obgyne notes (1)-1.pptx

Outline
 Definition
 Counseling by REDI frame work
 Types of family planning
 Advantages and dis advantages of each methods of FP
 Indication and CI of each methods
 Summary
9/25/2023 2

Objectives
 At the end of this session the learners will be able to:
 Define family planning
 Explain REDI frame work
 Describe the types of family planning
 Differentiate advantages and dis advantages of each methods of FP
 Identify indication and CI of each methods
 Discuss MEC
9/25/2023 3

Brain storming
What is family planning?
9/25/2023 4

Family planning
 Family planning: allows couples to anticipate and attain their desired
number of children and the spacing and timing of their births.
 Contraception refers to all measures temporary or permanent designed to
prevent pregnancy.
 It is achieved through the use of contraceptive methods.
9/25/2023 5

Ideal contraceptive method:
 Widely acceptable
 Inexpensive
 Simple to use
 Safe
 Highly effective
9/25/2023 6

 Counselling in FP (REDI framework)
REDI stands for:
 Rapport Building: establish a harmonious relationship
Exploring:
Decision Making and
Implementing the Decision
9/25/2023 7

 Rapport Building:
 Establish a harmonious relationship
 Explore:
 The Client’s Sexual and RH history, sexual Relationships, pregnancy, HIV,
and other STIs.
9/25/2023 8

 Decision Making
 Review decisions the client needs to make or confirm
 Confirm medical eligibility for methods client is considering
 Help the client consider the benefits and disadvantages of each option
 Confirm that any decision is informed, well-considered, and voluntary
9/25/2023 9

 Implementing the Decision
 Assist the client to make a concrete and specific plan to implement the
decision
 Make a follow-up plan
9/25/2023 10

Types of Family planning Methods
I. Natural family planning methods
II. Barrier Methods of family planning
III. Hormonal Methods of family planning
IV. Long acting family planning methods
V. Emergency contraceptives
VI. Permanent Methods of family planning
9/25/2023 11

Types of FP
I. Natural family planning method: is a method that teaches at what time
during menstrual cycle couples can have intercourse without using other
methods of contraception with a reduced risk of pregnancy
1. Fertility awareness Based method
2. with drawl method
3. Lactational amenorrhea method (LAM)
9/25/2023 12

1. Fertility-Awareness Based Method
 It involves identification of the fertile days of each cycle and
 Abstinence or use a barrier method during these days.
 Effectiveness depends on the user has 15% pregnancy rate.
 No side effects or health risks.
9/25/2023 13

 Fertility Awareness methods include:
a. Calendar-based methods
 Standard Days Method
 Calendar Rhythm Method
b. Symptom based methods
 BBT Method
 Cervical Mucus / Ovulation Method
 Sympto-thermal Method
9/25/2023 14

Standard Days Method
 Counting the first day of monthly bleeding as day 1
 Days 8 - 19 of every cycle are considered fertile so avoid unprotected
intercourse.
 For successful use Women must have regular monthly cycles of 26 to 32
days.
 Those who use this method can Mark a calendar
9/25/2023 15

Calendar Rhythm Method
 Before relying on this method, a woman records the number of days in each
menstrual cycle for at least 6 months.
 The woman subtracts 18 from the shortest cycle.
 This tells her the estimated first day of her fertile time.
 Then she subtracts 11 days from the longest cycle.
 This tells her the estimated last day of her fertile time
9/25/2023 16

 Fertile period = (shortest cycle – 18 ( 1st day) to longest -11 ( last day)
E. g if the shortest cycle is 26 & longest is 32
Fertile period= 26-18 ( first day ) to 32 -11(last day
day 8 to 21 are fertile days.
 She updates these calculations each month, always using the 6 most
recent cycles.
9/25/2023 17

Basal Body Temperature (BBT) Method
 The woman takes her body temperature at Same time each morning before
she gets out of bed and before she eats anything.
 She records her temperature and watches for her temperature to rise
slightly 0.2°C to 0.5°C (0.4°F)just after ovulation
 The couple avoids unprotected intercourse from 1st day of menstruation
until 3 days after temperature rise above her regular temperature.
 The elevation in the temperature is as a result of hormonal changes that
result in ovulation.
9/25/2023 18

Cervical mucus/Ovulation Method
 The method relies on the woman’s ability to predict her fertile days by
following the characteristics of cervical mucus.
 Between the end of monthly bleeding and the start of secretions, the couple
can have unprotected sex
 Around the time of ovulation cervical mucus becomes profuse, thin
transparent, watery, and slippery
 Avoid unprotected sex when cervical secretions begin to appear and until 4
days after the ‘peak mucus day’.
9/25/2023 20

Symptothermal Method
 It combines
BBT + cervical secretions + other fertility signs
 The couple avoids unprotected sex between the first day of monthly
bleeding and either the fourth day after peak cervical secretions or the
third full day after the rise in temperature (BBT), which ever happens
later.
9/25/2023 21

2. with drawl methods (coitus interruptus)
 It is to take the penis out of the vagina and ejaculate outside the vagina.
 The goal is to keep sperm from entering the vagina.
 Is one of the least effective methods
 about 27 pregnancies per 100 women per year.
 It doesn't protect from STI
9/25/2023 22

3.Breast feeding (LAM)
 It requires 3 conditions. All 3must be met:
1. The mother’s monthly bleeding has not returned
2. The baby is fully breastfed and is fed often, day & night
3. The baby is less than 6 months old
 Works primarily by preventing the release of eggs from the ovaries
(ovulation).
 Does not provide protection against STIs.
9/25/2023 23

II. Barrier Methods of family planning
 Male Condoms
 Female Condoms
 Condoms are the only contraceptive method that can protect against both
pregnancy and STIs that spread by discharge, such as HIV and STI which
spread by skin-to-skin contact, such as herpes &HPV.
9/25/2023 24

 Advantages of condoms
 Provides dual protection against STIs and unwanted pregnancy
 Have no hormonal side effects.
 Can be used as a temporary or backup method.
 Can be used without seeing a health care provider.
 Available in health facilities, over the counter and in shops
9/25/2023 25

III. Hormonal methods
i. Oral contraceptives
ii. Injectable
Further oral contraceptives can be divided in to two:
 Progestin only pills and
 COC
9/25/2023 26

i. Progestin only pills
 Also called mini pill
 Contains very low doses of progestin
 Characteristics:
 Contains no estrogen
 Doesn't affect breast feeding
 May cause irregular uterine bleeding
9/25/2023 27

 POP-mechanism of action
 Thickening of cervical mucus
 Atrophic endometrium
 Ovulation inhibition in 2 % of cases
9/25/2023 28

ii. Combined oral contraceptive (COC) Pills
 Pills that contain low doses of two hormones-a progestin and an
estrogen.
 Work primarily by preventing the release of eggs from the ovaries.
 Mechanism of action
 Inhibition of ovulation by Suppressing hormones responsible for
ovulation
 Thickens cervical mucus to block sperm
9/25/2023 29

