Investigations in gynaecology


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Investigations in gynaecology

  2. 2. COMMON INVESTIGTIONS IN GYNAECOLOGY1. Blood values 6. Imaging techniques2. Urine examination 7.Endomitrial sampling3. Urethral,vaginal,cervic 8. Biopsy al discharge 9.Culdocentesis4. Exfoliative cytology 10.Endoscopy5. Colposcopy 11.hormonal assays
  3. 3. BLOOD ROUTINE• Hemoglobin estimation-Excessive bleeding• Total and differential count PID• ESR• Platelet count,BT,CT—Pubertal menorhagia• Serology-VDRL,australia antigen,HIV
  4. 4. URINALYSIS1. Urine routine and microscopy• Physical examination• Chemical estimation of protein and sugar• Pus cells,casts2. Culture and drug sensitivity• Indications—Pus cells>5 UTI Cystocele Urinary complaints Fistula3.Urine pregnancy test– for diagnosis of pregnancy
  5. 5. Methods of urine collection1. Midstream collection2. Catheter collection3. Suprapubic bladder puncture
  7. 7. Suprapubic bladder puncture
  8. 8. URETHRAL DISCHARGEMethod of collection• Urethra squeesed against symphysis pubis from behind forwards using sterile gloved fingers.• Discharge through external urethral meatus collected with sterile swabs• Swabs—microscopy and culture
  9. 9. Vaginal dischargeMethod of collection• Patient not to have vaginal douche for 24hrs• Cusco’s bivalve speculum introduced• Discharge from posterior fornix on the blade of speculum or cervical canal taken with a swab• microscopic examination-Discharge mixed with normal saline• culture
  10. 10. Identification of organisms in the slide1.Normal discharge-normal vaginal cellswith doderlein bacilli2.Trichomonal vaginalis—hanging droppreparation shows motile flagellatedorganisms of varying shape3.Gardnerella vaginosis(bacterial/nonspecific vaginitis)—clue cells,fewinflammatory cells,free floating clumps ofgardnerella,scanty lactobacilli
  11. 11. 4.Vaginal candidasis• Vaginal discharge + equal amount of 10% KOH• Caustic potash dissolves all cellular debris,leaving behind more resistant yeast like organisms• Typical hyphae,budding spores or mycelia detected
  12. 12. EXFOLIATIVE CYTOLOGY- PAPANICOLAOU TEST• Pap test-Screening test for cancer• First described by Papanicolaou and Traut in 1943• Routine gynaecological examination in females,esp above 35 years• Yearly screening for 3 years followed by 5 yearly test• Uses—1.screening for cancer2.identification of local viral infections like herpes andcondyloma accuminata3.Cytohormonal study
  13. 13. Pap smear-screening of cancerPROCEDURE• Should be obtained prior to vaginal examination• Patient placed in dorsal position with labia separated• Cusco’s self retaining speculum inserted without lubricants• Cervix exposed,squamocolumnar junction scraped with concave end of Ayre’s spatula by rotating all around• Thin smear is prepared on a glass slide and fixed by equal amounts of 95% alcohol and ether• After 30 min,slide air dried and stained with papanicolaou or Short stain
  14. 14. • Modifications1. Endocervical sampling –endocervix scraped with a cytobrush and added to the slide2. Fixative spray—cytospray used in office setup
  15. 15. INTERPRETATIONS• Normal cells1.Basal cells-small,rounded basophilic with largenuclei2.Squamous cells from middle layer –transparent and basophilic with vesicular nuclei3.Cells from superficial layer-acidophilic withcharacterestic pyknotic nuclei4.Endometrial cells,histiocytes,blood cells andbacteria
  16. 16. ABNORMAL CELLS1)Mild dyskaryosis—• superficial/intermediate squamous cells• Angular borders,transcluscent cytoplasm• Nucleus < half of total area of cytoplasm• Binucleation is common• CIN-I
  17. 17. 2)Moderate dyskaryosis—• Intermediate/parabasal/superficial squamous cell type• More disproportionate nuclear enlaregement and hyperchromasia• Nucleus-1/2-2/3 of total cytoplasm area• CIN II
  18. 18. 3)SEVERE DYSKARYOSIS• Cells- basal type round/oval/polygonal/elongated singly/in clumps• Nucleus- almost fills the cell thick,dense,narrow rim of cytoplasm irregular with coarse chromatin pattern• CIN III• Fibre cells- severly dyskaryotic elongated cell• Tadpole cell- severly dyskaryotic cell with an elongated tail of cytoplasm
  19. 19. 4.Carcinoma in situ 5.Invasive carcinoma• Parabasal cells with • Cells-single/clusters increased nucleo- • Tadpole cells cytoplasmic ratio • Irregular nuclei• Cytoplasm scanty • Coarse clumping of• Nucleus- chromatin irregular,sometimes multiple• Chromatin pattern- granular
  20. 20. 6)Koilocytosis• Nuclear abnormalities due to HPV infection• Condyloma accuminata• Cells-perinuclear halo,peripheral conensation of cytoplasm• Nucleus-irregularly enlarged,hyperchromatic with multinucleation• Disappears with dysplasia
