,New Delhi
  • 3. Gynecological History Taking Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition. There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint. When taking any history in medicine it is essential to understand what the presenting complaint means and what the possible causes (differential diagnosis) of the presenting complaint may be.
  • 4. BIODATA OF PATIENT  Name  Age  Address  Ethnicity  Occupation  Religion  Marital status  Social status
  • 5. Presenting complaint “What is the problem that brought you to the hospital/clinic?” ƒBest to record this in the patient’s own words. “Were you referred by your doctor or did you self‐refer yourself to the hospital/clinic?”
  • 6. History of presenting complaint  Pain - Uterine; colicky pain felt in sacrum and groins Ovarian; Iliac fossa with radiation down anterior aspect of the thigh to the knee  • Site - Localized/general/symmetrical, abdominal or pelvic  • Onset (sudden or gradual), duration and evolution over time  • Character and Severity  • Relieving/Precipitating/Exacerbating factors - Help to date (Exercise, posture, external stimuli)  Associated features e.g. bowel or urinary symptoms, peritonitis, nausea  Timing  Effects - Impact on life, functional capacity, disability, hygiene, sexuality, employment,  Relationships  Spread - Radiation
  • 7. Menstrual History Menarche and menopause 1st day of last menstrual period Length of bleeding (days) Frequency Regularity Bleeding between periods Bleeding after intercourse Any post menopausal bleeding *Nature of periods Heavy? Clots? Flooding?
  • 8. Past Obstetric History Gravidity and Parity Dates of deliveries Length of pregnancies Induction of labor/Spontaneous Normal Delivery? Weight of babies Sex of babies Complications before, during and after delivery
  • 9. • Past Medical History • Operations (particularly pelvic or abdominal) and psychiatric illnesses. • Identify presence of diabetes, epilepsy, thromboembolism, UTIs, STIs and other chronic conditions (e.g. thyroid disease, cardiac disease, asthma, connective tissue disorders). Drug History •Prescribed medications •Non-prescribed medications/herbal remedies •Recreational drugs •Any known drug allergies .
  • 10. Sexual history  Frequency of sexual intercourse  Type of contraception used?  Any complaints before ,during and after sexual intercourse?  Dyspareunia –superficial or deep? Family history ƒ“Are your parents still alive?” “Do they suffer from any illness?” – if dead “What was the cause of death?” ƒ“Do you have any brothers or sisters?” – if yes – “What is their state of health?” ƒ“Is there any family related disease in your family that you are aware of?” –diabetes, hypertension,malignancy,twins.
  • 11. Social History Occupation Support network Smoking Alcohol marital status Ranking Personal History Sleep *Appetite *Micturition *Defecation *Weight loss or gain *Addiction Family History Medical conditions Gynecological conditions Malignancies consanguinity
  • 12. PREREQUISITES  The patient’s bladder must be empty-the exception being a case of stress incontinence.  A female attendant (nurse or relative of the patient)should be present by a side.  To examine a married or unmarried,a consent from the parent or guardian is required.  Lower bowel (rectum and pelvic colon) should preferably be empty.  A light source should be available.
  • 13. MATERIALS REQUIRED FOR PELVIC EXAMINATION  Sterile gloves  Sterile lubricant  Speculum  Sponge holding forceps  Swabs  Light source
  • 14. POSITIONS OF THE PATIENT Dorsal position Sim’s position Lithotomy position
  • 15. 1. DORSAL POSITION The patient is commonly examined in dorsal position with knees flexed. The physician usually stands on the right side. This position gives better view of the external genitalia and the bimanual pelvic examination can be effectively performed.
  • 16. 2. SIMS’ POSITION (LEFT LATERAL POSITION) A semi- prone position with buttocks on edge of the bed. Patient’s right knee and thigh drawn well up to the chest. Lower left leg semi extended. Left arm is placed along patient back and chest inclined forward so that patient rest upon it. Lateral or sims’ position is ideal for inspecting any lesion in anterior vaginal wall as the vagina balloons with air as soon as the introitus is opened by a speculum.
  • 17. 3. LITHOTOMY POSITION Lithotomy position is ideal for examination under anaesthesia.
