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SANDRA SHROFF ROFEL
COLLEGE OF NURSING
Subject : obstetrics and gynaecological nursing
gynaec Case Study
(PRIMARY AMENORRHOEA with HEMATOCOlPoMETRA)

2. Submitted To : Submitted By:
Mrs. SUDHA PETHE Ms. BINI P SAMUEL
PROFESSOR 1ST
Year M.Sc. NURSING.
DATE OF SUBMISSION: /04/13
HISTORY TAKING
I. DEMOGRAPHICAL INFORMATION
Name : Miss Varsha Mohan Dubda
Age : 13Years
Sex : Female
Address : Sanjan, Kibhariya, Maharashtra
Religion : Hindu
Marital status : Unmarried
Education : 8th
Std
Occupation : not working
Family Income : Rs.8000 / month
Ward : Gynec ward (SVBCH)
Bed no. : 3
Date of Admission : 25/04/13
I.P No : 11527
O.P.D. No : 8681
Diagnosis : Primary amenorrhoea with cryptomenorrhoea with hematocolpometra
Surgery : Drainage of hematometra colpos
Date of surgery : 26/4/2013
Care started : 25/04/13
Care ended : 28/04/13

3. II. CHIEF COMPLAINTS (ON THE DAYCARE STARTED):
She is being referred from private hospital at Umergaon with USG report suggestive of hematocolpometra,
hematosalphinx, right hemorrhagic ovarian cyst. She is being referred to the SVBCH. Her mother complaints of not
attended menarche. Miss. Varsha Mohan Dubda came with complaints of lower abdominal pain since 2-3 month and
2-3 episodes of vomiting previous night.
III. PRESENT ILLNESS / PRESENT HEALTH STATUS:
DAY-1(25/04/13)
She came with complaints of abdominal pain.
Examination findings
Patient conscious, oriented.
Vitals – Temperature – 98.6 o
F, Pulse – 80beats/min, Respiration- 20breaths/min, BP- 110/70 mmHg.
P/A- uterus palpable, abdomen soft and tenderness present at uterine side and around umbilicus.
Investigation advised - CBC, urine routine, RFT, RBS, ECG, chest X-ray,
- Her Hb was 12.5 gm% and blood group was B +ve.
Treatment advised- FD and NBM since midnight as she was posted for the surgery: drainage of hematocolpometra.
- Inj. Buscopan 20 mg I.V.Stat.
- Physician reference for fitness
DAY– 2(26/04/13)
PATIENT’S COMPLAINTS - lower abdominal pain, anxious regarding surgery.
FINDINGS
Patient conscious, oriented.
Vitals – Temperature – 98.8 o
F, Pulse – 82beats/min, Respiration- 22breaths/min, BP- 110/70 mm of Hg.
P/A- uterus palpable, abdomen soft and tenderness present at uterine side and around umbilicus
- TREATMENT (preoperative orders)
- NBM after 10 Pm - Inj T.T. 0.5 ml I.M stat
- Consent for surgery - Inj. C-tri 1 gm I/V stat
- Shave and prepare parts - Inj. Pantop 40 mg I/V stat
- Inj. Emset 4 mg I/V stat
- I/V RL from morning 5:00 a.m.
OPERATIVE NOTE
Surgery : Vaginal dilatation with laprotomy done under spinal anesthesia.
Vaginal dilatation done but the orifice of cervix not found, so laprotomy taken. Abdomen opened in layers, peritoneal
cavity opened. Haemoperitoneum noted about 200 cc blood suctioned out. Uterus was held with uterine
holding forceps. Bladder dissected downward. Nick was kept over vault, blood collected and drained out. One
finger was inserted from that orifice and one finger from vagina and orifice was made out. Dilator was
inserted in cervix which was kept in situ. Vagina was packed with hemlock soaked roller gauze piece.
Abdomen was closed in layers and sterile dressing applied.
Postoperative notes:
Complaints - pain at surgical side
- Per vaginal bleeding Temp: 98.6 F Pulse: 88 beats/mt Resp: 22 breaths/mt BP:110/70 mmHg
TREATMENT (post operative orders)
NBM , Head low position
Inj. Augmentin 1.2 gm iv bd
Inj. Metro100mg iv tds
Inj. Emeset 4mg iv bd
Inj. Dynapar i.m
Inj. Trenexa 500 mg iv diluted
Monitoring of Abdominal girth 52 cm
DAY– 3 (27/4/13) (1st postoperative day)

4. PATIENT’S COMPLAINTS -
-pain over surgical site.
FINDINGS TREATMENT – NBM
P/A – abdomen soft. - TPR/ BP chart
- uterus not palpable as before. – Inj. Augmentin1.2 gm I/V BD
- no tenderness. - Inj. Metro 100 cc I/V TDS
- Inj. Pantop 40mg I/V BD
P/V - dark red bleeding present - Inj. Emset 4 mg I/V sos
- pack in situation - Inj. Voveran 30 mg I/M BD
- I/V fluids 1pint RL, 1 Pint 5%dextrose.
DAY– 4 (28/4/13) (2nd
post operative day)
PATIENT’S COMPLAINTS - pain
Liquids orally allowed, but after drinking sips of water she had vomiting, so nothing given by mouth.
FINDINGS TREATMENT – Inj. Augmentin 1.2 gm I/V BD
P/A – soft - Inj. Metro 100 mg I/V TDS
- mild pain at surgical side - Inj.Pantop 40 mg iv bd
P/V - mild bleeding -Inj. Voveran 30 mg im sos.
DAY– 5 (29/4/13) (3rd
postoperative day)
PATIENT’S COMPLAINTS - mild pain at surgical site.
FINDINGS TREATMENT –Liquids orally, Inj. Augmentin 1.2 gm I/V BD
P/A – soft - Inj. Metro 100 mg I/V TDS
- mild pain at surgical side - Inj.Pantop 40 mg iv bd
-Inj. Voveran 30 mg im sos.
Vaginal pack removed, dilator removed, mould with condom with placenterax kept in vagina for patency. Dressing
twice to be done.
IV. PAST HISTORY
Medical : she had no history of any communicable disease like HT, DM or IHD any other
illness. No allergy to any medication and food
Surgical : she has no history of any surgery.
V. MENSTRUAL HISTORY –
Menarche not attained.
VI. PERSONAL HISTORY - She is from middle class family. She is not having any specific likes and dislikes. She
is shy in nature and she is introvert. She is not having allergy to any food or medications. She likes to play and watch
T.V.
VII.SOCIOECONOMIC HISTORY
She belongs to low socioeconomic family. Her father is the only earning member of the family.
They are having good relation with society, friends and even with the other patients in the ward.
They earns approximately Rs.5000/- per month.
VIII.ELIMINATION & BOWEL PATTERN:
Bowel – she has normal bowel pattern.( once a day)
Bladder –she complained regarding decreased urine output.
IX. ENVIRONMENTALHISTORY
She lives with her family in rural area. They are getting water from the boring or street tap. They have electricity
supply and closed drainage system in the house.
X. PSYCHO SOCIAL HISTORY:

