Gyn into....


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Gyn into....

  1. 1. Wollega UniversityCollege of Health sciencesDepartment of Midwifery Gynecology for Midwives 1
  2. 2. Unit IREPRODUCTIVE BASICS Approach to the Patient 2
  3. 3. Chapter outline……– Approach to the Pt– Gynecological assessment and dxtic procedures– The role of imaging techniques in GYN– Embryology of the urogenital system & congenital Anomalies of the female genitalia– Genetic disorders & sex chromosome Abnormalities 3
  4. 4. Introduction to Gynecology Gyn , gyne-, gyneco-, gyno- means= female Gynecology is the medical specialty concerned with diseases of the female genital tract, as well as endocrinology and reproductive physiology of the female. Gynecology is health care for women. It helps to take good care of sexual and reproductive health.• Routine gynecological care Prevents illness and discomfort Allows for early detection of cancerous disorders of female reproductive organs Detects sexually transmitted infections and other conditions before they cause serious damage Prevents sterility Promotes healthy pregnancy and childbirth 4
  5. 5. Approach to the patient• An effective relationship b/n health care provider & patient is based on the knowledge and skill of provider.• These qualify the provider for: Adequate communication between the individuals & An appreciation of the ethical standards that govern the conduct of the participants in the relationship.• The health care of women encompasses all aspects of medical science and therapeutics.• The special medical needs and concerns of women vary with the patients age, reproductive status, and desire to reproduce. 5
  6. 6. Approach to the patient cont...• The diagnostic possibilities and the choice of diagnostic or therapeutic intervention will be influenced by the possibility of, or desire for, pregnancy or, in some cases, by the patients hormonal profile.• In addition, the gynecologic or obstetric assessment must include an evaluation of the patients general health status and should be placed in the context of the psychologic, social, cultural, and emotional status of the patient.• Assessment of the patient is done by history taking & physical examination 6
  7. 7. History• To offer each woman optimal care, the information obtained at each visit should be as complete as possible.• The clinical database should include general information about the pt & her goals in seeking care.• History includes Id. history (IH), chief complaint (CC), history of present illness (HPI), past medical history (PMH), medications used, Allergies, etc.• The developmental history, menstrual history, sexual history, & obstetric history obviously assume central importance for the gynecologic or obstetric visit. 7
  8. 8. History cont…ID: Age :Problems and approach to them differ at various age group. Prepubertic Age of menarche Adolescent Age of telarche Reproductive age Menopause --- (15-49) Premenopausal Perimenopausal Post menopausal 8
  9. 9. Cont…b) Marital status: single , married, widowed, divorced, separated /geographicalC) Sexual status: Monogamous –one partner Heterosexual /Lesbian Polygamous –many sexual partnerd)Occupation – occupational hazards, allergies, industrial factor/carcinogenic---neoplastic d/se, heavy work---uterine prolapsee) Religious affilationf) Detail contact address etc… 9
  10. 10. History cont…CC/Chief compliant Cc is the main very cardinal problem of the patient which explained by the pt & which make him/her visits health facility. State the problem with durationWhat kind of problem are you having? How can I help you? E.g. – AVB- Vaginal bleeding/ discharge –LAP- lower abdominal pain –chronic /acute –Pelvic pressure - Amenorrhea –Inability to conceive 10
  11. 11. CC cont…- Dyspareunia – pain full sex- Dysmennorrhea – pain during menses- Mass protruding out of vagina- Ulcer on genital area- Urinary incontinency- Abdominal distention- Hersutism - abnormal hair growth on female- Sexual assault, Vulvar itching- Inguinal swelling, Recurrent abortion/misscurrhge- Sexual dysfunction,- Psychosomatic complaint- no pathological finding seen but they have complaint 11
  12. 12. HPI HPI- is an elaboration of CC - Start from their last sexual, reproductive performance - Gynecological illness related to parity- – Where? Anatomical location? – Date of onset?/duration? Intensity/worse? – Duration of the symptom? – Related problems? – Aggravating factors? Relieving factors? – Emotional change in patients life? 12