  • 18. • EXAMINATION OF LABIAL SWELLING(BARTHOLIN’S GLAND)
  • 19. SPECULUM EXAMINATION Speculum examination should preferably be done prior to bimanual examination. ADVANTAGES: 1. Cervical scrape cytology and endocervical sampling can be taken as screening in the same sitting. 2. Cervical or vaginal discharge can be taken for bacteriological examination. 3. The cervical lesion may bleed during bimanual examination which makes the lesion difficult to visualise.
  • 20. TYPES OF SPECULUM 1.CUSCO’S SPECULUM (BIVALVE SELF RETAINING SPECULUM)
  • 21. 2. SIMS’ SPECULUM
  • 22. USES OF CUSCO’S SPECULUM  In dorsal position,cusco speculum is widely used.  It allows satisfactory inspection of the cervix, taking of a pap smear, collection of vaginal discharge from the posterion fornix for hanging drop smear and colposcopic examination.
  • 23. USES OF SIM’S SPECULUM  SIMS’ SPECULUM IS ADVANTAGEOUS IN CASES OF GENITAL PROLAPSE.  ANTERIOR VAGINAL WALL IS TO BE VISUALISED BY SIMS’ SPECULUM.  IN LATERAL POSITION SIMS’ SPECULUM HAS GOT ADVANTAGES.
  • 24. BIMANUAL EXAMINATION
  • 25. RECTAL OR RECTOABDOMINAL EXAMINATION
  • 26. SAGITTAL VIEW OF RECTOABDOMINAL BIMANUAL EXAMINATION SHOWING PALPATION OF UTERUS IN PREPUBERTAL CHILD
  • 27. INDICATIONS  Children or in adult virgins  Painful vaginal examination  Carcinoma cervix-to note the parametrial involvement (base of the broad ligament and the uterosacral ligament can only be felt rectally) or involvement of rectum.  Atresia vagina  Patients having rectal complaints  To diagnose rectocele and differentiate it from enterocele.  To corroborate the findings felt in the pouch of douglas by bimanual vaginal examination.
  • 28. RECTOVAGINAL EXAMINATION
  • 29. Procedure  The procedure consists of introducing the index finger in the vagina and the middle finger in the rectum.  This examination helps to determine whether the lesion is in the bowel or between the rectum and vagina.  This is of special help to differentiate a growth arising from the ovary or rectum.
  • 30. CERVICAL AND VAGINAL SMEAR FOR EXFOLIATIVE CYTOLOGY
  • 31. MATERIALS REQUIRED FOR PAP SMEAR EXAMINATION
  • 32. WHAT IS PAP SMEAR? A Pap smear is a microscopic examination of cells scraped from the opening of the cervix. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina. It is a screening test for cervical cancer.
  • 33. INDICATIONS-  CERVICAL CANCER SCREENING.  WITHIN 5 YEARS OF BECOMING SEXUALLY ACTIVE.  ACTUALLY IN HIGH RISK GROUPS SUCH AS PATIENTS WITH RECURRENT STD’S AND HIV.  POST COITAL BLEEDING  POSTMENOPAUSAL BLEEDING
  • 34. Procedure of pap smear
  • 35. 1. The Ayres spatula is placed in the cervical os and rotated 360 deg to sample the entire ectocerivx. This specimen is then smeared on a glass slide. When cervical ectopy is present, the red endocervical lining extends to the ectocervix, and an additional circumferential scraping at this transition is sometimes necessary to ensure that the squamocolumnar junction is sampled. 2. The cytobrush is next inserted into the cervical os and rotated 360 degree. The brush is then rolled onto the slide, ensuring that the entire circumference of the brush makes contact with the slide. 3.The slide must be immediately sprayed with fixative to prevent desiccation of the cells, which begins to occur in as quickly as 15 sec. 4. If desired, a separate cervical specimen may be obtained and placed in specific transport medium for HPV testing.
  • 36. COLLECTION OF SMEAR
  • 37. NORMAL CERVICAL CELLS UNDER THE MICROSCOPE
  • 38. ABNORMAL CERVICAL CELLS UNDER THE MICROSCOPE
  • 39. Why is pap smear necessary? Early changes in the cervix may be the first warning signs that a problem is occuring. Early changes of cervix are treatable. 90% of cases can be prevented from progressing to cancer of cervix. Half of the new cases diagnosed each year are women of age 50 or more.