  21. 21. • Positive pap smear in genital herpes-giant cells with viral inclusion bodies• Silver pap test– pap test+PCR– used for diagnosis of herpes
  22. 22. Reporting system• normal/abnormal• Abnormal-CIN/papilloma infection/invasive malignancy• Doubtful/inconclusive smear-repeat smearPAPANICOLAOU CLASSIFICATION-GRADINGI. Normal cellsII. Slightly abnormal-inflammatory changeIII. Cells suspicious of malignancy-biopsy indicatedIV. Few Distinctly abnormal,possibly malignant cellsV. Malignant cells seen-numerous
  23. 23. Papanicolaou World Health Bethesda SystemClass I Normal Within normal limitsClass II AtypiaI inflammatory Inflammation-HPV Squamous, glandular ASCUS, AGCUSClass III Mild dysplasia CIN-I Low SILClass IV Moderate dysplasia CIN -II High SIL Severe dysplasia CIN -III Carcinoma in situClass V Squamous cell carcinoma Squamous cell Adenocarcinoma carcinoma Adenocarcinoma
  24. 24. LIMITATIONS OF PAP SMEAR• Detect only 60-70% of cervical cancer and 70% of endomitrial cancer• Reliability depends on slide preparation and skill of cytologist• 10-15% false negative results• False positive results in presence of infections• Difficulty if squamocolumnar junction-indrawn as in post menopausal women(10 day course of oestrogen cream suggested)• Postradiation cytology difficult- scarring and atrophy of vagina
  25. 25. Liquid based cytology-cancer screening• Plastic spatula after scraping placed in buffered methanol solution-hemolytic and mucolytic• Cells separated by centrifugation and gently sucked thrrough a filter membrane• Filter pressed onto a glass slide to form thin monolayer which is stained
  26. 26. CYTOHORMONAL EVALUATION• Exfoliative cytology• Non invasive study of epithelium for hormonal status• Principle-vaginal epithelium highly sensitive to oestrogen and progesterone. oestrogen—superficial cell maturation progesterone—intermediate cell maturation• Procedure—scrapings taken from lateral wall of upper third of vagina
  27. 27. INFERENCE• Normal smear-parabasal,intermediate and superficial cells• Oestrogen predominant smear-large eosinophilic cells with pyknotic nuclei and clear back ground• Progesterone predominant smear- predominantly basophilic cells with vesicular nuclei and dirty background• Pregnancy-intremediate and navicular cells• Post-menopausal smear- parabasal and basal cells
  28. 28. KARYOPYKNOTIC INDEX/MATURATION INDEX• KPI = Mature squamous cells Intermediate +basal cells• Proliferative phase-KPI>25%• Secretory phase-KPI-very low• KPI> 10% in pregnancy – progesterone deficiency• KPI peaks on the day of ovulation
  29. 29. UTERINE ASPIRATION CYTOLOGY• Screening test for endometrial cancer-endometrial sampling• Sample obtained by endometreal pipelle/uterine aspiration syringe or brush• 90% accuracy with no false positive findings• Hormonal studies also done
  30. 30. ENDOMETRIAL BIOPSY• Most reliable method to study endometrium• Endometrial tissue obtained by curretage and subjected for histopathologyIndications–• suspected cases of Endometritis,endometrial cancer• Infertility• Abnormal menstrual bleeding• Diagnosis of corpus luteal phase defect
  31. 31. CERVICAL BIOPSY• Confirmatory diagnosis of cervical pathology• Done at OP if pathology detectable• Wider tissue excision as in cone biopsy – IP procedure
  32. 32. COLPOSCOPY• Colposcope-binocular microscope- 10-20 X• Use-colposcope directed biopsy colposcopic examination of cervix and vagina
  33. 33. CULDOCENTESIS• Transvaginal aspiration of peritoneal fluid from the pouch of douglas• Diagnostic procedure- pelvic abcess ectopic pregnancy in haematocele detect malignancy in ascitis with ovarian cyst• Instruments- vulsellum forceps,posterior vaginal speculum,aspiration syringe
  34. 34. PROCEDURE• Patient-lithotomy position• Posterior lip of cervix-downwards and forwards with vulsellum forceps• Speculum-retracts posterior vaginal wall• Area disinfected• Aspiration syringe inserted into the pouch and aspirated• Done best in OT under full asceptic precautions and to proceed laproscopy/laprotomy if indicated
  35. 35. HORMONAL ASSAYS• RIA,ELISA• Hormones assayed- FSH,LH,PRL,ACTH,T3,T4,TSH,progesterone, oestradio ,testosterone,aldosterone,cortisol, hCG,dehydroepia ndrosterone,andostenedione• Uses- Diagnosis of menopause,PCOD,prolactinemia Monitoring treatment regimes in ovulation induction and AST