COCs: Characteristics
 Safe and more than 99% effective if
used correctly
 Can be stopped at any time
 No delay in return to fertility
 Do not interfere with intercourse
 Have health benefits
 Less effective when not used
correctly (91%)
 Require taking a pill every day
 Do not provide protection from
STIs/HIV
 Have side effects
 Have some health risks (rare)
9/25/2023 30

Contraindications to COC
 Previous thrombo-embolic event or stroke
 History of an estrogen-dependent tumor
 Active liver disease
 Pregnancy
 Undiagnosed abnormal uterine bleeding
 Cerebral vascular or coronary artery disease
 Women over age 35 years who smoke
9/25/2023 31

Adverse effects of COC
1) Minor complications
 Nausea, vomiting & headache (E) & leg cramps (P)
 Weight gain
 Cholasma & acne
 Menstrual abnormalities: amenorrhea, hypo menorrhea & breakthrough
bleeding
 Libido: may be decreased due to progesterone
9/25/2023 32

2) Major complications:
 Depression
 Hypertension (E): less than one percent
 Vascular complications: venous thromboembolism is
 Neoplasia: cervical cancer, breast cancer &hepatocellular adenoma
 Ovulation returns in three months after withdrawal in 90% of cases
 Lactation: reduction in milk production &quality of milk
9/25/2023 33

Injectable
 Progesterone only
 Depo-Provera/ Medroxy progesterone acetate
 150 mg IM every 3 months.
 It is most effective contraceptive method with failure rate of 0.3%
 Mechanism of action: Similar to COCs
 Inhibition of ovulation-suppressing mid cycle LH surge
 Thickening of cervical mucus
9/25/2023 34

Advantages of injectable
 Avoids regular medication
 Can be used in lactation
 Protective against endometrial cancer
 Reduction in PID, Ectopic, endometriosis & ovarian cancer
9/25/2023 35

Drawbacks of injectable
 Return of fertility is usually delayed (4 -24 months)
 May cause irregular uterine bleeding
 May cause amenorrhea
 Delay in fertility after discontinuation
 Need for injection
 May cause weight change, headache, dizziness and fatigue
9/25/2023 36

IV Long acting family planning methods
 Implants
 IUCD
9/25/2023 37

Implants
 Implants are matchstick sized flexible progestin-filled rods that are
placed just under the skin of the upper arm.
 Many types of implants:
 Norplant: 6 capsules, labeled for 5 years of use
 Jadelle: 2 rods, lasts 5 years
 Implanon: 1 implant rod with 60 mg etonogestrel, lasts 3 years
 Sinoplant: 2 rods, lasts 4 years
9/25/2023 38

 Mechanism of Action
 Inhibition of ovulation
 Increases cervical mucus viscosity
 Alters endometrium making it less conducive for implantation
9/25/2023 39

 Advantages of implants
 Highly effective
 Can be used during lactation
 Stable hormone levels
 Extended protection
 Contain no estrogen
 No delay in return of fertility after removal
9/25/2023 40

 Limitations of Implants
 Can cause irregular bleeding
 Requires clinician visits for insertion and removal
 Does not protect from STDs
9/25/2023 41

Pre-insertion Counseling for Implanon
 In a private setting, provide information on:-
 How it works
 Its effectiveness
 How it is inserted
 Common side effects
 When to return, Care of the site and
 Answer any questions that the client may have
9/25/2023 42

 Equipment's needed for Implanon insertion
 An examination table for the woman to lie on
 Sterile surgical drapes, sterile gloves, antiseptic solution, permanent
marker
 Local anesthetic, needles, and syringe
 Sterile gauze, adhesive bandage, pressure bandage
9/25/2023 43

Implanon® insertion procedures
 Step (1): Ask the woman to lie on her back on the examination table with
her non-dominant arm flexed at the elbow and externally rotated so that
her wrist is parallel to her ear or her hand is positioned next to her head
 Step (2): Identify the insertion site, the inner side of the non-dominant
upper arm about 8-10 cm above the medial epicondyle of the humerus
9/25/2023 44

Step (3): Make two marks with a permanent marker:
first, mark the spot where the etonogestrel implant will be inserted, and
second, mark a spot a few centimeters proximal to the first mark.This second
mark will later serve as a direction guide during insertion.
(4) Step (4): Clean the insertion site with an antiseptic solution.
Step (5): Anesthetize the insertion area injecting 2 ml of 1% lidocaine just under
the skin
Step (6): Remove the sterile pre-loaded disposable Implanon NXT applicator
carrying the implant from its blister.
9/25/2023 45

Step (7): Hold the applicator just above the needle, at the textured surface area.
Step (8): With your free hand, stretch the skin around the insertion site with
thumb and index finger
Step (9): Puncture the skin with the tip of the needle angled about 30°
Step (10): Lower the applicator to a horizontal position. While lifting the skin
with the tip of the needle slide the needle to its full length.
9/25/2023 46

 Step (11): Keep the applicator in the same position with the needle inserted to
its full length.
 Unlock the purple slider by pushing it slightly down.
 Move the slider fully back until it stops
 The implant is now in its final sub dermal position, and the needle is locked
inside the body of the applicator.
 Step (12): Always verify the presence of the implant in the woman’s arm
immediately after insertion by palpation.
 Step (13): Place a small adhesive waterproof bandage over the insertion site.
9/25/2023 47

 Step (14): Apply a pressure bandage with sterile gauze to minimize
bruising.
 Step (15): Complete the USER CARD and give it to the woman to keep.
Also, complete the patient chart label and affix it to the woman's medical
record.
 Step(16): dispose The applicator
9/25/2023 48

• Removal Of Implanon
• A. Preparation: equipment's needed for removal
• An examination table for the woman to lie on
• Sterile surgical drapes, sterile gloves, antiseptic solution
• Local anesthetic, needles, and syringe
• Sterile scalpel,
• forceps (straight and curved mosquito)
• sterile gauze, an adhesive bandage, and pressure bandages.
9/25/2023 49

 Removal Procedure
 Step (1): Clean the site with antiseptic.
 Locate the implant by palpation and mark the distal end (end closest to the
elbow)
 Step (2): Anesthetize the arm, 1 ml 1% lidocaine at the marked site where
the incision will be made
 Step (3): Push down the proximal end of the implant to stabilize it; a bulge
may appear indicating the distal end of the implant.
 Starting at the distal tip of the implant, make a longitudinal incision of 2
9/25/2023 50

Step (4): Gently push the implant towards the incision until the tip is
visible. Grasp the implant with forceps (preferably curved mosquito
forceps) and gently remove the implant
Step (5): If the tip of the implant does not become visible in the incision,
gently insert a forceps into the incision Flip the forceps over into your other
hand
Step (6): If the implant is encapsulated, make an incision into the tissue
sheath and then remove the implant with the forceps
9/25/2023 51