  • 40. How often should I have a pap? Regular pap smear every 2 yrs is very effective in detecting abnormalities that may lead to cancer of cervix. If you had treatment on the cervix with laser or loop then you require pap smears every 6 months until you have normal pap smears.
  • 41. COLPOSCOPY
  • 42. WHAT IS COLPOSCOPY ? Colposcopy is a procedure that uses an instrument with a magnifying lens and a light, called a colposcope, to examine the cervix and vagina for abnormalities. The colposcope magnifies the image many times, thus allowing the health care provider to see the tissues on the cervix and vaginal walls more clearly.
  • 43. PROCEDURE  Patient is placed in lithotomy position.  The cervix is visualised using a cusco’s speculum.  Colposcopic examination of the cervix and vagina is done using low magnification (6-16 fold).  Cervix is then cleared of any mucous discharge using a swab soaked with normal saline.  Next, the cervix is wiped gently with 3% acetic acid and examination repeated. Acetic acid causes coagulation of nuclear protein which is high in CIN. This prevents transmission of light through the epithelium which is visible as white areas.
  • 44. INDICATIONS FOR COLPOSCOPY Epithelial cell abnormalities detected by cervical cytology. Suspicious cervical lesions. Vulvar or vaginal neoplasia. Sexual partner of patients with genital tract neoplasia. Unexplained vaginal bleeding. Post coital bleeding.
  • 45. COLPOSCOPIC TERMINOLOGY  The squamo-columnar junction  The squamous metaplasia  The transformation zone  The adequate colposcopy
  • 46. The Squamocolumnar Junction •Border between squamous and columnar epithelium. Ectocervix or endocervix •Most dysplasia found on the leading edge of the SCJ
  • 47. Squamous Metaplasia •Replacement of columnar cells by squamous cells. •Stimulated by an acidic environment (puberty) and estrogen surges causing endocervical eversion (ovulation). •Subsequent maturation into well-differentiated, glycogenated squamous epithelium.
  • 48. TRANSFORMATION ZONE
  • 49. Adequate Colposcopy •Entire Squamocol umnar junction seen. •Borders of all lesions seen .
  • 50. HYSTEROSALPINGOGRAPHY (HSG)
  • 51. Purpose Hysterosalpingography is the radiographic demonstration of the female reproductive tract with a contrast medium. The radiographic procedure best demonstrates the uterine cavity and the patency (degree of openness) of the uterine tubes. The uterine cavity is outlined by injection of contrast medium throughout the cervix. The shape and contour of the uterine cavity are assessed to detect any uterine pathologic process. As the contrast agent fills the uterine cavity, the patency of the uterine tubes can be demonstrated as the contrast flows through the tubes and spills into the peritoneal cavity.
  • 52. INDICATIONS  To note the tubal patency in the investigation of infertility or following tuboplasty operation  To detect uterine malformation in recurrent midtrimester abortion.  To diagnose cervical incompetency.  To diagnose the translocated IUD whether lying inside or outside the uterine cavity.  To diagnose uterine synechiae.  To confirm diagnosis of secondary abdominal pregnancy.
  • 53. Major Equipment The major equipment required for an HSG is a radiographic fluoroscope room. Newer equipment may provide digital fluoroscopy capabilities. Ideally, the table should have the capability to tilt the patient to a Trendelenburg position if needed. If available, gynecologic stirrups should be attached to the table to assist the patient in the lithotomy position.
  • 54. Accessory and Optional Equipment Routinely, a sterile, disposable HSG tray is used The general contents of the tray include a vaginal speculum, basin, cotton balls, medicine cup, sterile gauze, sterile drapes, sponge-holding forceps, 10 ml syringes, 16 and 18 gauge needles, extension tubing, and lubricating jelly. In addition to the HSG tray, sterile gloves, an antiseptic solution, a cannula or balloon catheter, and contrast media are necessary
  • 55. Contrast Media Two categories of radiopaque (positive) iodinated contrast media have been used in HSG. Water-soluble iodinated contrast media, such as Omnipaque 300, is preferred. It is absorbed easily by the patient, does not leave a residue within the reproductive tract, and provides adequate visualization. This medium does, however, cause pain when injected within the uterine cavity, and the pain may persist for several hours after the procedure. In the past, oil-based contrast media that allowed for maximal visualization of uterine structures was used. However, it has a very slow absorption rate and persists in the body cavities for an extended time. It also introduces the risk that an oil embolus that could reach the lungs may form. The amount of contrast medium to be introduced into the reproductive tract is variable, depending on radiologist preference. On average, approximately 5 ml is necessary to fill the uterine cavity, and an additional 5 ml is needed to demonstrate uterine tube patency.