  36. 36. IMAGING TECHNIQUES-Overview1.X-RAY• Plain x ray chest and intravenous urogram- pelvic malignancy esp cervical cancer,prior to staging.• Plain x ray pelvis- To locate misplaced IUCD Visualize bone/teeth in benign cystic teratoma• Hysterosalpingography-to test tube patency, Intracavity uterine mass and mullerian anomalies of uterus• Lymphangiography-to locate lymph nodes involved in pelvic malignancy
  37. 37. 2.ULTRASONOGRAPHY• Simple,non invasive,painless,safe procedure• Pelvis and lower abdomen scanned longitudinally and transversely• D3 ultrasound-3-D images of pelvic organsTransabdominal sonography(TAS)-• Done with transducer operating at 2.5-3.5Mhz• Bladder full• Large masses examination –ovarian tumour/fibroid
  38. 38. Transvaginal sonography(TVS)• Probe placed close to organ• High frequency waves used-5-8MHz• No need of full bladder• Detailed evaluation of pelvic organs possible• Better image resolution but poor tissue penetration• Difficulty in narrow vaginaTransvaginal colour doppler sonography• Information regarding blood flow to,from or within the uterus or adnexa
  39. 39. Diagnostic USG in gynaecology• Infertility workup 1)folliculometry-measurement of ovarian follicle diameter 2)measurement of endometrial thickness 3)evidence of ovulation-internal echoes and free fluid in pouch of douglas 4)timing of ovulation-helps in ovulation induction,AI,ovum retrieval 5)sonographic guided oocyte retrtieval• Ectopic pregnancy-tubal ring in adnexa with empty uterine cavity• Evaluation of pelvic mass
  40. 40. • Oncology-to assess vascularity of tumour and confirm malignancy• Endometrial study in DUB• Diagnose uterine pathology-fibroids,adenomyosis• Location of misplaced IUD• Falloposcopy-to study medial end of tube• Diagnose endometriosis• To study ovarian pathology-PCOD,ovarian cyst,tumour• Congenital anomalies of uterus• Diagnose adnexal mass
  41. 41. 3) Computed tomography• Supplements information from USG• Whole abdomen and pelvis visualised in one sitting after taking 600-800ml of a dilute contrast medium 1 hour prior to procedure• Patient scanned in supine position• Accurate in accesing local tumour invasion and enables accurate localisation in biopsy• Diagnose pelvic vein thrombophlebitis, intraabdominal abcess and other extra genital abnormalities• Metastatic implants and lymphnodes < 1 cm—not detected• Contraindicated in pregnancy
  42. 42. 4) Magnetic resonance imaging• Well established cross sectional imaging modality• High soft tissue contrast resolution without air/bone interference• Limitations-cost,time,availability• Indicated only when a sonar or CT fails to detect a lesion or to differntiate post-tratment fibrosis or tumour5)Positron emission tomography(PET)• To differentiate normal tissue from cancerous one based on the uptake of 18F-FLURO-2DEOXYGLUCOSE
  43. 43. DIAGNOSTIC ENDOSCOPY-Overview• To visualize body cavityLapraroscopy-• Diagnose uterine,tubal,ovarian,generalised diseases affecting pelvic organs- endometriosis,PID,genital TB• Staging of genital cancers• Infertility workup• a/c pelvic lesions-ectopic pregnancy,salphingitis etc
  44. 44. 2)Hysteroscopy• Visualise endometrial cavity• Diagnostic uses1. Unresponsive irregular uterine bleeding2. Congenital uterine septum3. Missing threads of IUD4. Intrauterine adhesions5. Endometrial polyps/ malignant growth3)Salphingoscopy and falloposcopy• Visualise of fallopian tube• Permits selection of patients for IVF rather than tubal surgery
  45. 45. 4)Culdoscopy• Visualise pelvic structures via an incision in pouch of Douglas5)Cystoscopy• To evaluate cervical cancer prior to staging• Investigate urinary symptoms- haematuria,incontinence and fistulae6) Proctoscopy and sigmoidoscopy• To evaluate rectal invovement in genital malignancy
  46. 46. INFERTILITY IN FEMALESTESTS FOR TUBAL PATENCY• Hysterosalpingography• Laproscopic chromotubation• Sonosalpingography• Hysterofalloscopy• Ampullary and fimbrial salpingographyTESTS FOR OVULATION• Basal body temperature• Examination of cervical mucus-fern test• Ultrasound• Hormonal assays-estrogen and progesterone
  47. 47. INFERTILITY IN MALES• Semen analyisis• Post-coital test-Sim’s test• Sperm penetration test• Semen-cervical mucus contact test• Urine examination• Patency of vas-vasogram• Testicular biopsy• Hormonal assays-FSH,LH,testosterone,prolactin• Chromosomal study• Immunological tests-ELISA, RIA• Ultrasound scanning
  48. 48. PRE-OPERATIVE INVESTIGATIONS IN GYNAECOLOGY• Complete blood count• Urinalysis• FBS,PPBS• BT,CT• Blood group and Rh factor• RFT• LFT• Serology- VDRL• Serum electrolytes-Na,K,Cl,HCO3• Chest radiograph• ECG• IVP
  49. 49. • Tumour markers1. CA-125-Adenocarcinoma ovary2. CEA,α-fetoprotein,β-hCG—Ovarian teratomas• Bacterial examination of genital tract1.Smear and microscopy2.Culture3.PCR