5. Economic history - she belongs to middle class family
Mother tongue - Hindi
Language known - Gujarati, Hindi
Cultural Group - Friends
Mood - Anxious
XI. NUTRITIONAL HISTORY:
She is taking all types of vegetarian food. She does not have any specific likes or dislikes. She takes 3 meals
per day. At present patient was NBM since 4 day, then patient is started with liquid diet and then taking full diet.
XII FAMILYHISTORY:
She belongs to nuclear family. No family history of any disease eg. DM, HT. All family members are healthy.
Family Tree
- male
- female
- patient
No familial history of delayed menarche.
PHYSICAL EXAMINATION (12/03/13)
1) HEIGHT : 135 CMS
2) WEIGHT : 36 KGS
3) GENERAL OBSERVATION:
a) Constitution : thin body built
b) Stature : Normal
c) State of Nutrition : Poor
d) Personal appearance : Clean
S.No Name Age in
years
Sex Relation with
head of family
Education Occupation Health status
1. Mr. Mohan
Dubda
40 yrs M Head of
family
5th
std Company
employee
Healthy
2. Mrs. Leela
Mohan Dubda
38yrs F Wife Illiterate House wife Healthy
3. Mr. Harish
Mohan Dubda
20yrs M Son Degree - Healthy
4. Ms. Varsha
Mohan Dubda
13 yrs F daughter 8rd
std - Primary amenorrhea
with
cryptomenorrhoea
38 yrs
20 yrs13 yrs
40 yrs

6. e) Posture : Good
f) Emotional stage : Anxious
g) Skin : Pink
h) Cooperativeness : Cooperative
4) VITAL SIGNS:
Temperature : 98.6oF
Pulse : 80 beats/min
Respiration : 22 breaths/min
Blood pressure : 110/70 mm of Hg
5) HEAD TO TOE ASSESSMENT:
 HEAD
a) Scalp : clear, no injury scar. Dandruff present.
b) Hair : Black , hair equally distributed.
c) Movements of the head : Full range of movement
 EYES
a) Eye lids/Eye lashes : No lesion or infection
b) Conjunctiva : pink
c) Pupils : PERRLA
e) sclera : white
f) abnormal discharge : not present
g) vision : normal
 EARS
a) congenital anomalies : Not present
b) Discharge : absent
c) Hearing : Normal
d) Lesion : Absent
 NOSE
a) Appearance : No Septal deviation
b) Discharge : No
c) Polyps : Not evident
 MOUTH AND THROAT:
a) Lips : Dry
b) Tongue : No glossitis or coated tongue
c) Teeth : Dental carries present.
d) Gums : No Gingivitis
e) Tonsil : No swelling of redness.
 NECK:

7. a) Range of movement : Normal
b) Carotid pulse : felt
c) Lymph node : No enlargement
d) Thyroid gland : Feel smooth and firm
e) Cyst and tumor : Absence
 CHEST AND RESPIRATORY SYSTEM:
a) Inspection : Size and shape normal, chest expansion equal in both side and
respirations are normal. Small breast nodules
d) Auscultation : Breath sounds are normal, normal resonance sound on both side.
Respiratory rate 20 bpm, S1 and S2 heart normal, HR- 80 bpm.
 BREAST
Inspection Size : small
Shape : symmetrical
Areola : primary areola present
Skin of breast : no any other changes
Nipple : flat
Palpation : soft, no any abnormal mass.
ABDOMEN:
 Abdominal girth : 38 cm
a) Inspection : No any previous surgical scar is visible. Muscle tone intact. Contour normal. Visible
mild swelling at lower abdomen over uterus side.
b) Palpation : palpable swelling and tenderness at uterine side. Tenderness around the umbilicus.
 GENITALIA:,
 No any bleeding or discharge present. No complaints of itching.
 UPPER EXTREMITIES:
 Normal movement, No deformities, No lymph node enlargement
 LOWER EXTREMITIES
 Normal movement. No edema.
INVESTIGATIONS:
Sl.
No.
Investigations Patient’s
value
Normal value Remarks
1) Blood
Hemoglobin
Total W.B.C
Differential count
Neutrophills
12.5 gm/dl
12,600 cells /
cumm
73%
11 – 13 gm/dl
5,000 – 13,000 cells/
cumm
30-70%
Normal
Normal
Normal

8. 2)
3)
4)
Lymphocytes
Eosinophils
Monocytes
Basophils
Platelets count
RBS
RFT
Blood urea
Serum creatinine
Serum uric acid
HbsAg
HIV
Blood group
Urine routine examination
pH
Specific Gravity
Quantity
Color
Appearance
ChemicalExamination
Protein
Glucose
Ketones
Blood
Bile Salt
Bile Pigment
Urobilinogen
Microscopic examination
RBC
WBC/Pus cells
Epithelial cells
Casts
Crystals
24%
02%
01%
00%
5.30 lacs /
cumm
101 mg/dl
17 mg/dl
0.9 mg/dl
2.4 mg/dl
Negative
Negative
B +ve
Acidic
1.020
15ml
Pale Yellow
Clear
Nil
Nil
Nil
Nil
negative
negative
Nil
Nil
Nil
2-3/hpf
1-2/hpf
Absent
Absent
20-40%
1-6
1-08
2%
150000-400000
/cumm
80-120 mg/dl
10-50 mg/dl
0.6-1.2 mg/dl
2.60-6.00 mg/dl
-
1.016-1.025
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal

9. Amorphous materials
Bacteria
Absent
Trace
ECG: within normal limit.
Chest x-ray : normal
Ultrasonography (abdomen):
IMPRESSION – hematocolpometra,hematosalphinx, right hemorrhagic ovarian cyst.
DAYWISE TREATMENT -
(25/04/13) - FD
- Inj. Buscopan I.V.Stat.
- Physician reference for surgery fitness
(26/04/13) (preoperative orders)
- NBM after 10 Pm
- Consent for surgery
- Shave and prepare parts
- Inj T.T. 0.5 ml I.M stat
- Inj. C-tri 1 gm I/V stat
- Inj. Pantop 40 mg I/V stat
- Inj. Emset 4 mg I/V stat
- I/V RL from morning 5:00 a.m.
postoperative order – NBM
– Inj. Augmentin 1.2gm I/V BD
- Inj. Metro 100 cc I/V TDS
- Inj. Pantop 40mg I/V BD
- Inj. Trenexa 500mg iv diluted
- Inj. Voveran 30 mg I/M BD
- I/V fluids 1pint RL, 1 Pint 5% dextrose.
(27/4/13 & 28/4/13) (2nd
& 3rd
post operative day)
TREATMENT – Inj. Augmentin 1.2 gm I/V BD
- Inj. Metro 100 cc I/V TDS
- Tab. Rantac 150mg P/O BD
- Tab. Diclofenac 500mg sos.

10. MEDICATION:
Sl.
No
Name of
Medication
Route Dose Freq Class Action Indication contraindication Side effects Nurses
responsibility
1. Inj.
Augmentin
I.V 1.2g
m
BD Cephalospo
rin, third
generation
It interefer with the
final step in the
formation of the
bacterial cell wall,
resulting in unstable
cell membranes that
undergo lysis. Also cell
devision and growth
are inhibited. Most
affective against
rapidly dividing &
young organisms and
are considered
bactericidal.
- Lower
respiratory tract
infections
- urinary tract
infection
- skin & skin
structure
infections
- uncomplicated
cervical/urethral
and rectal
onorrhea.
- PID
- Bacterial
septicemia
-hypersensitivity
to cephalosporins
or related
antibiotics,
-Hypersensitivity
-rash
- eosinophilia
- diarrhea
- pain,
induration,
tenderness,
warmth at
injection site.
- ask for
hypersensitivity of
icephalosporin
group.
- Watch for side
effects
- Should be given
slowly with adequate
dilution
- monitor CBC,
platelets, PT, BS
renal and LFT’s.
-monitor I/O chart.
2. Inj. Metrogyl
(metronidazo
le)
I.V 100
mg
TDS - Trichomon
acide
- Amebicide
Inhibit bacteria and
protozoa. Specifically
inhibit growth of
trichomonae and
amoebae by binding to
DNA,resulting in loss
of helical structure,
strand breakage,
inhibition of nucleic
acid synthesis, and cell
death.
- serious infection
by anaerobic
bacteria
- peritonitis
- skin and skin
structure
infections.
- endometritis
- bacterial
septicemia
- bone and joint
infections
- meningitis and
brain abscess
- amebiasis
- Prophylaxis in
postoperative
period
- diarrhea
- crohn’s disease
- blood dyscrasias
- active organic
disease of CNS
- trichomoniasis
in first trimester
of pregnancy or
lactation
- hypersensitivity
to drug
Vomiting,
stomach upset,
diarrhea
-loss of appetite
-dry mouth or
sharp, unpleasant
metallic taste
-dark or reddish-
brown urine,
furry tongue or
mouth or tongue
irritation-
numbness or
tingling of the
hands or feet
Assess the vital
signs.
Special precautions,
if you have or have
ever had blood,
kidney, or liver
disease or Crohn's
disease.
-remember you
should not drink
alcoholic beverages
while taking
metronidazole. -
Alcohol may cause
an upset stomach,
vomiting,abdominalc
ramps, headache,
sweating, and
flushing.

11. 3. Inj Pantop
(Pentaprazol
e sodium)
I V 40
mg
BD Proton
pump
inhibitor
It suppresses the final
step in gastric acid
production by forming
a covalent bond to two
sites of the H+/K+-
ATPase enzyme
system at the secretory
surface of gastric
parietal cells. Results
in inhibition of both
basal and stimulated
gastric acid secretion.
-erosive gastritis
associated with
GERD.
- long term
treatment of
pathological
hypersecretory
conditions.
- treat duodenal
ulcer.
- Hypersensitivity
to any
components of the
formulation.
- Lactation.
Gastro-intestinal
complaints such
as upper
abdominal pain,
diarrhoea,
constipation or
flatulence,
headache
Assess the vital
signs.
Monitor liver
function regularly (if
enzymes increase,
discontinue) because
it may lead to liver
damage.
4. Inj. Rantac
(Ranitidine
hydrochloride)
I.V. 50
mg
TDS Histamine
H2 receptor
antagonist
Competitively inhibit
gastric acid secretion
by blocking the effect
of histamine H2
receptor.
- duodenal ulcer
- active benign
gastric ulcer
-GERD
- erosive
esophagitis
- peptic ulcer
-relief of
heartburn due to
indigestion or
sour stomach
- cirrhosis of liver
- impaired renal
and hepatic
function
- use with caution
in lactation and in
elderly
- Headache,
- abdominal pain
- insomnia
- diarrhoea
- flatulence
- constipation
-nausea and
vomiting
-
-Do not confuse with
rimantadine
-May take with or
without food.
- To report severe
diarrhoea, drug may
have a discontinued.
- instruct patient to
take with or
immediately
following meals.
- avoid alcohol,
aspirin containing
products and
baverages that
contain caffeine.
-report any evidence
of yellow
discolouration