  13. 13. History cont…Menstrual History  LNMP, LMP (last menstrual period)  Age of menarche, menopause  Cycle length, duration, regularity, flow  Associated symptoms: pain,  Abnormal menstrual bleeding: intermenstrual, post-coital• Normal Menses:- Menarche 11-14 yrs, Menopause 45-55 yrs,- Menstrual interval 21-35dys (av. 28 days),- Volume – 10- 80ml/ av.50ml- Duration 2-8 days( av. 5 days) - non offensive odor- Dark non clotting, associated with mild abdominal cramp 13
  14. 14. History cont…Sexual History  If the women is in RAG- sexual activity, chxs of intercourse  Age when first sexually active  Number and sexual of partner  Oral, anal, vaginal  Current relationship and partner’s health  Dyspareunia or bleeding with intercourse  Satisfaction  History of sexual assault or abuse 14
  15. 15. History cont…Contraceptive History  Present and past contraception modalities  IUCD---- may cause PID  Compliance  Complications / failure/side-effectsGynecological Infections • Sexually transmitted diseases (STDs), • Pelvic inflammatory disease (PID) • Vaginitis, vulvitis , lesions • Include treatments, complications 15
  16. 16. History cont…Gynecological Procedures • last Pap smear • history of abnormal Pap • follow-up and treatments • gynecological or abdominal surgery • previous ectopic pregnancies 16
  17. 17. Physical Examination P/E is the 2nd component of the pt assessment. P/E should also be directed toward evaluation of the total patient health. The patient again should be encouraged to view the examination as a positive opportunity to gain information about her body Pt should be offered feedback regarding the general physical examination and any significant findings. The examination should always include a discussion of any concerns expressed by the patient. 17
  18. 18. P /E Cont… GA: General appearance- comfortable, ASL, CSL, orientation, conscious level … Vital signs: PR, RR, BP, To Wt , ht- is important for postmenopausal women in decrease in ht due to osteoporosis The following examinations are essential in gynecologic physical examination. Breast examination Abdominal examination Pelvic examination 18
  19. 19. P/E Cont…  The Breast & axillary ExamThe breast examination provides a good opportunity to reinforce the practice of breast self-examination. Patient will change into an examination gown or be covered with a drape sheet. Put the mother in lying position on back, head tilt, adequate positioning help to gain accurate screen1. Inspection: - inspect for - Symmetricity /size, position , shape - Any observable scar, swelling, discharge ,color - The size of two breast may not necessarily equal, slight difference is normal but not too much 19
  20. 20. Bt ex. cont…2. Palpation:Clinician will examine the breasts for lumps, thickening, irregularities, and discharge.Breast lumps are often discovered by a woman or her sex partner.Ask the pt changes noticed in the breasts since last exam, if any. Should become familiar with the way breasts normally look and feel.That way patient will be more likely to notice any changesClassify in to 4 quadrant 20
  21. 21. Bt ex. cont… Start from axillary lymph node / using your finger Support the quadrant you are examining Feel :- tenderness – advanced Ca, tenderness during 1st trimester – Mass – Discharge while palpation – Retraction- in advanced case of breast problem – Engorgements Sitting position- arm above the head Litotomy – arm on the side of examiner/under the head 21
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  23. 23. Macromastia. 23
  24. 24. INFLAMMATION? Peau d’orange 24
  25. 25. Brest self examination Some women use breast self-exams (BSEs) to get to know their breasts. The best time for a BSE is one week after the period, when breasts are not swollen or tender. Lumps are also noticed during day-to-day activities such as showering or sex play. Most lumps are not cancerous. But report anything unusual to the clinician as soon as possible. Ninety percent of breast cancers are found by the woman or her partner. For this reason it is important that women understand the importance of examining the breast on a monthly basis. During pregnancy there is no special time of the month that is best to reform the examination. In non pregnant women, 5 days after cessation of menstruation, it is the optimum time to detect changes 25
  26. 26. Four-Step Breast Self-Exam1. Inspection in the Shower- It is easier to examine breast when hands are soapy.- With your right hand behind your head, examine your right breast with your left hand using a grid or circular motion- Reverse the procedure to examine the other breast.2. In front of the mirrorA. With arms at sides looks for: – Changes in size and shape of breasts – Changes in skin dimpling, puckering, scaling, redness, swelling – Changes in nipple inversion, scaling, discharge from 26 nipples pointing in different directions.