  • 56. STEPS The operation is done in radiology department and without anaesthesia.  Patient is to empty her bladder.  She is placed in dorsal position with the buttocks on the edge.  Internal examination is done.  Posterior vaginal speculum is introduced; the anterior lip of the cervix is held by allis forceps and an uterine sound is passed.
  • 57.  Hysterosalpingographic cannula is fitted with a syringe containing radio-opaque dye- either water soluble contrast medium, meglumine diatrizoate (Renografin 60) or a low viscosity oil based dye, ethiodized oil (Ethidol). The dye is introduced slowly. About 5-10 ml of the solution is introduced. The passage of the dye into the interior may be observed by using a x-ray image intensifier and a video display unit.  The speculum and the allis forceps are removed but not the cannula.  2 radiographic views are taken.the first one to show the filling of uterine cavity and the other at the completion of the procedure(after10-15 mins) showing tubal findings. The tubal patency is evidenced by peritoneal spillage.
  • 58. COMPLICATIONS Apart from the inherent complications of the uterine sound(uterine perforation) haemorrhage, HSG has got the following complications:  Peritoneal irritation and pelvic pain  Vasovagal attack  Intravasation of dye within the venous or lymphatic channels(common in tubercular endometritis).  Flaring up of pelvic infection(1-3%).
  • 59. CONTRAINDICATIONS TO HSG  Pelvic infection  Women known to have hydrosalpinges  Presence of adnexal mass(PID).  Pelvic tenderness on bimanual examination
  • 60. ENDOMETRIAL BIOPSY The endometrial biopsy is a medical procedure that involves taking a tissue sample of the lining of the uterus. The tissue subsequently undergoes histologic evaluation which aids the physician in forming a diagnosis
  • 61. Abnormal uterine bleeding: postmenopausal bleeding, malignancy/hyperpla sia, ovulation/anovulatio n. Evaluation of patient with one year of presumed menopausal amenorrhea. Assessment of enlarged utereus (combined with US and neg HCG). Evaluation of INDICATIONS Abnormal Pap smear with atypical cells favoring endometrial origin (AGUS) Follow-up of previously diagnosed endometrial hyperplasia Cancer screening (e.g., hereditary nonpolyposis colorectal cancer) Inappropriately thick endometrial stripe found on US Endometrial dating
  • 62. CONTRAINDICATIONS  Pregnancy  Acute PID  Clotting disorders(coagulopathy)  Acute cervical or vaginal infections  Cervical cancer
  • 63. EQUIPMENT  Non-sterile Tray (Examination for Uterine Position)  Nonsterile gloves  Lubricating jelly  Absorbent pad to place beneath the patient on the examination table  Formalin container (for endometrial sample) with the patient's name and the date recorded on the label  20 percent benzocaine (Hurricaine) spray with the extended application nozzle *
  • 64.  Sterile Tray for the Procedure  Sterile gloves  Sterile vaginal speculum  Uterine sound  Sterile metal basin containing sterile cotton balls soaked in povidone-iodine solution  Endometrial suction catheter  Cervical tenaculum  Ring forceps (for wiping the cervix with the cotton balls)  Sterile 4 x 4 gauze (to wipe off gloves or equipment)
  • 65. PROCEDURE  The patient is asked to lie on the table with her feet in the stirrups for a pelvic examination. She may or may not be given localized anesthesia. A speculum will be inserted into the vagina to spread the walls of the vagina apart to expose the cervix.The cervix will then be cleansed with an antiseptic solution.  A tenaculum, a type of forceps, will hold the cervix steady for the biopsy.  The biopsy curette will be inserted into the uterine fundus and with a scraping and rotating motion some tissue will be removed.  The removed tissue will be placed in formalin or equivalent for preservation.  The tissue will be sent to a laboratory, where it will be processed and tested. It will then be read microscopically by a pathologist who will provide a histologic diagnosis.[4]
  • 66. Endometrial suction catheter. (A) The catheter tip is inserted into the uterus fundus or until resistance is felt. (B) Once the catheter is in the uterus cavity, the internal piston is fully withdrawn. (C) A 360-degree twisting motion is used as the catheter is moved between the uterus fundus and the internal os.