Step (7): With a second pair of forceps carefully dissect the tissue around
the implant and grasp the implant and remove.
Step (8): Confirm that the entire implant, which is 4 cm long, has been
removed by measuring its length
Step (9): After removing the implant, close the incision with a Steri-strip
and apply an adhesive bandage
Step (10): Apply a pressure bandage with sterile gauze to minimize
bruising. The woman may remove the pressure bandage in 24 hours and the
small bandage in 3 to 5
9/25/2023 52

Copper Device (Paragard T 380a)
 The stem is 314 mm2 of fine copper wire, and the arms each have 33-mm2
copper bracelets, thus totaling 380 mm2 of copper.
 Two strings extend from the base of the stem.
 Effective for 12 years
 Less than 1 pregnancy per 100 women using an IUD over the first year.
9/25/2023 54

Mechanisms of Action of IUDS
 Intense local inflammatory response induced in the uterus leads to
inflammatory actions that are spermicidal
 Finally, the endometrium is transformed into a hostile site for implantation.
oPreventing fertilization by spermicidal action
ospeeding ovum transport through the fallopian tube or both.
9/25/2023 55

IUD-contraindications
 Presence of pelvic infection/puerperal sepsis
 undiagnosed uterine bleeding
 Suspected pregnancy
 Uterine prolapse
 Severe dysmenorrhea
 Endometrial or cervical cancer
 sexually transmitted diseases current or within the past 3 months
 Copper allergy
9/25/2023 56

Complications
 Immediate:
 Cramp like pain
 Syncopal attack at time of removal & insertion
 Partial or complete perforation
 Remote:
 Pain: usually in the first 3-6 months after insertion
 Abnormal menstrual bleeding: in the first 6 months
9/25/2023 57

 Pelvic infection:
 Spontaneous expulsion: it is about 5%.
 Perforation of the uterus
 Pregnancy
 Missing thread:
9/25/2023 58

Indications for removal of IUDs
 Persistent menstrual problems
 Perforation of the uterus
 Partial expulsion
 Pregnancy with IUD
 planning pregnancy
 Missing thread
 One year after menopause
 Effective life span is over
9/25/2023 59

Emergency contraception
 A type of contraception that is used as an emergency to prevent
unintended pregnancy following an unprotected sexual intercourse.
 Risk of pregnancy following unprotected intercourse around time of
ovulation is 8%
9/25/2023 60

 Indications:
 Unprotected intercourse
 Condom rupture
 Missed pill
 Sexual assault
9/25/2023 61

Types of EC
 Emergency contraceptive pills: Most effective if taken within 3 days
(or 72 hours)
 COC or
 POP
 Copper-releasing IUDs: can be used within 5 days of unprotected
intercourse as an EC
9/25/2023 62

 Mechanism of action
 Delay or inhibit ovulation
 Is the principal mechanism
 Prevent implantation
 Prevent transport of the sperm & ovum
9/25/2023 63

VI. Sterilization
 A surgical method where by the reproductive function of an individual male
or female is purposefully & permanently destroyed
 Couple need to be adequately informed before any permanent procedure
 Inform on individual procedure in terms of benefit, risks, side effects,
failure rate & reversibility
 Types
 Vasectomy in male
 Tubal ligation in female
9/25/2023 64

Vasectomy
 Segment of vas deferens of both sides are resected and cut ends are
ligated
 Advantages:
 Simple
 Out patient procedure
 Failure rate is low (0.15%)
 Minimal expenditures
9/25/2023 65

 Drawbacks:
 Additional contraceptive needed for the first 2-3 months
 Frigidity/impotence, most often psychological
 Candidates:
 Sexually active, psychological prepared & completed fertility
 No eczema or scabies around scrotal region
 Correct hernia &/or hydrocele before vasectomy
9/25/2023 66

Complications
 Immediate:
 Wound sepsis
 Scrotal hematoma
 Remote:
 Frigidity/impotence
 Sperm granuloma
 Spontaneous recanalization
9/25/2023 67

Female sterilization
 Occlusion of both fallopian tubes in some form
 Most popular method of terminal contraception world wide
 Indications:
 Family planning purposes
 Socioeconomic: after having the desired number of children
 Medico-surgical indications (therapeutic)
9/25/2023 68

Tubal ligation-complications
 Immediate: related to anesthesia & the procedure it self
 Remote:
 General: occasional obesity & psychological upset
 Gynecological: hypo menorrhea & pelvic pain
 Alteration in libido
9/25/2023 69

 Overall failure rate is 0.7%
 Mortality following tubal sterilization is 2 per100,000 procedures
 Chance of reversal is there
 Pregnancy after reversal is 80% as compared to vasectomy reversal (50%)
9/25/2023 70

Summary
 What is family planning?
 How can we counsel using REDI frame work?
 List the natural types of family planning methods?
 What are the Advantages and dis advantages of implanon?
9/25/2023 71

Reading assignment
 Spermicides
 Diaphragms and Cervical Caps
 Intrauterine device (hormonal type)
 Infection prevention in family planning
 Helping clients continue or switch methods.
 Misconception in FP and Reason for discontinuing contraceptives
 MEC
9/25/2023 72

Outline
 Overview of MTCT
 Guiding principles of PMTCT program
 Preventing MTCT during pregnancy, labour, delivery and postpartum
period
 Infant feeding options for infants born to HIV +ve mothers.
 Counselling (Pre & Post, treatment counselling)

Objectives
 At the end of this session the learners will be able to:
 Define Overview of MTCT
 Explain Guiding principles of PMTCT program
 Describe Obstetric measures preventing MTCT during pregnancy,
labour, delivery and postpartum period
 Differentiate Infant feeding options for infants born to HIV +ve mothers.
 Explain (Pre & Post, treatment counselling)

Brain storming
•What is PMTCT?