12. 5. Inj Emset
(ondansetron
hydrochloride)
I.V. 4 mg TDS Antiemetic Ondansetron blocks the
5-ht3 antagonists,
blocks the effect of
serotonin
- Prevent nausea
& vomiting
associated with
chemotherapy &
radiotherapy
- postoperatively
to avoid nausea &
vomiting
Use with caution
curing lactation
Diarrhea, malaise
headache,fatigue
dizziness,
constipation,
bradycardia,
drowsiness,
sedation,
hypoxia, anxiety,
pruritus, pyrexia,
shivers.
It should be given
exactly at prescribed
time.
Assess for any side
effects
Report rash if
persist.
Do not confuse with
Zoloft an
antidepressant
6. Inj. Voveran
(diclofenac
sodium
injection)
I.M. 30
mg
TDS NSAID Anti-inflammatory
effect is likely due to
inhibition of the
enzyme cyclooxygenas
That result in decrease
prostaglandin
synthesis. Analgesicn
due to relief of
inflammation
Rheumatic
inflammatory
disease
Non rheumatic
inflammatory
conditions mild to
moderate pain
e.g.sprain, strain,
dental pain
Primary
dismenorhoea
- children under
14 years
-lactation
- acute asthama
-urticaria
-bronchospasm
-hepatic porphyria
headache,
dizziness,
abdominal pain,
cramps, nausea,
diarrhea,
constipation,
dyspepsia.
Advise to take with
meal, or full glass of
water if G.I. upset
occur. Do not crush
or chew tablet.
Maintain fluid
intake,
7. Inj. T.T.
(tetanus toxoid
injection)
I.M. 0.5
ml
stat vaccine This medication is
given to provide
(immunity) against
tetanus (lockjaw) in
adults and children 7
years or older.
Vaccines work by
causing the body to
produce its own
protection (antibodies
- pregnancy
- given earlier in
routine childhood
immunization
- after any injury
-
- hypersensitivity
- bleeding
disorder
- gullian berre
syndrome
- neurological
disease
- less than 7 years
of age
fever,redness,
swelling around
the injections,
and soreness or
tenderness
around the
injection site.
- administer deep
intramuscularly
- use five R of giving
medication
- use aseptic
technique for giving
injection.
- if possible mote
than 1 inch needle.

13. 8. Inj. Trenexa iv 500
mg
tds Antifibrinol
ytic

14. 9. Inj.
Buscopan
(Hyoscine
butylbromide
injection)
I.V 20m
g
stat Antispasm-
odic.
Anticholin-
ergic
Cervical
relaxants
Hyoscine has selective
spasmodic effect in the
parasympathetic
innervations of the
cervical os.
- one of the belladonna
alkaloids; acts by
blocking the action of
acetylcholine at the
postaglandinic nerve
endings of the
parasympathetic
nervous system.
- Hypermotility in
spastic, colitis, -
spastic bladder,
cystitis,
- pylorospasm,
and associated
abdominal
cramps.
-irritable bowel
sundrome.
- parkonsinism
- preoperative
medication to
reduce saliva,
tracheobronchial
and pharyngeal
secretions.
- reduce motility
before diagnostic
procedure.
allergic to
hyoscine or any
ingredients of this
medication
are allergic to
other atropinics
(e.g.,atropine,
scopolamine)
have myasthenia
gravis, megacolon
(enlarged colon),
glaucoma,
orobstructive
prostatic
hypertrophy (enla
rged or blocked
prostate)
are receiving this
medication as an
intramuscular
injection and are
taking a blood
thinner
medication (e.g.,
warfarin, heparin)
have narrowing of
the
gastrointestinal
tract,a fast
heartbeat,angina,
or heart failure
- dry mouth
- drowsiness
- flushing of face
- headache
-blurred vision
-photosensitivity
-constipation
- decreased
perspiration
- thirst
- give as prescribed
- do not give antacid
within 1 hour of
giving drug
-report any loss of
symptom control so
dose can be adjusted
-advise patient to
avoid excessive
temperament and
activity
- males with
enlarged prostate
may experience
urinary retention
-stop drug and report
if any mental
confusion, impaired
gait, disorientation,
or hallucination.

16. ANATOMY AND PHYSIOLOGY
AMENORRHOEA
Definition : Amenorrhoea is the absence of a menstrual period in a woman of reproductive age.
 Physiological states of amenorrhoea are seen during pregnancy and lactation (breastfeeding), the latter also forming
the basis of a form of contraception known as the lactational amenorrhoea method. Outside of the reproductive years
there is absence of menses during childhood and after menopause.
Amenorrhoea is a symptom with many potential causes.
Primary amenorrhoea (menstruation cycles never starting) may be caused by developmental problems such as the
congenital absence of the uterus, failure of the ovary to receive or maintain egg cells, and genetic diseases such as 5-
alpha-reductase deficiency which causes one to be intersex. Also, delay in pubertal development will lead to
primary amenorrhoea. It is defined as an absence of secondary sexual characteristics by age 14 with no menarche or
normal secondary sexual characteristics but no menarche by 16 years of age.
Secondary amenorrhoea (menstruation cycles ceasing) is often caused by hormonal disturbances from
the hypothalamus and the pituitary gland, from premature menopause or intrauterine scar formation. It is defined as
the absence of menses for three months in a woman with previously normal menstruation or nine months for women
with a history of oligomenorrhoea.
CLASSIFICATION
There are two primary ways to classify amenorrhoea. Types of amenorrhoea are classified as primary or secondary, or
based on functional "compartments" (Speroff). The latter classification relates to the hormonal state of the patient that
could be hypo-, eu-, or hypergonadotropic (meaning FSH levels are either low, normal or high).
 By primary vs. secondary:
 Primary amenorrhoea is the absence of menstruation in a woman by the age of 16. As pubertal changes precede the
first period, or menarche,women by the age of 14 who still have not reached menarche,plus having no sign of
secondary sexual characteristics, such as thelarche or pubarche—thus are without evidence of initiation of puberty—
are also considered as having primary amenorrhoea.
 Secondary amenorrhoea is where an established menstruation has ceased—for three months in a woman with a
history of regular cyclic bleeding, or nine months in a woman with a history of irregular periods. This usually
happens to women aged 40–55. Amenorrhoea may cause serious pain in the back near the pelvis and spine. This
pain has no cure,but can be relieved by a short course of progesterone to trigger menstrual bleeding.
 By compartment:The reproductive axis can be viewed as having four compartments:
 1. outflow tract (uterus,cervix, vagina),
 2. ovaries,
 3. pituitary gland, and
 4. hypothalamus. Pituitary and hypothalamic causes are often grouped together.