  • 67. CERVICAL BIOPSY A cervical biopsy is the removal of tissue from the cervix, the lower third of the uterus to be analyzed for cellular abnormalities, precancerous conditions, or cervical cancer. The cervix is a canal from the uterus into the vagina, which leads to the outside of the woman's body.
  • 68. TYPES OF CERVICAL BIOPSYThere are several types of cervical biopsies. In addition to removing tissue for testing, some of these procedures may be used to completely remove areas of abnormal tissue and may also be used for treatment of precancerous lesions. Types of cervical biopsies include: Punch Biopsy: A surgical procedure to remove a small piece of tissue from the cervix. One or more punch biopsies may be performed on different areas of the cervix.  Cone Biopsy or Conization: A surgical procedure that uses a laser or scalpel to remove a large cone-shaped piece of tissue from the cervix.  Endocervical Curettage (ECC): A surgical procedure in which a narrow instrument called a curette is used to scrape the lining of the endocervical canal, an area that cannot be seen from the outside of the cervix.
  • 69. CONE BIOPSY (CONISATION) INDICATIONS Conisation is done as diagnostic and therapeutic purpose in CIN. Cases of CIN suitable for colonisation are: 1.Unsatisfactory colposcopic findings. The entire margins of the lesion are not visualised. 2.Inconsistent findings-colpascopic, cytology ,and directed biopsy. 3.When biopsy cannot rule out invasive cancer from CIS or microinvasion. 4.Positive endocervical curettage.
  • 70. PRINCIPLE STEPS(COLD KNIFE)  The operation is done under general anaesthesia.  Blood loss is minimised with prior haemostatic sutures at 3 and 9o’clock positions on the cervix by lighting descending cervical branches.  The cone is cut so as to keep the apex below the internal os.  After the cone is removed, a margin suture is placed at 12 0’clock position for identification of the cone.  Routine endocervical curette above the apex of the cone is performed and uterine curettage is done,if indicated.
  • 71.  Cone margins are repaired by haemostatic sutures.  The excised cervical tissue is sent for histological examination. If the margins of cone are involved in neoplasia ,hysterectomy should be seriously considered either within 48 hrs or at a later date to prevent infection.
  • 72. COMPLICATIONS  Secondary haemorrhage  Cervical stenosis leading to haematometra  Infertility  Diminished cervical mucuc  Cervical incompetence leadind to adverse pregnancy outcome  Midtrimester abortion or preterm labour.
  • 73. CULDOCENTESIS Culdocentesis is the transvaginal aspiration of peritoneal fluid from the cul-de-sac or pouch of Douglas. INDICATIONS: 1.In suspected disturbed ectopic pregnancy or other causes producing haemoperitoneum 2.In suspected cases of pelvic abscess.
  • 74. STEPS  The procedure is done under sedation.  The patient is put in lithotomy position.  Vagina is cleaned with Betadine.  A posteror vaginal speculum is inserted.  A 18 gauge spinal needle fitted with a syringe is inserted at point 1cm below the cervicovaginal junction in the posterior fornix.  After inserting the needle to a depth of about 2cm,suction is applied as the needle is is withdrawn.  If unclotted blood is obtained,the diagnosis of intraperitoneal bleeding is established.
  • 75. Endoscopy in obstetrics and gynaecology has many branches: Laparoscopy Hysteroscopy. Colposcopy Salpingoscopy
  • 76. Laparoscopy Definition Instruments The Procedures Indications and contraindications Complications
  • 77. Laparoscopy It is a technique which allows viewing (Diagnostic) and surgical maneuvers (Therapeutic) to be performed in abdominal organs through a surgical incision of < 1cm with help of pneumoperitoneum
  • 78. Instruments 1. Verres needle: used to inflate air to the peritoneal cavity (pneumoperitoneum) through the umbilicus where there is the thinnest abdominal wall.
  • 79. 2. Electronic laparoflator: Used to insufflate through the verres needle. Maintains constant intra-abdominal pressure without exceeding the safety limit. Some types have heating system to prevent lowering the patient body temperature.