Overview of MTCT
 Mother to Child Transmission of HIV
 During pregnancy--- 5-10%
 During labor/delivery---10-20%
 During breastfeeding---5-20%
 Overall without breastfeeding---15-30%
 Overall with breast feeding for 6 month-25-35%
 Overall with breast feeding 18-24 month 30-45%

Goals of PMTCT programs
 An HIV-positive mother can pass HIV on to her baby any time during
pregnancy, labor, delivery and breastfeeding.
 so the transmission of the virus must be blocked at each stage

 PMTCT programs aim to:
 Reduce new pediatric HIV infections
 HIV care and support services for women and their families
 Provide opportunity for testing and passing HIV prevention messages to
women and their families

UNFPA 4 pronged approaches to PMTCT

 Prong 1: Primary Prevention of HIV infection
 Prong 2: Prevention of unintended pregnancies in HIV positive women
 Prong 3: Prevention of transmission from HIV positive women to their
infants During Pregnancy, labor and delivery and Postpartum.
 Prong 4: Treatment, care and support for HIV positive mothers, their exposed
infants, partners and family

Antenatal interventions to reduce MTCT
 HIV testing and counseling services
 Behavior change communication:
 Sexual
 Alcohol use and smoking
 Identification and treatment of STIs
 Prevention and treatment of anemia (balanced diet and nutritional
supplementation)

 Avoiding invasive testing procedures in pregnancy
 Amniocentesis
 Cordocentesis
 External cephalic version
ART:according to (option B+) :
 HAART to all HIV positive pregnant women identified irrespective of
their CD4 count During pregnancy

Intrapartum interventions to reduce MTCT
 Application of good infection prevention practices during pelvic
examinations and delivery
 Avoiding unnecessary artificial rupture of membranes
 Avoiding prolonged labour and prolonged rupture of membranes
 Avoid unnecessary trauma during delivery: Unnecessary episiotomy
 Forceps delivery
 Vacuum extraction

Vaginal versus Caesarean
Risk concern Vaginal Caesarean
Blood loss - Increased
Infection -
Increased in HIV+ women; antibiotic
prophylaxis recommended
MTCT
No evidence of increased
MTCT with ARV Rx and
adequate viral load
Reduces risk of MTCT if performed
before labor onset
Mortality - Increased
Resource issues -
Requires greater resources (supplies,

 Minimize risk of PPH (to protect mother’s health and decrease provider
exposure to blood)
 Active management of 3rd stage
 Repair any genital tract lacerations
 Make sure placenta is complete

 Postpartum interventions to reduce MTCT
 In addition to routine postpartum care that is offered to all mothers, HIV
positive postpartum women should receive:
 Antiretroviral treatment:
 If mother was identified as HIV-positive during labor and delivery, initiate her
on ART.
 If mother is on antiretroviral treatment, ensure she continues to take her
medications during labor and postpartum period and check for adherence

 Extra nutrition and micronutrient supplement:
 Continue iron and folate supplement for at least 6 weeks postpartum and
longer if indicated.
 Additional two varied meals per day are recommended and
 avoid malnutrition while breastfeeding

 Close monitoring for secondary postpartum hemorrhage
 Early recognition and treatment of infections( UTI, RTI, wound infection from
C/S, mastitis and breast abscess and
 Counseling regarding early initiation of FP within three to four weeks
 Reinforcement of safe sexual practice and need for dual protection
 Counseling about safe disposal of potentially infectious soiled sanitary pads

 Care of Infants born to HIV Positive Mothers
 Respect confidentiality of the mother and family
 Care for the newborn like any other newborn, but pay particular attention to
infection prevention procedures.
 Promote and support exclusive breastfeeding for the first six months
 Avoid mixed feeding (breast milk plus any other liquid, including water, or
food) during the first six months, that can increase risk of MTCT of HIV, and
increase risk of morbidity and mortality compared to exclusive breastfeeding

 Administer NVP once daily for six weeks for the newborn
 Collect specimen (DBS) for DNA PCR testing at 6 weeks of age
 Start co-trimoxazole prophylaxis for all HIV exposed infants from 4-6 weeks
of age and continue until HIV negative status is confirmed.
 Assess growth and development of baby

 Routine Newborn and Postnatal Care
 Handle newborn with gloves
 Clamp cord after birth, and avoid milking the cord.
 Cover cord with gloved hand or gauze before cutting to avoid splashing of
blood to the eyes
 Wipe infant’s mouth and nostrils with gauze when the head is delivered

 Keep baby warm (skin to skin contact with mother)
 Administer eye care with antibiotic (Tetracycline 1% eye ointment) as
soon as possible after birth
 Administer BCG and OPV vaccines
 Support initiation of breastfeeding within one hour of delivery

Feeding options for the HIV exposed infant
“A little bit of this and a little bit of
that is not best for the baby! ”
Exclusive
formula
Feeding
Exclusive
breast
Feeding

Breastfeeding
 Exclusive breastfeeding should be encouraged among all women regardless
of HIV status
 For HIV free survival, all women for whom replacement feeding is not
acceptable, feasible, affordable, sustainable and safe (AFASS) should be
encouraged to exclusively breastfeed their infant for six months
 A woman should be supported in her infant feeding decision; the choice is
hers

Reading assignments
 Monitoring and evaluation in HIV/AIDS
 National strategies and guidelines to address MTCT of HIV/AIDS

Summary
 Overview of MTCT
 Guiding principles of PMTCT program
 Preventing MTCT during pregnancy, labour, delivery and postpartum
period
 Infant feeding options for infants born to HIV +ve mothers.

Outline
• Definition of Terms
• Definition OF AUB
 Types of AUB
 Etiologies
 Diagnosis
 Management
9/25/2023 101

Normal Menstruation
 Characteristics
Normal Abnormal
Duration 4-6 days <2d, >7d
Volume 30-35ml >80cc
Cycle length 21-35d <21d ,>35
Average Iron loss: 16mg
9/25/2023 102

Definition of Terms
 Menorrhagia (hypermenorrhea): prolonged (>7 days) and/or excessive
(>80cc) uterine bleeding occurring at Regular intervals.
 Metorrhagia: uterine bleeding occurring at completely irregular but
frequent intervals, the amount being variable.
 Meno-metorrhagia: uterine bleeding that is prolonged AND occurs at
completely irregular intervals.
 Poly-menorrhea: uterine bleeding at regular intervals of less than 21 days.
9/25/2023 103

 Inter-menstrual bleeding: bleeding of variable amounts occurring between
regular menstrual periods.
 Oligo-menorrhea: uterine bleeding at regular intervals from 35 days to 6
months.
 Amenorrhea: absence of uterine bleeding for > 6 months.
 Post-menopausal bleeding: uterine bleeding that occurs more than 1 year
after the last menses in a woman with ovarian failure.
9/25/2023 104

 Precocious Menstruation: Denotes the occurrence of menstruation before
age of 10 years.
 Post coital bleeding: Denotes vaginal bleeding after sexual intercourse.
 Ovulatory bleeding : cyclic bleeding accompanied by cyclic signs of
ovulation
 An-ovulatory bleeding : unpredictable, non-cyclic bleeding of variable
flow and duration with absence of signs of ovulation.
9/25/2023 105

Abnormal uterine bleeding
9/25/2023 106

Objectives
At the end of this session the students will be able to:
 Define abnormal uterine bleeding
 List types of abnormal uterine bleeding
 Describe the etiology of abnormal uterine bleeding
 Describe diagnosis of abnormal uterine bleeding
 Describe management of abnormal uterine bleeding
9/25/2023 107

Abnormal uterine bleeding
 Change in frequency, duration and amount of menstrual bleeding
 Prolonged uterine bleeding >10days
 Frequency < than 3 weeks
 Inter-menstrual spotting or bleeding
 Post coital bleeding
9/25/2023 108

