Obstetrics and gynecological procedures

1. INTRODUCTION
The gynaecological - history collection &
clinical examination should be thorough and
meticulous.
These include in-depth history taking and
general, breasts, abdominal and internal
examinations.
A meticulous history taking alone can give
provisional, positive diagnosis in majority of
the cases without any physical examination.

2. HISTORY
• Patient identification-Name, age, identity,
marital status, parity, occupation, address.
• A brief statement of the general nature and
duration of the main complaint.
• History of presenting single or multiple
complaints.
• Enquiry about bowel habits and urinary
pattern.

3. MENSTRUAL HISTORY
• Age of menarche.
• Regularity of the cycle.
• Usual duration of each period and length of
cycle, dysmenorrhoea.
• Amount of blood loss- greater or less than
usual or number of pads used.
• First day of Last Menstrual Period.(L.M.P)
can be recorded as 12/4/28.

4. PREVIOUS OBSTETRIC HISTORY
• Ask whether the patient had been previously
pregnant.
• Type of delivery anaesthesia, post op-
complications, no. of children with age and
birth weights, & date of last child birth.
• Any abortions.
• Any abnormalities with pregnancy, labour or
the puerperium.
• Breast feeding, immunization, etc.

5. PREVIOUS MEDICAL HISTORY
• Any serious illness or operations with
dates
• Family history of cancer, T.B, etc
• Enquire about any systemic, metabolic
or endocrinal disorders, like…
• Drug history –Warfarin, estrogens, anti
epileptics, drug allergy, etc.

6. PAST SURGICAL HISTORY
• Any previous gynaecological, obstetrical or
general surgery.
• Enquire - The nature of the operation,
anaesthesia related complications and post
operative convalescence.
• Ask about the histo pathological report or
relevant investigations related to previous
surgery.

7. FAMILY HISTORY
• Any malignancy in the breast, colon, ovary or
other genital organs.
• Tuberculosis/AIDS/Asthma/twins.
• Affection of any family member with T.B, can
give a clue in diagnosis of pelvic tuberculosis.

8. PERSONAL HISTORY
• Educational status
• Appetite, Diet, weight loss, weight gain,
• Exercise or yoga,
• Occupation, Socio-economic status,
• Smoking, drugs, alcohol intake.
• History of taking medicines for a long time,
• Allergy to certain drugs is to be noted.

9. PERSONAL HISTORY
Sexual history
• History of discomfort, pain, etc.
• No. of times,
• No. of partners,
• Type of partners,
• Route of sex, etc.

10. Contraception history
• The use of contraception
• Type of contraception
• Duration used.
• Reasons for continuation or
discontinuation as………

11. GYNAECOLOGICAL
EXAMINATION

12. The examination includes:
• General and systemic examination
• Gynaecological examination
- Breast examination
- Abdominal examination
- Pelvic examination

13. GENERAL AND SYSTEMIC EXAMINATION
• The general and systemic examination
should be thorough and meticulous.
• Check Temperature, Pulse, Respiration,
Blood pressure.
• Note any, physically challenged condition,
sensory deficits - deaf, dumb, blindness, etc.
• Pallor, Jaundice, gasping, edema of legs, etc.

14. GENERAL AND SYSTEMIC EXAMINATION
• Look – Anxious, depressed, comfort level, etc.
• Built - Too obese or too thin - may be the
result of endo crinopathy, aging, CAD, DM,
drugs or related to menstrual abnormalities.
• Nutrition- Average / Poor
• Stature- gait, developmental abnormalities,
secondary sex characters, polio, etc.

15. GENERAL & SYSTEMIC EXAMINATION
• Neck- Palpation of thyroid gland.
• Lymph nodes are present throughout the body.
• The head and neck region contains over 300 lymph
nodes, including the supra clavicular lymph nodes.
• Specifically, the right supra clavicular lymph nodes
drain the breast, lung & upper esophagus.
• The left supra clavicular lymph nodes extensively
drain distant regions including the kidneys, cervix,
testis, pancreas, etc.

16. • Examine the teeth, gums and tonsils for any
septic foci.
• Cardiovascular and respiratory systems for...
• Any abnormalities may modify the surgical
procedure, if it deems necessary.

17. GYNAECOLOGICAL EXAMINATION
Breast Examination
Breast Examination is of two types: BSE & CBE
• This should be a routine specially in women
above 30 yrs , to detect any breast pathology,
the important benign carcinoma.
• In India, breast carcinoma is the second most
common site of malignancy in female, next to
carcinoma cervix.

18. Breast Self Examination

19. Clinical Breast Examination
• Clinical Breast Examination is done by a trained
health personnel to detect any breast pathology.

20. Abdominal Examination
Prerequisites
• Bladder should be empty (exception is stress
incontinence).
• If history is suggestive of chronic retention of
urine, catheterize.
• The patient is to lie flat on the table with the
thighs slightly flexed and abducted to make the
abdominal muscle relaxed.