  • 80. 3. Trocars: Permit access to the intraperitoneal cavity in which other instruments can pass. The trocar used should be adapted to the diameter of the telescope selected.
  • 81. 4. Telescope: There are different sizes each with a different use. They are used to visualize the peritoneal cavity.
  • 82. 5. Camera equipment. 6. Light source.
  • 83. 7. Forceps and scissors There are two types: - Disposable Reusable They can be either atraumatic or grasping foreceps.
  • 84. Instruments 8. Bipolar elecrtosurgey. 9. Unipolar electrosurgery. 10. Laser. 11. Ultrasound system. 12. Suction and irrigation system. 13. Suture. 14. Laparoscopic bag. 15. Tissue morcellator: used to remove large specimens like myomas or an entire uterus in small pieces. 16. Uterine manipulator: used to mobilize or stabilize the uterus and adnexa.
  • 85. Procedure 1. Preparation of the patient: Inform the patient about the therapeutic benefits and potential risks (informed consent). Intestinal preparation: Simple intestinal emptying, for better viewing and preventing injuries. Place the patient in the dorsolithotomy position.
  • 86. 2. Creation of pneumoperitoneum: a. The abdominal wall is lifted by hand or by grasping forceps b. Pnemoperitoneum is created by verres needle introduced to the umbilical area (less subcutaneous and preperitoneul tissue). c. The needle is inserted in an oblique angle toward the uterine fundus d. The negative pressure will allow the underlying structures to fall away. e. After making sure that the needle is in correct position, air flow can be increased to 2.5 liters per minute till a pressure of 15mmHg
  • 87. 3. Trocar introduction a. Once the intra- abdominal pressure reaches 15 mmHg the main trocar is introduced after removal of veress needle. b. The position of the trocar must be verified by inserting the laparoscope and viewing the pelvic cavity.
  • 88. 4. Viewing the peritoneal cavity: A. The omentum, bowel and bifurcation of pelvic vessels should be evaluated to avoid injuries caused during the introduction of Verres needle or trocar. B. The site of introduction of other trocars should be verified by finger palpation and transillumination of abdominal wall to avoid injury to epigastric vessels. C. Identify if there is any bleeding
  • 89. After the procedure CO2 gas must be evacuated completely to reduce post-operative pain In operative procedures: - 1 or 2 bottles of Ringer’s lactate are used to wash the peritoneal cavity after laparoscopy. - Leave 500/1000 cc of ringer’s lactate to reduce the incidence of post operative pain.
  • 90. Indications Used as a diagnostic tool Infertility: status of the fallopian tube (morphology and functionality) and any pathological condition e.g. adhesions. Ovarian cysts or tumors. Ectopic pregnancy. PID: tubal abscess or adhesions. Endometriosis: define the sites of implants and endometrial cysts.
  • 91. As a therapeutic tool - Management of ovarian cyst by: - Drainage. - Ovarian cystectomy. - Ovarian drilling of the cortex and stroma to decrease androgens in the ovaries - Correcting ovarian torsion. - As a treatment of endometriosis - By removal of the endometrial cyst, cauterization of endometrial spots and adhesiolysis
  • 92. Adhesiolysis Myomectomy
  • 93. Management of infertility: - Adhesiolysis - Treat the cause (endometriosis, PCOS) Myomectomy for fibroids: used for subserosal and intramural fibroids only, not used for submucosal fibroids. Management of PID: by draining tubal abscess and adhesiolysis.
  • 94. MANAGEMENT OF ECTOPIC PREGNANCY Salpingotomy Used to preserve the tubes for desired reproductivity. Done if the patient is hemodynamicaly stable If size < 5 cm Location must be ampullary, infundibular or isthmic. Contralateral tube either normal or absent.