  27. 27. Four-Step Breast Self-Exam cont…B. Holding arms over the head, inspect closely in the mirror for masses, breast symmetry, puckering.C. Press hands firmly on hips, below slightly forward. – Inspect in mirror for lumps or pulling of the skin.D. Each breast should be a mirror image of the other. – If you think you detect a lump in breast, check the other side to see if it feels the same. – If so this is undoubtedly normal tissue. – Examine using the circular or grid motion as in the shower.E. Gently squeeze the nipple of each breast b/n your thumb & index finger to check for signs of discharge or bleeding. 27
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  29. 29. Four-Step Breast Self-Exam cont…3. Inspection on Lying Down• Lying flat on your back, with your right hand under your head and a pillow or towel under your right shoulder, use your left hand to gently feel your right breast, using concentric circles to cover the entire breast and nipple.• Examine every part of the breast with the fingers of the left hand held flat.• Gently press in small circles. Start at the top outermost edge and spiral in to the nipple.• Feel for lumps, bumps, or thickening.• Repeat on your left breast. 29
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  32. 32. P/E Cont… Abdominal examination: follow the same procedure as obstetric abdominal examination What methods/skills are used during abdominal examination? Pelvic examination• The pelvic examination is a procedure feared by many women, so it must be conducted in such a way as to allay her anxieties.• A patients first pelvic examination may be especially disturbing, so it is important for the care giver to attempt to allay fear and to inspire confidence and cooperation.• Reassurance of the patient is helpful in securing patient relaxation and cooperation. 32
  33. 33. P/E Cont… There are four steps: 1. The External Genital Exam 2. The Speculum Exam 3. The Bimanual Exam 4. The Rectovaginal ExamStep 1. The External Genital Exam The pubic hair should be inspected for: Pattern (masculine or feminine), The nits of pubic lice, for infected hair follicles, and for any other abnormalities. 33
  34. 34. P/E Cont… The skin of the vulva, mons pubis, and perineal area should be examined for evidence of dermatitis or discoloration. The glans clitoridis can be exposed by gently retracting the surrounding skin folds. The clitoris is at the ventral confluence of the 2 labia; it should be no more than 2.5 cm in length, most of which is subcutaneous. The major and minor labia usually are the same size on both sides, but a moderate difference in size is not abnormal. 34
  35. 35. P/E Cont… The urethra, just below the clitoris, should be the same color as the surrounding tissue and without protuberances. Normally, vestibular (Bartholins) glands can be neither seen nor felt, so enlargement may indicate an abnormality of this gland system. The perineal skin may be reddened as a result of vulvar or vaginal infection. Scars may indicate obstetric lacerations or surgery. The anus should be inspected at this time for the presence of hemorrhoids, fissures, irritation, or perianal infections (eg, condylomata or herpesvirus lesions). 35
  36. 36. P/E Cont… The clinician visually examines the soft folds of the vulva and the opening of the vagina to check for signs of irritation, discharge, cysts, genital warts, or other conditions. 36
  37. 37. Step 2. The Speculum Exam¤ The clinician inserts a metal or plastic speculum into the vagina.¤ When opened, it separates the walls of the vagina, which normally are closed and touch each other, so that the cervix can be seen.¤ Feels some degree of pressure or mild discomfort when the speculum is inserted and opened.¤ Will likely feel more discomfort if tensed or if vagina or pelvic organs are infected. 37
  38. 38. P/E Cont…¤ The position of the cervix or uterus may affect the comfort as well.¤ Talk with your client about any feeling of discomfort.¤ Once the speculum is in place, check for any irritation, growth, or abnormal discharge from the cervix.¤ Tests for gonorrhea, human papilloma virus, chlamydia, or other sexually transmitted infections may be taken by collecting cervical mucus on a cotton swab.¤ These tests could be done according to the patients symptoms. 38