21. • The physician usually prefers to stand on the
right side.
Actual steps
• Inspection
• Palpation
• Percussion
• Auscultation

22. Inspection
• Note the skin condition of the abdomen-
presence of old scar, striae, prominent veins
or eversion of the umbilicus.
• Cullen's sign is superficial edema and
bruising in the subcutaneous fatty tissue
around the umbilicus.
• Ask the patient to strain, elicit either
incisional hernia or diversification of the
rectus abdominus muscles.

23. In intestinal obstruction, the abdomen is uniformly
distended & the respiration is of thoracic type.
In ascitis, one can find fullness only in the flanks with
the centre remaining flat.

24. In pelvic peritonitis, the lower abdomen is only
distended with diminished inspiratory movements.
A huge pelvic tumour is more prominent in the
hypogastrium situated either centrally or to one side.

27. PALPATION
• The palpation (superficial & deep) should be
done with the flat of the hand rather than the
tips of the fingers.
• Rigidity of the abdominal muscles may be
encountered (due to high tension/ muscle
guard). The former may be overcome by
asking the patient to take deep breath.

28. PALPATION
 Whether a mass is felt or not, routine
palpation of the viscera includes- liver, spleen,
caecum and appendix, pelvic colon, gall bladder
and kidneys.
• If a mass is felt in the lower abdomen, note, its
location, size, above or below the symphysis
pubis, consistency, feel, surface, mobility from
side to side, above to down, and margins.

30. PALPATION
• Also, try to reach the lower border of the mass. If
it could not be reached, it is a pelvic mass.
• But in ovarian tumour with a long pedicle, one
can go below the lower pole.
• If the tumour is cystic and huge, a fluid- thrill can
be felt with the tapping with flat hand placed on
one side of the tumour, supporting the tumour
with other hand.

33. PALPATION OF THE LIVER

36. PERCUSSION
• A pelvic tumour is usually dull. Dull or thud like
sounds are normally heard over dense areas
such as the heart or liver.
• It is mandatory to elicit presence of free fluid
in peritoneal cavity, in cases of pelvic tumour.
• Resonance is heard when fluid replaces the
air-containing lung tissues, such as occurs
with pneumonia, pleural effusions/tumors.

37. AUSCULTATION
In the pregnant uterus, FHR can be heard beyond 24
weeks. Funic souffle/funicular/fetal souffle, is a
blowing sound heard in synchronous with fetal heart
sounds, and originate from the umbilical cord.

38. PELVIC EXAMINATION
Pelvic Examination includes :
• Inspection of the external genitalia
• Vaginal examination
-Inspection of the cervix and vaginal walls
-Palpation of the vagina and vaginal cervix
-Bimanual examination of the pelvic organs.
• Digital examination.
• Rectal examination
• Recto vaginal examination

39. Pre requisites
• The patients bladder must be empty-the
exception being a case of stress incontinence.
• A female attendant- chaperone (nurse or relative
of the patient) should be present by the side.
• To examine a minor or unmarried, a consent from
the parent or guardian is required.

40. Pre requisites
• Lower bowel (rectum and pelvic colon)
should preferably be empty.
• A light source should be available.
• Sterile gloves, sterile lubricant (preferably
colorless without any antiseptics),
speculum, sponge holding forceps and
swabs are required.

41. Position of the patient
• The patient is commonly examined in dorsal
position with the 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.
• However , the patient can examine in any
position of the physicians choice.

42. • Lateral or Sims’ position seems 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.
• Lithotomy position is ideal for examination
under anesthesia.

45. INSPECTION OF THE VULVA
Inspection of the vulva is done,
• To note any anatomical abnormality starting
from the triangle area of pubic hair(eucutcheon),
clitoris, labia and perineum.
• To note any palpable pathology over the areas.
• To note the character of the visible vaginal
discharge, if any.
• To separate the labia using fingers of the left
hand to note,
external urethral meatus,
visible openings of the Bartholin’s ducts and
character of the hymen.

47. INSPECTION OF THE VULVA – Cont’d…
To ask the patient to strain to elicit,
• Stress incontinence- urine comes out
through urethral meatus.
• Genital prolapse and the structures involved,
 Anterior vaginal wall,
 Uterus alone,
Posterior vaginal wall or,
All the three.

48. • The Skene's glands, known as the lesser
vestibular glands (homologous to prostate in
males), are two glands (secrete a substance -
antimicrobial & lubricant) on either side of
the urethral opening.
• Lastly to look for haemorrhoids, anal fissure
or anal fistula if any.

49. Inspection of the vagina and cervix
Apart from inspection, collection of the
discharge from the cervix or from the vaginal
fornices or from the external urethral meatus
is taken for bacteriological examination.
It is a routine screening procedure, to take
cervical scrape cytology and endo cervical
sampling for cytological examination in all
patients in the advanced countries, and
selected centers in the developing countries.

51. VAGINAL EXAMINATION
Inspection of the vagina and cervix
• Speculum examination should preferably be done prior
to bimanual examination. The advantages are;
• Cervical scrape cytology and endo cervical sampling can
be taken as screening in the same sitting.
• Cervical or vaginal discharge can be taken for
bacteriological examination.
• The cervical lesion may be bleed during bimanual
examination which makes a lesion difficult to visualize.