17. P/S Outflow tract anomalies/obstruction Gonadal/end-organ disorders
Pituitary and hypothalamic/central regulatory
disorders
Overview
The hypothalamic-pituitary-ovarian
axis is functional.
The ovary or gonad does not respond to pituitary stimulation.
Gonadal dysgenesis or premature menopause are possible
causes. Chromosome testing is usually indicated in younger
individuals with hypergonadotropic amenorrhoea. Low
oestrogen levels are seen in these patients and the hypo-
oestrogenism may require treatment.
Generally, inadequate levels of FSH lead to
inadequately stimulated ovaries which then fail to
produce enough oestrogen to stimulate
theendometrium (uterine lining), hence amenorrhoea.
In general, women with hypogonadotropic
amenorrhoea are potentially fertile.
FSH
Outflow tract abnormalities tend to be
normogonadotropic and FSH levels are
in the normal range.
Gonadal, usually ovarian, abnormalities tend to be linked to
elevated FSH levels or hypergonadotropic amenorrhoea. FSH
levels are typically in the menopausal range.
Both hypothalamic and pituitary disorders are linked to
low FSH levels leading to hypogonadotropic
amenorrhoea.
Primary
 Uterine: Mullerian agenesis (Second
most common cause,15% of
primary amenorrhoea)[5]
 Vaginal: Vaginal
atresia,cryptomenorrhoea,imperforat
e hymen.
 Gonadal dysgenesis, including Turner syndrome, is the
most common cause.
 Androgen insensitivity syndrome (Testicular feminization
syndrome)
 Receptor abnormalities for hormones FSH and LH
 Specific forms of congenital adrenal hyperplasia
 Swyer syndrome
 Galactosaemia
 Aromatase deficiency
 Prader-Willi syndrome
 Male pseudo-hermaphroditism (about 1 in every 150,000
births)
 Other intersexed conditions
 Hypothalamic: Kallmann syndrome
Secondary  Intrauterine adhesions (Asherman's
syndrome)
 Pregnancy (most common cause)
 Anovulation
 Menopause
 Premature menopause
 Polycystic ovary syndrome (PCO-S)
 Drug-induced
 Hypothalamic: Exercise amenorrhoea, related
to physical exercise, stress amenorrhoea, eating
disorders and weight loss (obesity, anorexia
nervosa, or bulimia)
 Pituitary: Sheehan
syndrome, hyperprolactinaemia,haemochromatosis
 Other central
regulatory: hypothyroidism, hyperthyroidism,arrhe
noblastoma

18. CRYPTOMENORRHOEA
 DEFINITION
 Cryptomenorrhea or cryptomenorrhoea, also known as hematocolpos, is a condition
where menstruation occurs but is not visible due to an obstruction of the outflow tract. Specifically
the endometrium is shed, but a congenital obstruction such as a vaginal septum or on part of
the hymen retains the menstrual flow. A patient with cryptomenorrhea will appear to
have amenorrhea but will experience cyclic menstrual pain. The condition is surgically correctable.
 The patient usually presents at the age of puberty when the commencement of menstruation blood gets
collected in the vagina and gives rise to symptoms.
 ETIOLOGY
Book picture Patient picture
 CONGENITAL
- Imperforated hymen due to failure of disintegration
of the central cells of the mullerian eminence that
projects into the urogenital sinus
- Transverse vaginal septum due to failure of
canalization of the fused mullerian ducts and the
urogenital sinus.
- Atresia of upper- third of vagina and cervix
 ACQUIRED
- Stenosis of the cervix following amputation, deep
cauterization and conisation.
- Secondary to vaginal atresia following neglected
and difficult vaginal delivery.
PATHOPHYSIOLOGY
periodic shedding of the endometrium and bleeding
obstruction in the passage may be congenital or acquired
menstrual blood fails to come out from the genital tract
accumulation of blood in the vaginal cavity behind hymen & it distend the vagina ( haematocolpos)
extension of accumulation upto uterus and uterine cavity dilate (haematometra)
if neglected blood may enter in the tubes and distend the tube
block the fimbrial ends
distention of tubes by blood
Haematosalpinx

19. CLINICAL MANIFESTATION
DIAGNOSTIC EVALUATION ( laboratory investigation)
S.No Book picture Patient picture
1. Abdominal USG
- CBC
- RFT
- URINE ROUTINE
- RBS
- HIV & HBs Ag
- ECG
- Chest X-ray
MANAGEMENT
S.No Book picture Patient picture
1.
2.
3.
4.
5.
6.
Surgical management- cruciate incision is made in the hymen. The quadrant
of the hymen are partially excised not too close to the vaginal mucosa.
Spontaneous escape of the dark tarry coloured blood is allowed.
Antibiotic treatment
Dilatation of the cervix in stenosis
Transverse vaginal septum can be treated with Z-plasty
Blind vagina will require a partial or complete vaginoplasty
Hematosalpinx may require laprotomy or laparoscopy for removal and
reconstruction of affected tube
Book picture Patient
picture
 At the age of 13-15 chief complaints are
- Periodic continuous lower abdominal pain
- Primary amenorrhoea
- Urinary symptoms like frequency, dysuria, and even
retention of urine.
 Per abdominal examination
- Suprapubic swelling
 Vulval inspection
- Tense bulging membrane of bluish colouration
 Rectal examination
- Buldged vagina
 Amenorrhoea dated back from the events
 Pelvic examination reveal the offending lesion in the vagina or cervix