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  40. 40. •Speculae, from left to right: small metal Pedersen,medium metal Pedersen, medium metal Graves, largemetal Graves, and large plastic Pedersen 40
  41. 41. Speculum insertion 41
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  43. 43. Step 3. The Bimanual Exam¤ Wearing an examination glove, the clinician inserts one or two lubricated fingers into the vagina.¤ The other hand presses down on the lower abdomen.¤ Then feel the internal organs of the pelvis between the two fingers in the vagina and the fingers on the abdomen.¤ Examine the internal organs with both hands to check for – Size, shape, and position of the uterus – An enlarged uterus, which could indicate a pregnancy or fibroids – Tenderness or pain, which might indicate infection – Swelling of the fallopian tubes – Enlarged ovaries, cysts, or tumors 43
  44. 44. Bimanual exam. Cont…¤ The bimanual part of the exam causes a sensation of pressure.¤ May find it somewhat uncomfortable.¤ Deep breathing through the mouth helps.¤ Instruct the patient to tell you when feeling pain,. 44
  45. 45. Bimanual Pelvic Exam 45
  46. 46. Step 4. Rectovaginal Exam¤ Many clinicians complete the bimanual exam by inserting a gloved finger into the rectum to check the condition of muscles that separate the vagina and rectum.¤ Check for possible tumors located behind the uterus, on the lower wall of the vagina, and in the rectum¤ Feel for tenderness, masses, or irregularities.¤ Insert one finger in the anus and another in the vagina for a more thorough examination of the tissue in between.¤ When the examining finger has been inserted a short distance, the index finger can then be inserted into the vagina until the depth of the vagina is reached 46
  47. 47. • This is normal and lasts only a few seconds.• During this procedure, she may feel as though she need to have a bowel movement. 47
  48. 48. Gynecological Diagnostic procedures In addition to routine gynecologic examination some other diagnostic procedures could be performed upon necessity .Mammography Mammography has long been used as a screening test for breast cancer. It involves taking an X-ray of the breast. It is widely accepted that screening mammography leads to early detection of breast cancer 48
  49. 49. Gyn. Dx procedures cont… Pap smear test- is an important part of the gynecologic examination.¤ Usually a small spatula or tiny brush is used to gently collect cells from the cervix for a Pap test.¤ The cells are tested for abnormalities — the presence of precancerous or cancerous cells.¤ May have some staining or bleeding after the sample is taken.¤ The Pap smear is a screening test only.¤ Positive tests are an indication for further diagnostic procedures, such as colposcopy, endocervical curettage, cervical biopsy or ,endometrial biopsy, or D&C¤ The properly collected Pap smear can accurately lead to the diagnosis of carcinoma of the cervix in approximately 95% of cases. 49
  50. 50. Cont… Hysterosonography. This diagnostic technique uses an ultrasound probe to obtain images of the uterine cavity. Hysterosalpingography. This technique uses a dye to highlight the uterine cavity and fallopian tubes on X-ray images. Hysteroscopy. Insertion of a small, lighted telescope called a hysteroscope through the cervix into the uterus. The tube releases a gas or liquid to expand uterus, allowing you to examine the walls of uterus and the openings of fallopian tubes. Its application is used evaluation for abnormal uterine bleeding, resection of uterine synechiae and septa, removal of polyps and intrauterine devices (IUDs), resection of submucous myomas, and endometrial ablation 50
  51. 51. Cont…Culdocentesis: is the passage of a needle into the cul-de-sac—culdocentesis—in order to obtain fluid from the pouch of Douglas .The type of fluid obtained indicates the type of intraperitoneal lesion, eg, bloody with a ruptured ectopic pregnancy, pus with acute salpingitis, or ascitic fluid with malignant cells in cancer. Is performed less frequently today, due presence of U/S, which could provide definative diagnosis. 51
  52. 52. Culdocentesis … 52