52. Digital examination
• Digital examination is done using a gloved index
finger lubricated with sterile lubricant.
• In virgins with intact hymen, this is withheld (can be
employed under anesthesia).

53. The urethra is now pressed from above down for any
discharge escaping out through the meatus.
Palpation of any labial swelling (Bartholin cyst or
abscess) is made with the finger placed internally
& thumb outside.
Integrity and tone of the perineal body
• This is elicited by flexing the internal finger
posteriorly and palpating the perineal body b/w
the internal finger and thumb placed externally.

55. • Inspection of the vaginal walls reveals cystocele or
rectocele.
• Palpation of the vaginal walls is done from below
upwards to detect any abnormality in the wall or in the
adjacent structures. Rugae is scarce in the aged.
The vaginal cervix is next palpated to note:
• Direction-In anteverted uterus, the anterior lip is felt
first and in retroverted position either the external os
or the posterior lip is felt first.
• Station –Normally the external os is at the level of
ischial spines.

56. • Shape- Cx is conical with smooth surface in nulliparae
but cylindrical in parous women.
• External os –Note the color, appearance, etc. It is the
smooth and round in nulliparous but may be dilated
with evidence of tear in parous women.
• Movement- painful or not.
• Texture- like tip of the nose in…

57. EXAMINATION UNDER ANAESTHESIA (EUA)
• EUA is indicated where,
bimanual examination
cannot be conducted due to,
• Extreme tendernes,
• To examine freely virgins
• In cases with pediatric, gynaecologic problems
• Inadequate relaxation of abdominal, pelvic muscles
• Non- cooperative patient &
• In all cases of uterine malignancy for clinical staging.
• This procedure may be performed and procedures
for which the patient may be under anesthesia, such
as Transurethral Resection of Bladder Tumor (TURBT)
is also done simultaneously.

58. BIMANUAL EXAMINATION

59. BIMANUAL EXAMINATION
• The gloved right index and middle fingers
smeared with lubricant are inserted into the
vagina.
• If the introitus is narrow or tender, one finger
may be used.
• The left hand is placed on the hypogastrium well
above the symphysis pubis so that the pelvic
organs can be palpated between them.

60. BIMANUAL EXAMINATION
• The information obtained by, palpation of the
uterus & uterine appendages, (adnexa uteri - the
fallopian tubes, ovaries, & ligaments).

61. BIMANUAL EXAMINATION
Pouch of Douglas

62. RECTAL OR RECTO ABDOMINAL EXAMINATION
• Rectal examination can be done as an adjunct to
vaginal examination.
It is indicated in,
• Children or in adult virgins
• Painful vaginal examination
• Carcinoma cervix
• Atresia vagina
• Patients having rectal symptoms
• To diagnose rectocele

63. RECTO VAGINAL EXAMINATION
• The procedure consists of introducing the index
finger in the vagina & middle finger in the rectum.
• This examination helps to determine whether the
lesion is in the bowel/between rectum and vagina.

64. GYNAECOLOGICAL PROCEDUREs

65. PRINCIPLES TO BE FOLLOWED
• Get a informed consent.
• The surgeon must have skill in the procedure.
• Explain the name of the procedure and in
what way it is helpful.
• Keep up the confidentiality about the
procedure.
• Provide psychological support to the patient.

66. COMMON INVESTIGTIONS IN GYNAECOLOGY
• Blood values
• Urine examination
• Urethral, vaginal, cervical discharge
• Exfoliative cytology
• Colposcopy
• Imaging techniques
• Endometrial sampling
• Biopsy
• Culdocentesis
• Endoscopy
• Hormonal assays

67. ROUTINE BLOOD EXAMINATION
• Hemoglobin estimation should be done in all
cases of excessive bleeding.
• Total and Differential count of white cells and
ESR are helpful in diagnosis of pelvic
inflammation.
• Platelet count, BT, CT are helpful in Pubertal
menorrahagia.
• Serological investigation includes blood for
VDRL, Australian antigen and HIV.

68. URINALYSIS
Urine routine and microscopy
• Chemical estimation of protein and sugar.
• Microscopic examination for detecting pus
cells and casts.
Methods of urine collection
• Midstream collection
• Catheter collection
• Supra pubic bladder puncture

69. Culture and drug sensitivity
• Indications - Pus cells > 5
- UTI
- Cystocele
- Urinary complaints
- Fistula
• 3.Urine Pregnancy Test– for diagnosis of
pregnancy

71. Midstream collection
• The patient herself should separate the
labia with the fingers of left hand.
• A sterile cotton swab moistened with sterile
water is passed over the external urethral
meatus from above down.
• With the vulva still separated the patient
has to pass urine.
• During the middle of the act of micturition,
a part of the urine is collected in a sterile
wide mouth container.

72. Catheter collection
• This should be collected by a doctor or nurse. This is
specially indicated when the patient is not ambulant or
having chronic retention.
• Meticulous washing of the hands with soap and wearing
sterile gloves are mandatory.
• The patient is in dorsal position with thighs apart. The
labia are separated using the fingers of the left hand.
• A sterile cotton swab moistened with sterile water is
passed from above down over the external urethral
meatus.
• The sterile autoclaved rubber catheter or a disposable
plastic catheter is introduced with the proximal 4 c.m
remaining untouched by fingers.