20. COMPLICATIONS:
S.No Book picture Patient picture
1.
2.
3.
4.
hematometra (collection of blood in the uterine cavity)
hematosalpinx (collection of blood in fallopian tubes)
endometriosis in long-standing cases
in severe, untreated forms, infertility and urinary retention
DIET PLAN
CALORIE REQUIREMENT CALCULATION
Height: 135 cm Weight: 36 kg Age: 12 yrs
BMR=66.47+13.75(w)+5.0(H)+6.76(A)
= 66.47+13.75×36+5.0×135+6.76×12
= 66.47+ 495+675+81.12
= 1317.59 Kcal
Time Menu Amount Calories Protein
(gram)
Fat
(gram)
Iron
(mg)
Calcium
(mg)
8:00 am
12:30pm
5:00 pm
8:00pm
8:00 am
Tea
Bread slice
Rice
Dal
roti
mixed veg. curry
Tea
Salted biscuit
roti
mutter curry
Tea
puri
1 cup (100ml)
1
1 vati
1 cup
2
1 vati
1 cup (100 ml)
2
2
1 vati
1 cup (100ml)
1
36
60
200
118
160
210
36
40
160
200
36
63
1.4
10
6.0
6.0
5.0
15.8
1.4
4.4
5.0
12
1.4
3.6
1.6
1.8
10.9
10.9
5.5
19.94
1.6
1.6
5.5
112
1.6
6.8
-
0.65
3.8
3.8
5.3
15.7
-
-
5.3
0.4
-
1.0
0.06
0.003
0.004
0.14
0.04
27
0.06
0.02
0.05
0.06
0.014
Total 1319 kcal 72 59.34 35.95 27.451

21. APPLICATION OF THEORY ( FAYGLENN ABDELLAH’S NEED ORIENTED THEORY)
MAJOR ASSUMPTION
1. PERSON
Miss. Varsha Mohan Dubda is at age of 13 years. She is diagnosed as primary amenorrhoea with
cryptomenorrhoea with hematometracolpos. Patient is having physical, Emotional and sociological needs.
2. ENVIRONMENT
Person’s surrounding environment is Hospital, Nursing Staff, Family member other patients.
3. HEALTH
Patient is having primary amenorrhoea with crypyomenorrhoea with hematometracolpos. Patient is having
small vaginal pouch.
4. NURSE
- Preoperative diagnosis
 Pain related to distention of vagina and uterus as evidence by pain scale 7/10 and verbalization
 Anxiety related to surgical procedure as evidenced by verbalization and anxious look.
 Imbalance nutrition less than body requirement related to poor economy as evidence by verbalization
- Postoperative diagnosis
 Pain related to surgical incision as evidence by pain scale 8/10 and verbalization.
 Self care deficit related to pain and surgery as evidence by verbalization
 Knowledge deficit related to lack of exposure as evidence by verbalization.
 Risk for infection related to lack of information and presence of surgical incision & I.V. intraceth.
SUMMARY
Patient is having congenital cryptomenorrhoea with hematometrocolpos. She is having acute pain. Patient is
in preoperative phase and she is planned for surgery that is drainage of hematocolpos under general
anesthesia.
- Reduce the patient and parents fear and anxiety related to surgery and outcome of disease condition.
- explained about future requirement for reference.

22. THEORY APPLICATION
ENVIRONMENT
Ward ,Father, nurses, doctors, other patients
PERSON
Name – Miss. Varsha Mohan, Age- 13 yrs
Diagnosis- Primary amenorrhoea with
cryptomenorrhoea with Colpohematometra
Physiological changes
1. Nutrition
Health- Patient has poor
nutritional status.
Nurse – advice the patient
to take High protein, Iron
containing nutritious diet.
2. Elimination
Health - Patient has risk of
urinary tract infection.
Nurse- given perineal care
changed pad and advice to
Maintain good perineal
hygiene.
3.Fluid and electrolyte
Health – Patient’s fluid and
electrolyte balance is
maintained.
Comfort, Hygiene and Safety
1. Hygiene and Physical comfort
Health – Patient is not able to
sleep because of pain at surgical
site.
- Bleeding from vagina
Nurse – Advice the patient to
take rest and gave analgesic
drugs.
Activity and rest
Health – Patient do not able to
perform activity because of pain.
Nurse – help patient in her daily
activity. Kept required things
near to her.
3. Safety
Health – Patient at risk of
infection because of surgery,
presence of intracath and low
nutritional status.
Nurse- Advice the patient to keep
perineal area clean. Wear clean
pads and change it frequently.
Administer antibiotic
Psychological and social factor
1. Response to Disease
Health – Patient is anxious and tense
as she is alone in hospital and she is
unknown about the condition
Nurse – Advice the patient to take
help of staff member whenever
needed. Advice her mother to be with
her. Explain about menstruation and
its hygiene.
2. Regulatory mechanism
Health – normal outflow of menstrual
can be achieved as vaginal canal is
formed.
- Pain can be reduced with analgesic.
Nurse – check the amount of blood.
3. Feeling and Reaction
Health – Patient is having fear and
anxiety related to disease condition.
Nurse – Reduce the fear and anxiety
of the patient by explaining positive
effect of treatment.
Sociological and community
factor
1. Emotions and illness
Health – Patient is not talking
much. Patient is alone in ward.
worried about the disease
condition.
Nurse – Informed her about
disease condition in her language
and gave information about
menstrual cycle.
2. Therapeutic Environment
Health – Patient is taking
treatment from the hospital.
Nurse – Nurse,Doctor and her
Father is providing care to the
patient.
E
N
V
I
R
O
N
M
E
N
T
E
N
V
I
R
O
N
M
E
N
T
ENVIRONMENT (ward, Family member, hospital, nurses, doctors )

23. HEALTH EDUCATION PLAN:
S.No Topic Education
1 Hygiene Bathing- advised her to take daily bath with adequate perineal wash.
Advice her to use pad, or clean clothes during menstruation and maintain
cleanliness of perineal area.
2. Dietary
management
- To take iron rich diet as she is in adolescent period.
- Good sources of iron are beef, whole meal bread and cereals, eggs, spinach
and dried fruit.
- Supplementing the diet with iron, vitamins and especially folic acid. A
combined iron and folic acid supplements is very useful.
- To absorb the maximum amount of iron from the diet and for healing, it will
help to eat a diet rich in vitamin C. Raw vegetables, potatoes, lemon, lime
and oranges are all good sources of vitamin C.
- Advice her mother to give protein rich diet for her adequate growth.
3.
1. 3
Follow -up - Advised her parents to bring her for follow up on given date.
- Advised her parents to take physician and obstetrician opinion for her further
management.
4.
2.
General
advice
–advice her mother to be with her as first time she is having this type of
experience.
- be careful with her renal function as she is having absence of right kidney and
enlarged left kidney.
- gave information about need of future surgery and consultation.
 List of nursing diagnosis
- Preoperative diagnosis
 Pain related to distention of vagina and uterus as evidence by pain scale 7/10 and verbalization
 Anxiety related to surgical procedure as evidenced by verbalization and anxious look.
 Sleep disturbance related to hospitalization and pain as evidenced by verbalization.
 Imbalance nutrition related to anorexia as evidenced by less body weight secondary to
hospitalization.
- Postoperative diagnosis
 Pain related to surgical incision as evidence by pain scale 8/10 and verbalization.
 Self care deficit related to pain and surgery as evidence by verbalization
 Knowledge deficit related to lack of information as evidence by verbalization.
 Risk for infection related to surgical incision and presence of I.V. intracath.

24. Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient
complaints
about pain in
lower
abdomen.
Obj data :
Visible
swelling at the
suprapubic
area.
- On palpation
tenderness is
present at
suprapubic
area and uterus
is palpable
upto below the
umbilicus.
Pain related to
distention of
vagina and
uterus as
evidence by
pain scale 7/10
and
verbalization
Patient will
experience
less pain as
evidenced by
verbalization
of decreasing
pain levels.
- assess the generalcondition of
patient
- assess the pain and discomfort.
- explain about reason and its
management
- provide the comfortable
position, assist in her work
- provide non pharmacological
Measures.
- Use diversional activities
- administer antispasmodic drugs
as per doctors order.
- Assessed the generalconditions
of the patient.
- Assessed the pain, tenderness &
discomfort. Pain scale was 7/10
- Explained the reason at her
understanding level and inform
about complete recovery from
pain after surgery.
- Provided the sideline position as
patient is feeling some comfort in
this position.
- Use diversional activities such as
watching TV or talking to other
patient and family members.
- Provided back massage
- Administered Inj Buscopan 20
mg I.V.at 10:00 am
Sub evaluation :
Patient verbalizes that
she is felling little
comfortable after
providing warm
applications
-pain is not reduced
much.
Objective evaluation :
Patient is look little
comfortable than
before but still
tenderness is
present.ing
comfortable.
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient is
asking about
type of
surgery, its
duration etc.
Obj data :
Patients looks
anxious and
verbalize that I
am having too
much fear
about surgery.
Anxiety related
to surgical
procedure as
evidenced by
verbalization
and anxious
look.
Patients will
verbalize of
less anxiety
- provide clear information about
surgery and ascertain for cope up
- accompany patient
- advice mother to be with her.
- give consolation
- advice to clear doubts from
doctor or staff nurse.
- provide information about surgery
and its duration in her language and
at her understanding level.
- ascertain for patients
understanding for outcome of her
surgery.
- accompany patient upto O.T. and
introduce her to O.T. staff of
preoperative area.
- advice mother to be with her till
she will go for surgery.
- Gave psychological support and
allow her to cope by her own
manner
- Advised to consult obstetrician or
staff nurse if any doubt about
surgery is there in their mind.
Subjective evaluation
Patient verbalizes for
reduced level of
anxiety.
Objective evaluation
Parents and patient still
have some anxiety.

25. Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient
complaints of
not getting
sleep during
night because
of pain.
Obj. data
Patient
complaints of
improper
sleep at night
because of
pain. patient
does not look
fresh in
morning and
feel sleepy
during day
time.
Sleep
disturbances
related to
hospitalization
and pain as
evidenced by
patients
verbalization
Patient will
not sleep
during day
time and looks
fresh.
- observe for underlying cause
of disturbed sleep
- determine level of pain
- provide measure to assist
with sleep
- keep environment quiet
-give sleep protocol
- pain is the reason in my patient
for sleep disturbance.
- provided information about her
surgery and reason for pain to
reduce anxiety
-advice patient to verbalize her
anxiety and use diversional
therapy.
- explained effect of not
sleeping on her health.
- try to provide quiet
environment by reducing noise
producing events in ward.
- advice patient to take short nap
before routine working hours of
wards.
- advice patient to take luke
warm milk if possible.
Subjective evaluation
Patient verbalize for
getting good sleep
during yesterday night.
Objective evaluation
Patient looks fresh in
morning. Patient is not
feeling sleepy during
daytime.
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Subjective
data:
Patient
complaints of
weakness and
not feeling to
eat food
Objective
data:
Patient is not
eating
adequate food.
weight is 36
Kg. only
Imbalance
nutrition less
than body
requirement
related to
anorexia as
evidenced by
less body
weight
secondary to
hospitalization.
- patient will
progressively
gain weight
- determine healthy body
weight for age and height.
- Provide companionship at
mealtime
- weigh client weekly under
same condition
- monitor food intake. Consult
dietician for actual calorie
requirement.
- monitor state of oral cavity
- advice for environment
change.
- Patients weight is 36 Kg which
is less according to her height.
-provided food in attractive
manner and advice mother to be
with her and if possible feed her.
- Patient is taking less food than
requirement. So advice mother
to give small feed in between.
- Took diet plan from dietician
and hand over to mother.
- oral hygiene is poor. So advice
to maintain oral hygiene.
- advice mother to take her out
for meal with permission of
staff..
Objective evaluation
Patient eats given food.
She shows interest in
eating with companion.
Oral hygiene
improved. Appetite
improved.