  53. 53. Cont… Colposcopy The method of examining the VAGINA & CERVIX UTERI by means of the binocular instrument known as the colposcope. It is used to screen for cancer of the cervix and in investigation of child sexual abuse Diagnostic use  Provides a magnified view of the surface structures of the vulva, vagina and cervix  Special green filters allow better visualization of vessels  Application of 1% acetic acid wash dehydrates cells and reveals white areas of increased  Nuclear density (abnormal) or areas with epithelial changes  Biopsy of visible lesions or those revealed with the acetic acid wash allows early identifica of dysplasia and neoplasia 53
  54. 54. Cont… Bloodwork CBC - evaluation of abnormal uterine bleeding, preoperative investigation ßhCG - investigation of possible pregnancy or ectopic pregnancy • work-up for gestational trophoblastic neoplasia (GTN) • Monitored after the medical management of ectopic and in GTN to assess for cure and recurrences LH, FSH, TSH, PRL • Amenorrhea, menstrual irregularities, menopause, infertility 54
  55. 55. The role of imaging techniques in GYNUltrasound (U/S)- it records high-frequency sound waves as they are reflected from anatomic structures. As the sounds waves pass through tissues, they encounter variable auditory densities. Each of the tissues returns a different echo, depending on the amount of energy reflected. This echo signal can be measured and converted into a 2- dimensional image of the area under examination, with the relative densities shown as differing shades of gray. Simple & painless procedure that has the added advantage of freedom from any radiation hazard It is especially helpful in patients in whom an adequate pelvic examination may be difficult, such as in children, virginal women, and uncooperative patients. 55
  56. 56. Cont… Imaging modality of choice for pelvic structures Transvaginal U/S provides enhanced details of structures located near the apex of the vagina (i.e. intrauterine and adnexal structures) Used to  Rule in or out ectopic pregnancy, intrauterine pregnancy, type of abortion  Assess uterine, adnexal, ovarian masses (i.e. solid or cystic)  Determine uterine thickness  Monitor follicles during assisted reproduction 56
  57. 57. A: Longitudinal view. B: Transverse sectionC: Longitudinal view D: Longitudinal 57
  58. 58. Cont…Hysterosalpingography X-ray after contrast is introduced through the cervix into the uterus Contrast flows through the tubes and into the peritoneal cavity if tubes are patent Used for evaluation of size, shape, configuration of uterus, tubal patency or obstruction Sonohysterography Saline infusion into endometrial cavity under U/S visualization expands endometrium, allowing visualization of uterus and fallopian tubes 58
  59. 59. Cont… Useful for investigation of: AUB Uncertain endometrial findings on vx U/S, Infertility, Amenorrhea, Allergies to iodine dyes Abnormal x-ray hysterosalpingogram Congenital/acquired uterine abnormalities (i.e. uterus didelphys, uni/bicornate, arcuate uterus) Easily done, minimal cost, extremely well-tolerated, sensitive and specific• Frequently avoids need for hysteroscopy 59
  60. 60. Cont…Angiography Angiography is the use of radiographic contrast medium to visualize the blood vascular system. By demonstrating the vascular pattern of an area, tumors or other abnormalities can be delineated. Angiography also is used to delineate continued bleeding from pelvic vessels postoperatively, to visualize bleeding from infiltration by cancer in cancer patients, or to embolize the uterine arteries in order to decrease acute bleeding and/or reduce the size of uterine myomas. These vessels then can be embolized with synthetic fabrics to stop the bleeding or indicate therapy that can prevent the need for a major abdominal operation in a highly compromised patient. 60
  61. 61. Cont…Computed tomography (CT) scan: is a diagnostic imaging technique that provides high-resolution 2- dimensional images. In gynecology, the CT scan is most useful in accurately diagnosing retroperitoneal lymphadenopathy associated with malignancies. It also has been used to determine the depth of myometrial invasion in endometrial carcinoma as well as extrauterine spread. It is an accurate tool for locating pelvic abscesses that cannot be located by ultrasonography. 61
  62. 62. CT scan of the pelvis showing a large fibroid uterus with 3 62calcified fibroids in the body of the uterus.