73. CATCATHETERIZCCVCATIONCCCHETERIZAT
ION

74. Supra pubic bladder puncture
• In this method, the result is more reliable
and bladder infection is minimum.
• The patient is asked not to void urine to
make the bladder full. A fine needle fitted
with a syringe is passed through the
abdominal wall just above the symphysis
pubis into the bladder.
• About 5- 10 ml of urine is collected. The
patient is asked to void the urine
immediately.

75. Suprapubic bladder puncture

76. URETHRAL DISCHARGE
• With a sterile gloved finger the urethra is
squeezed against the symphysis pubis from
behind forwards .
• The discharge through the external urethral
meatus is collected with sterile swabs .
• One swab may be sent for culture and the
other may be spread on to a slide, stained and
examined under microscope.

77. URETHRAL DISCHARGE DIS
Method of collection

78. VAGINAL OR CERVICAL DISCHARGE
Method of collection
• Patient is advised not to have vaginal douche in
previous 24hrs.
• Cusco’s bivalve speculum introduced.
• Discharge from posterior fornix on the blade of
speculum or cervical canal taken with a swab.
• The cotton swab stick is put in a sterile container
with a stopper is sent to the lab for culture.
• Microscopic examination of the discharge mixed
with normal saline.

79. EXFOLIATIVE CYTOLOGY - PAPANICOLAOU TEST
• Pap test-This is the screening test for cancer.
• First described by Papanicolaou & Traut in 1943.
• It is a routine gynaecological examination in females,
especially above 35 years.
• Yearly screening up to 30 years, thereafter should be at
the interval of every 2-3 years after three consecutive
yearly negative smears.

80. Pap smear-screening of cancer
PROCEDURE
• 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

81. Modifications
1. Endoc ervical sampling –endo cervix scraped with a
cytobrush and added to the slide.
2. Fixative spray—cyto spray used in office setup.

82. Uses of Pap smear
1. Screening for cancer
2. Identification of local viral infections like
herpes and condyloma accuminata.
3. Cytohormonal study

83. SCREENING PROCEDURE
• Collection of material
• The cervix is exposed with a vaginal
speculum without lubricant and prior to
bimanual examination.
• Lubricants tend to distort cell morphology.

84. • Cervical scraping
• The material from the cervix is best collected
using Ayre’s spatula made of wood or plastic .
Whole of the squamo columnar junction has
to be scrapped to obtain good material.

85. Vaginal pool aspiration
• The exfoliated cells accumulated in the vaginal
pool in the posterior fornix is collected either
using a glass pipette about 15 cm long and 0.5
cm in diameter with a strong rubber bulb at one
end or by a swab stick. This is not much reliable.
Fixation and staining
• The material so collected should be immediately
spread over a microscopic slide and at once be
put into the fixative ethyl alcohol before drying.
After fixing for about 30 minutes ,the slide is
taken out, air dried and sent to the laboratory.

86. INTERPRETATIONS
• Morphological abnormalities of the nucleus
(Dyskaryosis).
• Disproportionate nuclear enlargement.
• Irregularity of the nuclear outline.
• Abnormalities of nucleus in number, size & shape.
• Hyper chromasia.
• Condensation of chromatin material.
• Multi nucleation.

87. INTERPRETATIONS - Normal cells
1.Basal cells-small,rounded basophilic with large
nuclei
2.Squamous cells from middle layer –
transparent and basophilic with vesicular nuclei
3.Cells from superficial layer-acidophilic with
characterestic pyknotic nuclei
4.Endometrial cells,histiocytes,blood cells and
bacteria

88. ABNORMAL CELLS
1. Mild dyskaryosis
• Superficial/intermediate squamous cells
• Angular borders,
• Transluscent cytoplasm
• Nucleus < half of area of cytoplasm
• Binucleation is common
• CIN-I

89. 2.Moderate dyskaryosis-CIN II
• Intermediate/parabasal/superficial squamous
cell type
• More disproportionate nuclear enlargement and
hyper chromasia
• Nucleus-1/2-2/3 of total cytoplasm area

90. 3.SEVERE DYSKARYOSIS-CIN III
• 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
• Fibre cells- severely dyskaryotic, elongated cell
• Tadpole cell- severely dyskaryotic cell with an elongated
tail of cytoplasm.

91. 4.Carcinoma in situ
• Parabasal cells
with increased
nucleo-
cytoplasmic ratio
• Cytoplasm scanty
• Nucleus-irregular,
sometimes
multiple
• Chromatin
pattern-granular

92. 5.Invasive
carcinoma
• Cells-
single/clusters
• Tadpole cells
• Irregular nuclei
• Coarse clumping
of chromatin

93. • Abnormal cells are:
• Mild dyskaryosis – cells are of superficial or
intermediate type squamous cells. Cells have
angular bodies with translucent cytoplasm.The
nucleus occupies less than half of the total area
of the cytoplasm.
• Moderate dyskaryosis – The cells are of
intermediate parabasal or superficial type
squamous cells.Cells have more
disproportionate nuclear enlargement and
hyperchromasia. The nucleus occupies one half
to two –thirds of the total area of the cytoplasm

94. • Severe dyskaryosis – Cells are of basal type,
looking round, oval, polygonal or elongated
in shape. The nucleus is irregular with coarse
chromatin patterns. The cells may be
different in size and shape.
• Koilocytosis – It is the nuclear abnormalities
associated with human papiloma virus
infection. The nucleus is irregularly enlarged
and shows hyperchromasia with multi
nucleation.