26. Post-operative care plan
Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient
complaint of
pain at surgical
site.
Objective
data
Patient is not
allowing for
any
examination.
Pain related to
surgical incision
as evidence by
pain scale 8/10
and verbalization
Patient will
experience
less pain as
evidenced by
verbalization
of decreasing
pain levels.
- assess the generalcondition of
patient
- assess the pain and discomfort.
- provide the comfortable
position provide extra pillows
- , assist in her work
- Use diversional activities
- give consolation.
- administer analgesics drug as
per doctors order.
- Assessed the pain & discomfort.
Pain scale was 8/10
- Provided the semifowler position
with additional pillows. patient is
feeling comfortable in this
position.
- Assist he in changing perineal
pad.
- use diversional activities such as
watching TV or talking to other
patient and family members.
- Provided information that this
pain will be for short time and
reduce gradually.
- Administered Inj Voveran 30 mg
I.M. at 1:00 pm
Sub evaluation :
Patient
verbalizes that
pain reduced after
1 hour
Objective
evaluation :
Patient is
allowing to assess
for amount and
type of bleeding.
look little
comfortable than
before but still
tenderness is
present.ing
comfortable.
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient
verbalize that I
can not
perform my
routine work..
Objective
data
Patient has not
change the
clothes or
perineal pad.
Self care deficit
related to pain
and surgery as
evidence by
verbalization
Patient will
perform her
activity with
assistance of
caregiver.
- assess the client’s ability to
perform
- help to perform daily
activities
- explain importance of
hygiene
- patient can perform activity
within bed with help
- help the patient in brushing,
bathing, changing clothes
combing of hair and other
activities.
- provided perineal care with all
aseptic measures.
- explained the importance of
cleanliness for good health and
for prevention of infection at
surgical site.
Sub evaluation :
Patient verbalize
for feeling fresh.
Objective
evaluation :
Patient looks
clean and fresh.
- Patient assures
that she will
maintain good
hygiene.

27. Theory
applied Assessment Diagnosis Objective Interventions Implementations Evaluation
For Miss. Varsha
Mohan I am
going to provide
care by applying.
Fayglenn
abdellah’s theory
Sub. data :
Patient’s
mother ask
question
about her
treatment and
outcome of
surgery
Obj. data
Patients
mother looks
tense and
worried.
Knowledge
deficit related
to lack of
information as
evidence by
verbalization.
Patient’s
mother
verbalize for
understanding
of
information.
- determine mother’s
knowledge.
- determine the mother’s
understanding level
- use pictures to explain
treatment and outcome
- help the family to identify
resources for continuing
information and support
- assess Knowledge available
with patient’s mother. She has
incomplete information about
her daughter’s management.
- mother can understand with
simple explanation.
- used picture for her doubt
clearing.
- advice them to meet
obstetrician of ward staff for
their doubts or problem and take
their help.
Subjective evaluation
Patient’s mother
verbalize for decreased
tension about her
daughter.
Objective evaluation
Patient’s mother
thanked for providing
information.
looks less worried.
For Miss.
Varsha Mohan I
am going to
provide care by
applying.
Fayglenn
abdellah’s theory
Objective
data:
Patient has
surgical wound
and intracath
for I.V.
injection.
Risk for
infection
related to
surgical
incision and
presence of
I.V. intraceth.
patient will
show no signs
of infection as
evidence by
vitals, ESR,
and WBC
within normal
limit and no
increase in
pain and
discomfort.
- assess wound line
- monitor vital signs
- assess for signs of infections
- monitor WBC and ESR count
- Administer prescribed
antibiotic
- maintain aseptic technique for
all nursing procedure
- advice to maintain personal
hygiene
- Assessed the general
conditions of the patient and
Monitor patient’s vital signs.
- WBC and ESR count compared
with previous report.
- Administered Inj. C-tri1gm,
Inj. Metrogyl 500 mg I.V. at
11:00 am
- Advice to take daily bath and
maintain perineal hygiene &
wear clean clothes
No signs of infection
present as patients
vitals ESR, WBC are
within normal limit.
Patient verbalize for
reduction in pain.

28. PROGNOSIS:
DAY-1
 perform physical examination of patient
 carry out pre- operative orders and accompany patient up to operation theatre.
 prepare patient physically and psychologically for operation.
DAY-2
 Done post operative assessment of patient. Assess for pain & bleeding
 Monitored vitals & administered Inj C-tri l gm, Inj. Metrogyl 500 mg I.V. and Inj. Voveran 30 mg I.M.
 Provide perineal care to patient with all aseptic precautions.
 Teach the patient’s mother about perineal care.
 Educated patient’s mother regarding diet in rich sources of Protein, iron and vitamin-c.
DAY-3
 Assess for pain & bleeding
 Monitored vitals & administered Inj Augmentin 1.2 gm. Inj. Metrogyl 100 m.g I.V. and Inj. Voveran 30
mg I.M.
 Provide perineal care to patient with all aseptic precautions.
 Educated patient’s mother regarding regular follow up to maintain good health.
 Explain her regarding positive outcome of surgery.
SUMMARY:
My Patient Miss Varsha Mohan came with complaints of lower abdominal pain and menarche not attained. I
have attended her on 1st day of her hospitalization. Patient was stable and NBM as she is posted for surgery
on that day. Done physical examination of patient and accompany her upto operation theatre. On 1st
postoperative day do assessment and gave perineal care and assist patient for her daily activity. On the last
day of my care I have given health education regarding importance of follow up care, diet, rest, and personal
hygiene and advice her to be more attentive for her menstruation.
CONCLUSION:
During my clinical posting in SVBC Hospital at Vapi, I got chance to provide care to Miss. Varsha Mohan
with diagnosis of primary amenorrhoea with cryptomenorrhoea with colpohematometra. By this study I learn in
detail about cryptomenorrhoea with colpohematometra and its surgical management. I thank my client for her
cooperation and my clinical coordinator for her valuable guidance.

29. BIBLIOGRAPHY:
1. Dr Dawn C. S.. Textbook of Gynaecology, contraceptives & reproductive & demography .16th
edition. Kolkata: Smt. Arati Dawn, Debabrata Dawn publishers;2004.chapter.10.p.77
2. Dutta D.C., Textbook of Gynaecology, 6th Edition, India: published by new central book agency;
2004. Page no.413-415.
3. Howkins & Bourne, Textbook of Gynaecology, 13th edition, Reed Elsevier Private Limited, Delhi;
2006. Page no. 279-80
4. Jeffcoate’s, Principles of Gynaecology. 7th edition, Jaypee Brothers medical publication; 2008 .
Page.no.579
5. Padubidri V.G. Prep manual for Undergraduates of Gynaecology, Reed Elsevier Private Limited,
Delhi; 2005. Page no. 33.
Internet sources:
http://kidshealth.org/amenorrhoea/ cryptomenorrhoea.html
http://www.nlm.nih.gov/medlineplus/ency/article/000810.htm