Causes:
 AUB is a symptom and not a disease.
 Early pregnancy complications (abortion, ectopic pregnancy, hydatidiform
mole)
 Pelvic inflammatory disease (PID)
 Benign tumors
 malignant tumors ( endometrial and cervical carcinoma)
 Dysfunctional uterine bleeding
9/25/2023 109

Diagnosis of AUB
 History : about the nature of bleeding (frequency, duration, volume,
relationship to activities such as coitus)
 Quantity: number of pads
 Inter-menstrual bleeding: structural lesion (endometrial polyp,,
cervical neoplasia)
 Menometrorrhagia – anovulatory bleeding
 Regular cyclic periods – ovulatory
 Anticoagulants – menorrhagia
 IUCD or OCP - intermenstrual bleeding
9/25/2023 110

Physical Examination
 Speculum examination
 Bleeding site: vulva, vagina, cervix, urethra, or anus
 Any suspicious findings (mass, laceration, discharge, foreign body)
 Assess the size, contour, and tenderness of the uterus
 Examine the adnexa for an ovarian tumor
 Evaluate for pain - infection
9/25/2023 111

Laboratory Evaluation
 Pregnancy test in all reproductive age women
 Intrauterine pregnancy
 Ectopic
 Gestational trophoblastic disease
 Any visible cervical lesion should be biopsied
 Endometrial biopsy - endometrial cancer
9/25/2023 112

Additional Lab. Evaluation
 Hemoglobin/hematocrit
 Coagulation tests :Platelet count – thrombocytopenea
 STD: Gonorrhea, Chlamydia, trichomonas
 Ultrasound :Fibroids, endometrial lining, ovaries
9/25/2023 113

Management
 Is bleeding ovulatory or an-ovulatory?
 Ovulatory: treat the underlying cause
 An-ovulatory: Acute management
 OCP
 D&C
9/25/2023 114

Dysfunctional uterine bleeding (DUB)
 It is an abnormal bleeding from the uterus in the absence of organic
disease of the genital tract.
 It is characterized by dysfunction of the uterus, ovary, pituitary,
hypothalamus or other part of reproductive system.
 the pattern of bleeding is mainly heavy & regular (menorrhagia) but it
could be irregular uterine bleeding or intermenstrual bleeding.
9/25/2023 115

Classification of DUB:
 Primary DUB: abnormal bleeding from the uterus where there is no disease
of the genital tract, no other disease responsible for the bleeding, no IUCD
and no history of sex hormone administration.
 Secondary DUB: Abnormal bleeding from the uterus secondary to:
1. IUCD
2. Administration of sex hormones.
3. organic disease outside the genital tract e.g. hypothyroidism, bleeding
disorders. 116

 Ovulatory DUB (heavy regular bleeding & painful):
 occurs after the adolescent years and before the peri-menopausal years.
 An ovulatory DUB (heavy irregular bleeding):
 The main cause of DUB is anovulation
 In pre-menarchal girls, FSH > LH and hormonal patterns are an ovulatory.
117

Diagnosis of DUB:
 History: Age of the patient, menstrual history, pattern and amount of
menstrual loss.
 Examination: abdominal and pelvic examination
 Ultrasound
 Hysteroscopy
 Endometrial biopsy (to exclude hyperplasia & carcinoma).
 Hormonal assays: progesterone, LH, FSH and thyroid function test.
 Blood tests: CBC, clotting screen 118

Management of DUB:
 Medical management:
1. Non-hormonal therapy
 NSAID: ovulatory DUB
 Anti-fibrinolytic drugs: to inhibit the increased plasminogen activators
2. Combined oral contraceptive pills
 low-dose estrogen-progestogen is used
 progestogen dominant pills is used in progesterone deficiency and estrogen
dominant pills are used in estrogen deficiency. 119

Medical management of DUB:
3. Progestogens: used in an-ovulatory cycles to reduce the blood
loss.
4. Levonogestrel-releasing IUCD: Induces endometrial atrophy with
reduction of blood loss.
5. Androgens and gonadotrophin releasing hormone (GnRH): used
when the above medical therapy has failed or surgery is
contraindicated.
120

Surgical management of DUB:
 Endometrial ablation (resection): removal of the endometrium
 If the medical management doesn’t help
 Hysterectomy: removal of the uterus
121

Outline
 Definition
 Pathogenesis
 Clinical manifestations
 Diagnosis
 Treatment

Definition
 PID is Infection & inflammation of the female upper genital tract
(internal genitalia above internal cervical os) involving any or all of the
uterus, fallopian tubes, & ovaries
 endometritis, salpingitis, oophoritis, tubo-ovarian abscess

Factors that potentially facilitate PID
 Previous episode of PID
 Bacterial vaginosis
 Intrauterine device

Pathogenesis
 Up to 75% of cases of PID occur within 7 days of menses due to loss of
endo-cervical barriers & poor quality of the cervical mucus
 Pregnancy is protective of PID because of the mucus plug & decidua seal off
the uterus from ascending bacteria.

 The 3 proposed pathways of spread of microorganisms in PID
1. Ascending infection :endometrial-endo-salpingeal-peritoneal
spread of microorganisms.
 It is the most common forms
 Pathogenic bacteria gain access to the lining of the uterine tubes
purulent inflammation & tubes  into the peritoneal cavity.
 E.g. endometritis, peritonitis

1. Ascending infection Endometrial Endo-salpingeal
Peritoneal Spread

2.Lymphatic dissemination
 Postpartum, post-abortion, & some IUD-related infections

3.Hematogenous routes
 Rarely, certain diseases (e.g. tuberculosis) may gain access to pelvic
structures by haematogenous routes

clinical manifestations
 Lower abdominal &/or pelvic pain
 Yellow vaginal discharge
 Fever ,Chills
 Menorrhagia ,
 Dysmenorrhea
 Dyspareunia .

Diagnosis
History
Lab investigations
 pregnancy test
 U/A
 CBC: leucocytosis
 Gram stain & microscopic examination of vaginal & cervical discharge
 Cultures and Ultrasonography

Treatment
 Early diagnosis & prompt treatment to ↓the risk of both short- & long-
term complications.
 The primary goal of therapy is to eradicate bacteria, relieve symptoms,
& prevent complications like infertility.