95. Koilocytosis

96. • Carcinoma in situ – Cells are parabasal
type with increased nuclear cyttoplasmic
ratio. The nucleus may be irregular
sometimes multiple and the cytoplasm is
scanty.
• Invasive carcinoma – Cells are single or
grouped in clusters. The cells show
irregular nuclei and clumping of nuclear
chromatin which is also coarse. Large
tadpole cells are seen.

97. CYTO HORMONAL EVALUATION
• Exfoliative cytology
• Non invasive study of epithelium for
hormonal status
• Principle-The 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.

98. 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-intermediate and navicular cells
• Post-menopausal smear- parabasal and basal
cells

99. EXAMINATION OF CERVICAL MUCOUS
Indications
• Bacteriological study
• Hormonal status
• Infertility investigation

100. Bacteriological study
• Cusco’s bivalve speculum is introduced
without lubricant.
• With the help of a sterile cotton swab ,the
cervical canal is swabbed.
• The material is either sent for a culture or
spread over a microscopic slide for gram
staining.

101. Hormonal status
• The physical, chemical and cellular
components of the cervical secretions are
dependent on hormones – oestrogen and
progesterone.
• The influence of the hormones on the
cervical mucous is utilized in detection of
ovulation in clinical practice. The pH around
the time of ovulation is about 6.8 – 7.4.

102. • Spinnbarkeit (stretchability or elasticity)
During the midcycle, the cervical secretion is collected
with a pipette and placed over a glass slide. Another
glass slide is placed over it. Because of increased
elasticity due to high oestrogen level during this
period, the mucus placed between the slides can
withstand stretching upto a distance of over 10 c.m.
• After ovulation ,when corpus luteum forms,
progesterone is secreted. Under its action, the cervical
mucus loses its property of elasticity and the mucus
fractures if the same is attempted. This loss of elasticity
after its presence in the midcycle is the indirect
evidence of ovulation.

103. • Fern test – During the mid cycle , the cervical
mucus is obtained by a platinum loop or pipette
and spread on a clean glass slide and dried. When
seen under low power microscope it shows
characteristic pattern of fern formation due to
high estrogen in the midmenstrual phase prior to
ovulation.
• After ovulation with increasing progesterone, the
ferning disappears completely after 21st day. Thus
the presence of ferning even after 21st day
suggests anovulation and its disappearance is
presumptive evidence of ovulation.

104. Infertility investigations
• Postcoital test (PCT)
• The patient should report to the clinic preferably
within 8-12 hours following intercourse.
• The cervix is exposed with a cusco’s speculum.
Using a polythelene catheter attached to syringe.
• The endocervical mucus is collected and placed
over a warm glass slide and is examined
microscopically.
• Presence of atleast 10 progressively motile
sperms signifies the test to be normal.

105. COLPOSCOPY
• The instrument was devised by Hinselmann in
1925. This instrument is designed to magnify
the surface epithelium of the vaginal part of
the cervix including entire transformation
zone.
Procedure
• The client is placed in lithotomy position.
• Cervix can be cleared with help of normal
saline.
• High magnification used.

106. COLPOSCOPY

107. • Cervix is visualized by using a cusco’s speculum
• Colscopic examination of the cervix and vagina is
done using low power magnification. Cervix is
then cleared of using a swab soaked with normal
saline. Green filter and high magnification are
used.
• Cervix is wiped with 3% acetic acid and
examination is repeated. Acetic acid causes
coagulation of nuclear protein and it prevents
the transmission of light through the epithelium
which is visible as white areas.

108. INDICATIONS
• Women with abnormal smears.
• Women with clinically suspicious cervices,
specially with history of contact bleeding
despite the presence of negative smear.

109. IMAGING TECHNIQUES IN GYNAECOLOGY
• X- ray
• Ultrasound
• CT scan
• MRI
• PET

110. X- ray
• A chest X-ray and intravenous urogram are
essential for investigation in pelvic malignancy.
Plain X-ray of the pelvis is helpful to locate an
IUCD or to look for shadows of teeth or bone in
benign cystic teratoma. Special X-ray using
contrast media are;
• Hysterosalpingogram
• Lymhangiography
• Pelvic neumography

111. IMAGING TECHNIQUES-Overview
1.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

112. ULTRASOUND
• Sonography is used widely in gynaecology
either with the transabdominal or with the
transvaginal probe.
• Transabdominal sonography (TAS), is done
with a linear or curvilinear array transducer
operating at 2.5 – 3.5 MHz. It is best used for
large masses like fibroid or ovarian tumour.