  63. 63. Cont…Magnetic Resonance Imaging Magnetic resonance imaging (MRI) is a diagnostic imaging technique that creates a high-resolution, cross-sectional image of the body like a CT scan. Its main use in gynecology appears to be staging and follow-up of pelvic cancers. MRI in obstetrics is limited to its use as an accessory prenatal diagnosis of fetal anomalies. It allows for multiple image cuts that can help interpret complex anomalies. Other potential uses of MRI include evaluation of placental blood flow and accurate performance of pelvimetry 63
  64. 64. Embryology of the Urogenital system The female urinary and genital tracts are closely related, both anatomically & embryologically. Both are derived largely from primitive mesoderm and endoderm. About 10% of infants are born with some abnormality of the genitourinary system, and Anomalies in one system are often mirrored by anomalies in another system. Developmental defects may play a significant role in the DDx of certain clinical signs and symptoms. Thus it is important for you to have a basic understanding of embryology. 64
  65. 65. Embryology of Urinary System•The kidneys, renal collecting system, and ureters derive from the longitudinal mass of mesoderm (known as the nephrogenic cord) found on each side of the primitive aorta.•This process gives rise to three successive sets of increasingly advanced urinary structures, each developing more caudal to its precursor.•The pronephros , or ―first kidney, ‖ is rudimentary and nonfunctional; it is succeeded by the ―middle kidney,‖ or mesonephros, which is believed to function briefly before regressing.•Although the mesonephros is transitory as an excretory organ, its duct, the mesonephric (wolffian) duct, is of singular importance for the following reasons: 65
  66. 66. Cont…1. It grows caudally in the developing embryo to open, for the first time, an excretory channel into the primitive cloaca and the ―outside world.‖2. It serves as the starting point for development of the metanephros, which becomes the definitive kidney.3. It ultimately differentiates into the sexual duct system in the male4. Although regressing in female fetuses, there is evidence that the mesonephric duct may have an inductive role in development of the paramesonephric or müllerian duct 66
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  68. 68. Cont…Bladder and Urethra The bladder and urethra form from the most superior portion of the urogenital sinus, with surrounding mesenchyme contributing to their muscular and serosal layers. The remaining inferior urogenital sinus is known as the phallic or definitive urogenital sinus. Concurrently, the distal mesonephric ducts and attached ureteric buds are incorporated into the posterior bladder wall in the area that will become the bladder trigone. As a result of the absorption process, the mesonephric duct ultimately opens independently into the urogenital sinus below the bladder neck 68
  69. 69.  The allantois, which is a vestigial diverticulum of the hindgut that extends into the umbilicus and is continuous with the bladder, loses its lumen and becomes the fibrous band known as the urachus or median umbilical ligament. In rare instances, the urachal lumen remains partially patent, with formation of urachal cysts, or completely patent, with the formation of a urinary fistula to the umbilicus. 69
  70. 70. Embryology of the Urogenital system 70
  71. 71. Embryology of the Urogenital system 71
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  73. 73. Embryology of the Urogenital system 73
  74. 74. Embryology of the Urogenital system 74
  75. 75. Embryology of the Urogenital system 75