Outpatient Therapy
 PID can be treated in OPD: if
 Temperature is < 39 °C
 Lower abdominal findings are minimal, &
 The patient can take oral medication.
These women can be treated with antibiotics, IUD removal, analgesics,
& bed rest.
 Ceftriaxone (+)Doxycycline for 14 days, With or without Metronidazole

Hospitalization
 If no response to outpatient therapy
 Inpatient therapy is indicated for patients with
 A temperature > 39 °C (102.2 °F)
 Guarding & rebound tenderness in lower quadrants

Ectopic pregnancy
9/25/2023 136

Outline
 Objectives
 Definition of Ectopic pregnancy
 Etiology of ectopic pregnancy
 Clinical presentation
 Diagnosis
 Management of ectopic Pregnancy
9/25/2023 137

Objectives
 After completion of this session the students will able to:
 Define ectopic pregnancy
 List etiology of ectopic pregnancy
 Discuss about clinical presentation
 Describe about diagnosis of ectopic pregnancy
 Describe about management of ectopic pregnancy
9/25/2023 138

139
Ectopic pregnancy
 Definition
 Ectopic pregnancy is any pregnancy where the fertilised ovum gets
implanted & develops in a site other than the uterine cavity i.e. the
endometrium
 It represents a true gynecologic emergency
 About 97% of ectopic pregnancies occur in the fallopian tubes and the
term tubal pregnancy is commonly used.
9/25/2023

 Etiology
 Any factor that causes delayed transport of the fertilized ovum
 These factors may be:
 Structural factors/ Pathologic fallopian tube
 Functional factors
 Contributing factors
9/25/2023 140

141
1. Structural factors : anatomical abnormalities
 Classified as: congenital and acquired
 Congenital
 Tubal hypoplasia: lack of the cells that affects their functioning
 Congenital diverticulitis : like pocket
 Partial stenosis : narrowing of the tubes
9/25/2023

 Acquired
 Adhesions of the tube
 Multiple induced elective abortions
 Inflammatory: PID, septic abortion, puerperal sepsis, salpingitis
 Surgical: Tubal reconstructive surgery, recanalization of tubes
 Neoplastic: Broad ligament myoma, ovarian tumour
 Miscellaneous causes:, Endometriosis, ART (IVF and GIFT)
142
9/25/2023

2. Functional factors: includes
Menstrual reflux and decreased tubal motility
Ovulation induction
9/25/2023 143

3. Contributing factors
 History of pelvic inflammatory disease (PID)
 Previous tubal surgery
 Uterine curettage
 Surgical corrections of fallopian tube occlusions
 Elective sterilizations being reversed at a later date
144
9/25/2023

Site of Occurrences
Nearly all (97%) are implanted within the distal (ampullary) 2/3rd of the
fallopian tube, although implantation can occur within:
The proximal portion of the extra uterine part (isthmus)
Abdomen
Cervix
Ovary, or
Uterine cornua
9/25/2023 145

146
Site of occurrencesF ECTOPIC
PREGNANCY
1) Fimbria 2)Ampullary 3) Isthmus 4)Interstitial 5)Ovarian
6)Cervical 7) Cornual-Rudimentary horn 8)Secondary
abdominal 9)Broad ligament 10)Primary abdominal
Ampulla (>85%)
Isthmus (8%)
Cornual (< 2%)
Ovary (< 2%)
Abdomen (< 2%)
Cervix (< 2%)
9/25/2023

Clinical Manifestations
 Symptoms
 Is remains asymptotic until it ruptures when it can present in two variations
 Abdominal and pelvic pain
 Irregular vaginal bleeding usually scanty and dark
 Amenorrhea
 Dizziness
 Pregnancy symptoms
 Passage of tissue 147
9/25/2023

 Signs
 Adnexal tenderness
 Abdominal tenderness on palpation
 Adnexal mass
 Fever
148
9/25/2023

Diagnostic Evaluation
Traditionally, the diagnosis of it has been based on the clinical
signs and physical symptoms of tubal rupture
However, it may be diagnosed before rupture by:
 Progesterone level
 Ultrasound
 HCG
149
9/25/2023

Differential Diagnosis
 Appendicitis
 PID
 Threatened, incomplete, missed abortions
 Endometriosis
150
9/25/2023

151
Management of Ectopic Pregnancy
 Depends on the stage of the disease and the condition of the patient at
diagnosis
 Options:
 Surgery – Laparoscopy / Laparotomy
 Medical – Administration of drugs at the site / systemically
 Expectant – Observation
9/25/2023

152
SUMMARY
 Definition of Ectopic pregnancy
 Etiology of ectopic pregnancy
 Clinical presentation
 Diagnosis
 Management of ectopic Pregnancy
9/25/2023

Outline
Definition of abortion
Types of abortion
Etiology spontaneous abortion
Clinical manifestation
Lab findings
Management of abortion
Complications and management of complications
9/25/2023 154

Abortion
 Definition
 Abortion is the termination of pregnancy before 20/28 weeks' gestation or
less than 500-g birth weight.
 It is spontaneous or induced termination of pregnancy before fetal
viability(GA or weight).
9/25/2023 155

Types of spontaneous abortion
Threatened abortion: is abortion with or without uterine contractions,
without dilatation of the cervix, and without expulsion of the products of
conception.
Complete abortion is the expulsion of all of the products of conception
before the 20th completed week of gestation,
 Incomplete abortion is the expulsion of some, but not all, of the products
of conception.
9/25/2023 156

 missed abortion, the embryo or fetus dies, but the products of conception are
retained in utero.
 Inevitable abortion :- refers to bleeding before the 20th completed week,
with dilatation of the cervix without expulsion of the products of conception.
 Septic Abortion:- infection of the uterus and sometimes surrounding
structures.
 Unsafe Abortion:-A procedure for terminating an unwanted pregnancy either
by persons lacking the necessary skills or in an environment lacking the
minimal medical standards or both.
9/25/2023 157

Etiology
 fetal factor: An abnormal karyotype or chromosomal anormality.
 Maternal factors: infection
 Anatomic defects: Congenital anomalies that distort or reduce the size of
the uterine cavity, such as bicornuate
 Endocrine factors: Endocrine disorders such as hyperthyroidism
 Previous scarring:- D&C, myomectomy, has been implicated in
spontaneous miscarriage,
9/25/2023 158

…Etiology
9/25/2023
Immunologic Disorders:-BG incompatibility due to ABO, Rh
Malnutrition
Toxic Factors:- radiation, antineoplastic drugs, anesthetic gases, alcohol,
and nicotine ,
Trauma
In a significant percentage of spontaneous abortions, the etiology is
unknown.
159

Clinical manifestations
 Threatened Abortion:-bleeding, The cervix remains closed, and slight
bleeding with or without cramping may be noted.
 Inevitable Abortion:- Abdominal or back pain and bleeding with an open
cervix, CX effacement, CX dilatation, and/or rupture of the membranes is
noted.
9/25/2023 160

9/25/2023
 Incomplete Abortion:- products of conception have partially passed
from the uterine cavity.
 with a portion of the products retained in the uterine cavity.
 Cramps are usually present.
 Bleeding generally is persistent and is often severe.
161

 Complete Abortion:- is identified by passage of the entire conceptus.
 Slight bleeding may continue for a short time,
 pain usually ceases after pregnancy has traversed the cervix.
9/25/2023 162