113. 2.ULTRASONOGRAPHY
• Simple,non invasive,painless,safe procedure
• Pelvis and lower abdomen scanned longitudinally and
transversely
• D3 ultrasound-3-D images of pelvic organs
Transabdominal sonography(TAS)-
• Done with transducer operating at 2.5-3.5Mhz
• Bladder full
• Large masses examination –ovarian tumour/fibroid

114. • Transvaginal sonography (TVS)
• It is done with a probe which is placed close to
the target organ and operates at a high
frequency, thus detailed evaluation of pelvic
organs is possible.
• Transvaginal Colour Doppler Sonography
• This provides additional information of blood
flow to ,from or within an organ.

115. 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 vagina
Transvaginal colour doppler sonography
• Information regarding blood flow to & from or
within the uterus or adnexa can be obtained.

116. Computed Tomography
• Supplements information from USG.
• Whole abdomen and pelvis visualized in one sitting
after taking 600-800ml of a dilute contrast medium 1
hour prior to procedure
• Patient is scanned in supine position.
• Accurate in assessing local tumour invasion and
enables accurate localisation in biopsy.
• Diagnose, pelvic vein thrombophlebitis, intraabdominal
abscess and other extra genital abnormalities.
• Metastatic implants and lymphnodes < 1 cm—not
detected.
• Contraindicated in pregnancy.

117. 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-
treatment fibrosis or tumour

118. Positron Emission Tomography(PET)
• To differentiate normal tissue from cancerous
one, based on the uptake of 18F-FLURO-
2DEOXYGLUCOSE
Endometrial Sampling
• The endometrial sampling is one of the
diagnostic tests employed in the clinical
workup of women with infertility or abnormal
uterine bleeding. The instrument commonly
used is either a Vabra Aspirator or a Sharman
Curette .

119. • A thin plastic cannula with aplunger within ,is
negotiated within the uterus. When the
plunger is withdrawn ,adequate endometrium
is obtained due to suction action
• This procedure is used to study hormonal
effect whereas, in endometrial tuberculosis or
post menopausal bleeding endometrial
curettage is done under local anaesthesia.

120. ENDOMETRIAL BIOPSY
• The most reliable method to study the
endometrium is by obtaining the material by
curettage after dilatation of the cervix usually
under general anaesthesia

123. TUBAL PATENCY TEST
• Dilatation and insufflations
• Hystero salpingography
• Laparoscopy
• Sono hystero salpingography
• Fallopscopy
• Salpingoscopy

124. TEST FOR TUBAL PATENCY

125. • Dilatation and insufflations
• It is an operative procedure of dilation of the
cervix and introduction of air (or) co2 in to the
uterine cavity to know the patency of the
fallopian tube

126. DILATATION AND INSUFFLATION

127. Principle
• The cervical canal is in continuity with the
peritoneal cavity through the tubes. As such,
entry of air or CO2 into the peritoneal cavity
when pushed trans cervically under pressure
give evidence of tubal patency.
WHEN TO BE DONE
• After menstrual phase at least 2 days after
stoppage of menstrual bleeding

128. INDICATIONS
• To know the tubal patency
• Investigation for infertility
• Following tuboplasty operation
CONTRAINDICATIONS
• Presence of pelvic inflammation

129. HYSTERO SALPINGOGRAPHY
DEFINITION
• Its an operative procedure used to assess the
interior anatomy of the uterus and tube
including tubal patency,
• It is a radiographic study in which contrast
media is used.

130. INDICATIONS
• To note the tubal patency
• To detect uterine malformation
• To diagnose cervical incompetency
• To identify trans located IUD
• To confirm the secondary abdominal
pregnancy

131. PROCEDURE
• It should be done under local anesthesia in radiologic
department
• All preliminaries should be followed before the procedure
• Internal examination done
• Posterior vaginal speculum is introduced the visualize the
cervix
• Hystero salpingo graphic cannula is fitted with a syringe
containing radio-opaque dye injected in the uterine cavity
then fallopian tube.
• The dye is introduced slowly about 5-10ml of solution is
introduced.
• The passage of the dye into the interior may be observed
by using X-ray image transfer and a Videos Display Unit.

132. LAPARAOSCOPY
DEFINITION
• Laparascopy is a technique of visualization of
peritoneal cavity by means of a fiber optic
endoscope introduced into the abdominal
wall.

133. INDICATIONS
Diagnostic Laparoscopy:
• 1.Infertility work up- Ovulation study
-Tubal patency
-Endometriosis
- Pelvic adhesions
• 2.Acute pelvic lesion -Acute ectopic
-Acute Appendicitis
-Acute Salpingitis
3.Pelvic mass-Fibroid
-Ovarian Cyst

134. 4.Follow up of pelvic surgery
-Tuboplasty
-Ovarian malignancy
-Evaluation of endometriosis Rx
5.Suspected Mullerian abnormalitis
6.Suspected Uterine perforation
7.To take biopsy

135. • Therapeutic Laparoscopy
• Adhesiolysis
• -Aspiration of ovarian cyst
• -Ovarian drilling
• -Ovarian cystectomy
• -Ectopic pregnancy
• -Tubal sterilization
• -Endometriosis(Laser or thermal ablation)
• -Myomectomy
• -LAVH