  • 95. Salpingotomy
  • 96. Contraindications 1. Generalized peritonitis 2. Hypovolemic shock 3. Severe cardiac disease 4. Hemoglobin less than 7 g/dL 5. Uterine size > 12 wks. 6. Multiple previous abdominal procedures 7. Extreme body weight
  • 97. Complications - Pneumoperitoneum: - Extraperitonel emphysema due to failure of introducing verres needle correctly into the peritoneal cavity and not checking the negative pressure on the machine. - Gas may extend to the mediastinum and compromise cardiac function - Pneumoomentum: and put the patient on the trendlenberg - Injury to abdominal organs - GI: if the intestine is distended or adherent to the abdominal wall (prevented by good intestinal preparation) and putting the patient on the telendelenburg position. - Bladder injury: prevented by emptying the bladder
  • 98. Hysteroscopy Definition Instruments The Procedures Indications and contraindications Complications
  • 99. Hysteroscopy Definition: It is a technique which allows viewing and surgical maneuvers to be performed in the uterine cavity. It has many advantages that made it wide spread and fundamental diagnostic method in daily gynecological practice
  • 100. INSTRUMEN TS 1. Distention media of the uterine cavity (CO2 distention) 2. Light source. xenon light source gives the best image quality
  • 101. 3. Camera Equipment 4. Endoscope flexible: high cost and fragile cannot be autoclaved. rigid: gives different direction of the view.- 0°, 12°, 30° (bes for diagnostic purpose).
  • 102. 5. Hysteroscope: There are 2 types of hysteroscopes: Diagnostic Therapeutic
  • 103. PROCEDURE 1. Preparation of the patient:  Detailed history and complete physical examination  It is preferable to do the procedure in the first part of the menstrual cycle, because there is less mucus (better viewing) and no chance of encountering early pregnancy  Informed consent  Patient is placed in lithotomy position  Accurate bimanual examination to asses the uterine (position, morphology, volume).
  • 104. PROCEDURE 2. Technique:  Clean cervix with antiseptics  Cervical forceps is placed on the front labia  Light source & CO2 gas supply are connected to the instrument  Insert hysteroscope into the cervical canal, which dilates from the gas pressure.
  • 105. INDICATIONS Used as a diagnostic tool: - Abnormal uterine bleeding caused by: - submucous and intramural myoma. - endometrial polyps. - endometrial atrophy. - Endometrial tumors. - Infertility related to: - Intrauterine adhesions (Asherman’s syndrome) - Submucous fibroids. - Endometrial polyps. - Uterine malformation (it cannot differentiate between sepatate and bicorneate uterus)<- this can be done by laparoscopy
  • 106. Used as a therapeutic tool Endometrial ablation (using laser):  Abnormal uterine bleeding but we should role out cancerous or pre cancerous cause of bleeding. Also used in patients with high risk for hysterectomy or the patient does not want to do the surgery.steroscopic Surgeries and Correct uterine malformation like septate uterus by resection of the septum. (bicorneate uterus is corrected by laparotomy using metroplasty). Polypectomy. Intrauterine adhesions. Myomectomy: The main indication for hysteroscopic myomectomy is AUB caused by submucous myomas in infertile patients
  • 107. Uterine anomaly Uterine polyp
  • 108. Intrauterine Adhesions
  • 109. Endometrial carcinoma
  • 110. CONTRAINDICATIONS  Pregnancy.  Current or recent pelvic infection.  Current vaginitis, cervicitis and endometritis.  Recent uterine perforation.  Active Bleeding.
  • 111. COMPLICATIONS - Distension media: - Fluid overload pulmonary oedema, cerebral oedema hyponatremia neurological symptoms - Intraoperative complications: - Uterine perforation (<1%) - Hemorrhage either from: - Perforation - Tenaculum used to hold the cervix. -Trauma. - Thermal damage.
  • 112. COLPOSCOPY  Indications: – Evaluation of CIN – Biopsy target – Vaginal and vulval examination – DES exposure  Techniques: – Acetic acid – Schiller’s iodine  Intervention: – Outpatient treatment of CIN e.g. Laser
  • 113. SALPINGOSCOPY  In salpingoscopy, a firm telescope is inserted through the abdominal ostium of the uterine tube so that the tubal mucosa can be visualised by distending the lumen with saline infusion. The telescope is to be introduced through Laproscope.  Salpingoscopy allows study of the physiology and anatomy of the tubal epithelium and permits more accurate selection of patients for IVF rather than tubal surgery.
  • 114.  www.wikipedia.com  www.google.com  Shaw’s textbook of gynaecology(15th edition)  Textbook of gynaecology –by D.C DUTTA (5th edition) MADE BY- Jasleen kaur luthra 4th year NHMC, New Delhi.

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