9/25/2023
 Missed Abortion:- implies that the pregnancy has been retained
following death of the fetus.
 After embryonic death, there may or may not be vaginal bleeding or other
symptoms of abortion.
163

Diagnosis
 Suprapubic pain, uterine cramping, and/or back pain
 Vaginal bleeding
 Cervical dilatation
 Extrusion of products of conception
 Disappearance of symptoms and signs of pregnancy
 Abnormal ultrasound findings (e.g. empty gestational sac, lack of fetal
growth).
 WBC count
9/25/2023 164

Management
 Vacuum Aspiration:
 Medication: Misoprostol and mifepristone
 Expectant Management
9/25/2023 165

 Misoprostol: Effects on the Uterus and Cervix
 Induces uterine Contractions
 Cervical Ripening
 Mifepristone :
 Augments uterine contractility
 Cervical ripening
9/25/2023 166

Complications
Immediate
Sepsis,
Hemorrhage,
Uterine perforations,
 Genital tract injury,
Long-term consequences:
Pelvic inflammatory disease
Tubal occlusion
Ectopic pregnancy
Infertility
9/25/2023 167

Post abortion care
What is Post abortion Care (PAC)?
9/25/2023 168

PAC
 It is series of interventions designed to manage the complications of abortion
and address women’s related health care needs after abortion.
 Elements of PAC
 Community and provider partnerships
 Counseling to respond to women’s needs
 Treatment of incomplete and unsafe abortion
 Contraceptive and family planning services
 Reproductive and other services
9/25/2023 169

 Restrictive abortion law in Ethiopia
 Termination of pregnancy by a recognized medical institution within the
period permitted by the profession is not punishable where:
 The pregnancy is a result of rape or incest; or
 The continuation of the pregnancy endangers the life of the mother
or the child or the health of the mother or
 The fetus has an incurable and serious deformity; or
 The pregnant woman, owing to a physical or mental deficiency she
suffers from or her minority, is physically as well as mentally unfit to
9/25/2023 170

References
 Clinical practice handbook for Safe abortion WHO 2014
 Current diagnosis and treatment in obstetrics and gynecology 2007
 WHO standards for management of post-abortion complications
 Williams obstetrics 23rd edition
9/25/2023 171

quiz
1. what is AUB?
2. define abortion
3. describe the clinical presentations of spontaneous abortion?
4. define ectopic pregnancy and the most common site
5. explain the management of AUB?
9/25/2023 172

Presentation Outline
174
Definition
Types of GTD
Etiology/predisposing Factors
Diagnosis
Management
9/25/2023

GTD
 Refers to a spectrum of interrelated but histologically distinct tumors
originating from the placenta villose trophoblastic cells
 These diseases are characterized by a reliable tumor marker (- subunit
of hCG) and have varying tendencies toward local invasion and spread.
175
9/25/2023

Types of GTD
 Benign: Hydatid form mole/molar pregnancy
 Malignant: Invasive mole
Chorio-carcinoma
176
9/25/2023

Hydatidiform Mole (Molar Pregnancy)
 Is abnormal pregnancies characterized by vesicular swelling of
placental villi and usually the absence of an intact fetus
 Specifically, the chorionic villi in these placentas show varying
degrees of trophoblastic proliferation and edema of the villous stroma
 The chorionic villi develops abnormally in to fluid filled grapelike
clusters
 The abnormal tissue growth may invade the myometrium and produce
tumor growth
177
9/25/2023

 Formations of fluid filled, grape like
cluster grow in the uterus
 These cluster grow rapidly so the uterus
appears large for gestational age
178
Hydatidiform Mole (Molar
Pregnancy)…cont’d
9/25/2023

 Classification of molar pregnancy
 Based on the degree and extent of the tissue changes
 Complete mole: The mass of tissue is completely made up of abnormal
cells
 There is no fetus and nothing can be found at the time of the first scan
 Partial mole: The mass may contain both abnormal cells and often a fetus
that has severe defects
 In this case the fetus will be destroyed by the growing abnormal mass very
179
9/25/2023

 Etiology
 remains unclear, but cytogenetic studies shows due to abnormal
gametogenesis and fertilization
180
9/25/2023

Clinical risk factors for molar pregnancy
 Age extremes: <15 , >40
 Reproductive history
 Prior hydatid form molar
 Previous spontaneous abortion
 diet : vitamin A deficiency
 Familial tendency
9/25/2023 181

sign and symptoms of hydatid form mole
 Vaginal bleeding
 Excessive nausea and vomiting (hyper emesis)
 Preeclampsia
 Amenorrhea
 Vaginal passage of vesicles
 Anemia
 Large for date uterus
 Absence of fetal heart tone
9/25/2023 182

Diagnosis
 Vaginal bleeding: The most common symptom of a mole is vaginal bleeding
during 1st trimester
 Uterine size: Occasionally, a uterus that is too large for the stage of the
pregnancy can be an indication.
 U/S
9/25/2023 183

 Differential diagnosis
 Abortion
 Multiple pregnancy
 Polyhydramnios
184
9/25/2023

Management
 Evacuation and curettage and then oxytocin
 Chemo therapy
 Hysterectomy: if future pregnancy not desired
9/25/2023 185

Follow-up
 Regular estimation of urinary hCG for at least a year
 Pregnancy should avoid for 6 months after hCG returned to normal
 Test monthly for six months after that, every two months.
 Persistence after one month suggest incomplete evacuation or
malignant
 Persistence is indicator for chemotherapy
186
9/25/2023

Invasive mole
 The molar villi grow into the myometrium or its blood vessels, and may
metastasize to the lungs, the vagina or the vulva.
 Simple invasive mole cause uterine enlargement and bleeding.
 In severe cases trophoblast penetrates in to the peri-metrium and leads to
internal hemorrhage
 The level of HCG is very high.
 Treatment: Hysterectomy
187
9/25/2023

Common Sites for Metastatic Gestational Trophoblastic Tumors
9/25/2023 189

Chorio-carcinoma
 A malignant tumor invades the uterine wall and metastasizes widely
through the blood stream
 Characterized by abnormal trophoblastic hyperplasia and anaplasia,
absence of chorionic villi
9/25/2023 190

191
Gross specimen of chorio-carcinoma
9/25/2023

Clinical manifestations
 Uterine bleeding
 Infection
 Abdominal swelling
 Vaginal mass
 Lung symptoms
9/25/2023 192

Diagnosis
 Rising of hCG following evacuation of a molar pregnancy or any
pregnancy event
 Once the diagnosis established X-ray, CT, MRI to determine the
extent of disease
193
9/25/2023