136. Contraindications
• Severe cardiopulmonary diseases
• Generalized peritonitis
• Intestinal obstruction
• Significant hemo peritoneum
• Extensive peritoneal adhesions
• Large pelvic tumour
• Obesity
• Pregnancy >16 wks

137. PROCEDURE
• Laparoscopy is usually performed on an outpatient basis
under general anesthesia.
• After the patient is under anesthesia, a needle is inserted
through the navel and the abdomen is filled with carbon
dioxide gas.
• The gas pushes the abdominal wall away from the internal
organs so that the laparoscope can be placed safely into the
abdominal cavity and decrease the risk of injury to
surrounding organs such as the bowel, bladder and blood
vessels.
• The laparoscope is then inserted through an incision in the
navel. Or alternate sites based upon physician experience
or the patient’s prior surgical or medical history.
• While looking through the laparoscope, the physician can
see the reproductive organs including the uterus, fallopian
tubes, and ovaries.

138. • A small probe is usually inserted through
another incision above the pubic region in
order to move the pelvic organs into clear
view.
• Additionally, a solution containing blue dye is
often injected through the cervix, uterus, and
fallopian tubes to determine if the tubes are
open.
• If no abnormalities are noted at this time, one
or two stitches close the incisions. If
abnormalities are discovered, diagnostic
laparoscopy can become operative
laparoscopy.

139. SONO HYSTERO SALPINGOGRAPHY
• Advantages
• Its non invasive procedure
• It can detect uterine malformation
• There is no radiation exposure

140. Sonohysterosalpingography

141. FALLOSCOPY
• This is to study the entire length of tubal
lumen with the help of a fine and flexible
fibro-optic device.
• It is performed through the uterine cavity
using a hysteroscope.
• It helps direct visualization of tubal ostia,
mucosal pattern, intra tubal polyps or debris.

142. SALPHINGOSCOPY
• This is used to study the tubal lumen by
introducing a rigid endoscope through the
fimbrial end of the tube.
• It is performed through the operating channel
of a laproscope.

143. CERVICAL BIOPSY
TYPES
• Surface biopsy
• Punch biopsy
• Wedge biopsy
• Ring biopsy
• Cone biopsy

144. CERVICAL BIOPSY
• Confirmatory diagnosis of cervical pathology
• Done at OP if pathology detectable
• Wider tissue excision as in cone biopsy – IP
procedure

145. INDICATIONS
• Diagnostic and therapeutic purpose
• Identification of extent of the lesion
• Unsatisfactory coloposcopic findings
• Cytology and directed biopsy

146. PROCEDURE
• The procedure is usually performed by
conventional knife.
• The operation can be done under local
anesthesia.
• Blood loss is minimized with prior hemostatic
sutures.
• The cone is cut from the apex of the internal os.
• After that the margin suture is placed at
12”0”clock direction.
• Then send to the laborartory

147. COMPLICATIONS
• Secondary haemorrhage
• Cervical stenosis
• Infertility
• Diminished cervical smear
• Mid trimester abortion

148. • CULDOCENTESIS
• It is the trans vaginal aspiration of periotoneal fluid
from the posterior cul-de-sac (or) pouch of Douglas.
Two small pouches called cul-de-sacs (French, literally
‘bottom of a sack)’ are located on either side of the
uterus.
INDICATIONS
• Ectopic pregnancy
• Pelvic abscess

150. • PROCEDURE
• It should be done under local anesthesia
• Lithotomy position
• Vagina is cleaned with betadine
• Vaginal speculam inserted
• 18G needle is inserted in to the cervico vaginal
route
• After inserting, on withdrawal, if unclotted blood
comes it is from intra peritoneal cavity.
• If it is fluid means we can withdraw with help of
suction catheter.

151. ENDOSCOPY IN GYNAECOLOGY
• Laparoscopy
• Hysteroscopy
• Salpingoscopy
• Cyctoscopy
• Sigmoidoscopy & proctoscopy

152. DIAGNOSTIC ENDOSCOPY-Overview
• To visualize body cavity
Lapraroscopy-
• 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

153. LAPAROSCOPY
Indications
• Abnormal HSG findings
• Failure to conceive after reasonable period
• Unexplained infertility
• Women who have endometriosis

154. HYSTEROSCOPY
• Hysteroscopy is an operative procedure whereby
the endometrial cavity can be visualised with the
aid of fibre optic telescope.
• The uterine distension is achieved by co2, normal
saline, or glycerin.
• The instrument is to pass transcervically, usually
without dilatation of the cervix or local anaesthetic.
• However, for operative hysteroscopy, either
paracervical block or GA is required.
• Diagnostic hysteroscopy should be performed in
the postmenstrual period for better view without
bleeding.

155. Hysteroscopy cont.,
INDICATIONS
• Diagnostic
• Abnormal uterine bleeding
• Infertility
• Recurrent miscarriage
• Misplaced IUD
• Chronic pelvic pain

156. HYSTEROSCOPY

157. Hysterocsopy indications cont.,
Therapeutic
• Polypectomy
• Endometrial resection
• Metroplasty
• Tubal cannulation
• Sterilization

158. COMPLICATIONS OF HYSTEROSCOPY
• Uterine perforation
• Peritonitis
• Cervical laceration
• Intrauterine infection

159. SALPHINGOSCOPY
• In salpingoscopy, a firm telescope is
inserted through the abdominal ostium of
the uterine tube to visualize the tubal
mucosa by distending the lumen with
saline infusion. The telescope is to be
introduced through the laproscope.
• Salphingoscopy allows study of physiology
and anatomy of tubal epithelium and
permits more accurate selection of patients
for IVF rather than the tubal surgery.

160. CYSTOSCOPY
• DEFINITION
• Cystoscopy (cysto urethroscopy) is
a diagnostic procedure that uses
a cystoscope, which is an endoscope
especially designed for urological use to
examine the bladder, lower urinary tract,
and prostate gland.
• It can also be used to collect urine
samples, perform biopsies, and remove
small stones

161. USES OF CYSTOSCOPY
• Cervical cancer prior to staging
• Blood in the urine (hematuria)
• Inability to control urination (incontinence)
• Urinary tract infection
• Signs of congenital abnormalities in the
urinary tract
• Suspected tumors in the bladder
• Bladder or kidney stones
• Signs or symptoms of an enlarged prostate
• Pain or difficulty urinating (dysuria)
• Disorders of or injuries to the urinary tract
• Symptoms of interstitial cystitis

162. FALLOPOSCOPY
• It is to study the entire length of tubal
lumen with the help of a fine and flexible
fiberoptic device.
• It is performed through the uterine cavity,
using a hysteroscope.
• It helps direct visualization of tubal ostia,
mucosal pattern, intratubal polyps, or
debris.

163. CULDOSCOPY
• It is a medical diagnostic procedure performed
to examine the rectouterine pouch and pelvic
viscera by the introduction of a culdoscope
through the posterior vaginal wall. The word
culdoscopy (and culdoscope) is derived from
the phrase cul-de-sac, which means literally
in French"bottom of a sac".
• More accurately, the name hints to a blind
pouch or cavity in the female body that is
closed at one end and, in a more specific sense,
refers to the rectouterine pouch (or called
the pouch of Douglas).

164. Culdoscopy cont.,
• Culdoscopy is an important gynecological
diagnostic technique, is gaining wide
acceptance.
• Under local anesthesia, insert a small
illuminated telescope through which one may
inspect the pelvic organs, without having to
resort to a major abdominal operation.
• Conditions diagnosable by culdoscopy
include tubal adhesions (causing
sterility), ectopic pregnancy, salpingitis, and
appendicitis.

165. Culdoscopy cont.,
• "A major advantage of a culdoscopy is that
there are no abdominal incisions.
• Culdoscopy tends to be reserved for obese
patients or in retroverted uterus.
• This transvaginal procedure involves a
small incision made into vaginal wall &
shows that this method is safer.
• Yet, a culdoscopy may be difficult to
perform because it requires a woman to be
in a knee-to-chest position while under
local anesthesia.

166. Culdoscopy cont.,
• A culdoscopy takes about 15 to 30
minutes, and women can go home the
same day.
• It may take a few days at home to
recover.
• Sexual intercourse is usually postponed
until the incision is completely healed,
(requires several weeks), and there are no
visible scars.

167. PROCTOSCOPYAND
SIGMOIDOSCOPY
• For rectal involvement of genital
malignancy, a digital examination or
proctoscopy is usually adequate.
• Proctoscopy is a common medical
procedure in which an instrument called a
proctoscope (also known as a rectoscope,
although the latter may be a bit longer) is
used to examine the anal
cavity, rectum or sigmoid colon.

168. Proctoscopy cont.,
• A proctoscope is a short, straight, rigid,
hollow metal tube, and usually has a small
light bulb mounted at the end.
• It is approximately 5 inches or 15 cm long,
while a rectoscope is approximately
10 inches or 25 cm long.
• During proctoscopy, the proctoscope is
lubricated and inserted into the rectum, and
then the obturator is removed, allowing an
unobstructed view of the interior of the
rectal cavity.

169. PROCTOSCOPE CONT.,
• This procedure is normally done to
inspect for hemorrhoids or
rectal polyps and might be mildly
uncomfortable as the proctoscope is
inserted further into the rectum.
• Modern fibre-optic proctoscopes allow
more extensive observation with less
discomfort.

170. SIGMOIDOSCOPY
• Sigmoidoscopy (from Greek Sigma -
eidos - scopy, to look inside an s-like
object) is the minimally
invasive medical examination of the
largeintestine from the rectum through the
last part of the colon.
• There are two types of
sigmoidoscopy: flexible sigmoidoscopy,
which uses a flexibleendoscope, and rigid
sigmoidoscopy, which uses a rigid
device.

171. Sigmoidoscopy cont.,
• Flexible sigmoidoscopy is generally the
preferred procedure.
• A sigmoidoscopy is similar to, but not
the same as, a colonoscopy.
• A sigmoidoscopy only examines up to
the sigmoid, the most distal part of the
colon, while colonoscopy examines the
whole large bowel.

172.  SUMMARY ANDCONCLUSION
ASSIGNMENT
THEORY APPLICATION