Treatment of Nonmetastatic GTD
 Hysterectomy is advisable as initial treatment in patients who no
longer wish to preserve fertility
 This choice can reduce the number of course and duration of
chemotherapy and
 single-agent chemotherapy at the time of operation to eradicate any
occult metastases and reduce tumor dissemination
 Like Methotrexate and Actinomycin-D for patients wishing to
preserve their fertility
194
9/25/2023

Outline
 Objectives
 Terminologies
 Causes of infertility
 Diagnosis of infertility
 Treatment options
196

Session objectives
 At the end of this session the learners will be
able to:
 Define infertility and related terminologies
 Describe causes of infertility
 Describe treatment options
197

BRAINSTORMING
• WHAT IS INFERTILITY?
198

Overview
 Infertility: is defined as inability to conceive and
carry a pregnancy to viability after at least 1 year of
regular sexual intercourse with out contraception
199

…
 Sterility: inability to create offspring (children) as
a result of a procedure: such as tubal ligation,
hysterectomy, or vasectomy.
 It denotes a total irreversible inability to
conceive
 Subfertility: delay in conceiving, the possibility
of conceiving naturally exists, but takes longer
than the average.
200

Types of infertility
 Primary infertility- is inability to conceive and
carry a pregnancy to viability with no previous
history of pregnancy carried to alive birth.
 Secondary infertility- is an inability to conceive
and carry a pregnancy to alive birth following one or
more successful pregnancies.
201

Causes of infertility
 Male factor: 25-40 %
 Female factor: 40-55%
 Both: 10%
 Unexplained:10%
202

Male factor infertility
1. Defective spermatogenesis
2. Obstruction of efferent duct system
3. Failure to deposit sperm high in the vagina
4. Errors in seminal fluid
203

…
1. Defective spermatogenesis
 Congenital: undescended testis
 Thermal factor
 Infection
 Iatrogenic: radiation, cytotoxic drugs
204

…
2. Obstruction of the ducts
 Infection
 Trauma
3. Failure to deposit high in the vagina:
 Erectile dysfunction
 Ejaculatory defect
 Hypospadias
205

4. Defects in seminal fluid:
 Unusually high or low volume of fluid
 Low fructose level
 viscosity
206

Female causes
1. Ovulatory dysfunction: 30-40 %
2. Tubal or peritoneal factor: 30-40%
3. Unexplained: 10-15%
4. Miscellanous: 10-15%
207

Evaluation of infertility
Objectives:
 Discover etiologic factor
 Resolve the abnormality to improve fertility
 Reassure the couples
208

 When to investigate:
 After one year
 After 6 months in women older than 35 years &
after 40 years in men
209

General principles:
 Sharp decline in fertility following first year
 Psychological factors contributing for infertility
increases with time
 Involve both partners at first
 Detailed general & reproductive history to be
extracted in the presence of both
 Clinical examination to be taken separately
210

Evaluation of Male factor infertility
History:
 Age, proven fertility if any
 Duration of marriage
 History of previous marriage if any
 Medical history:DM, STDs
 Surgery:
 Occupation: radiation, heat
 Sexual history
211

Physical examination:
 Examination of reproductive system: inspection &
palpation of genitalia
1. Size & consistency of testis
2. Urethral meatus
3. Presence of varicocele
212

Investigations
Routine investigations: U/A ,RBS
Seminal fluid analysis: Normal values
 Volume: 2ml or more
 PH: 7.2-7.8
 Concentration: >20 million/ml
 Motility: > 50% progressive
 Morphology: > 30%
 Leucocytes: <1 million
213

Terminologies in seminal fluid analysis
 Aspermia: failure of formation or emission of semen
 Oligospermia: < 20 million/ml
 Polyzoospermia:>350 million/ml
 Azoospermia: no spermatozoa
 Asthenozoospermia: abnormal motility
 Teratozoospermia: abnormal morphology
 Necrozoospermia: dead or motionless
214

Female evaluation
History:
 Age, duration of marriage
 History of previous marriage, proven fertility
 General medical history: STD, PID or DM
 Contraceptive history
 Sexual problems
215

…
 Physical examination:
 General examination:
1. Obesity or weight loss
2. Secondary sexual characteristics
3. Physical features for endocrinopathy
216

Gynecologic examination:
 Evidences of cervical infection
 Undue elongation of cervix
 Uterine size, mobility & position
Speculum examination:
 Abnormal cervical discharge
 Cervical smear
217

Cervical factor
 Post-coital test (Sims-Huhner test):
 assesses sperm interaction with mucus in two
parts:
 First assess quality of cervical mucus: it appraises
mucus characteristics favorable to sperm
penetration; and
 Second assesses ability of sperm to survive in it:it
gauges the number and motility of observed sperm
218

Treatment
Couple instructions:
 Assurance: when faults found in both, treat both at
a time,
 Optimal body weight
 Avoid excessive alcohol ingestion & smoking
 Coital problems need to be carefully evaluated by
intelligent interrogation
219

Treatment of male infertility
 Improve general health
 Avoid smoking, alcohol ingestion, tight underwear
 Clomiphene citrate: 25mg/day for 25 days, for three
cycles
 Testestrone
 GnRH therapy
 ART
220

Treatment of female infertility
1. Ovulatory dysfunction:
Drugs used for ovulation induction
 Clomiphene citrate
 FSH
 hcG
 GnRH
221

CERVICAL FACTORS
• Treat proven infections
• IUI, IVF or GIFT
IMMUNOLOGICAL FACTORS
• Dexamethasone
222

Assisted Reproductive Technologies (ART)
 Encompasses all the procedures that assist the
process of reproduction by retrieving oocytes from
ovary or sperm from testis or epididymis
 Includes:
1. IUI(Intrauterine insemination):sperm is
placed directly into the uterus using a small
catheter.
223

 goal : to improve the chances of fertilization by
increasing the number of healthy sperm that reach
the fallopian tubes when the woman is most fertile.
2. IVF-ET(In Vitro Fertilization and Embryo Transfer):
transfer of embryo to uterus for implantation.
3. ZIFT: (Zygote intra fallopian transfer): transfer of
the fertilized egg To tube.
 The woman must have healthy tubes for ZIFT to
work.
224

4. GIFT(Gamete intrafallopian transfer): is used for
infertile women who are ovulating but have blocked
fallopian tubes or for infertile couples who, for
religious reasons, wish to avoid fertilization outside
the human body.
225

Uterine descent
 Uterine prolapse is: downward displacement of women’s uterus (womb)
into the vaginal canal or outside the vagina.
 Slipping down of the uterus from its normal position to vaginal canal.

 Support of uterus
 A group of muscles and ligaments supports the pelvis in its place. i.e.
pelvic floor muscles and ligaments
 As this muscles and ligaments weaken, they become unable to hold the
uterus in position and it begins to sag.

 Causes of uterine prolapse
 Aging and menopause: Weakening of the pelvis muscles and the natural
reduction in estrogen at menopause contribute to less elasticity.
 Pregnancy and childbirth: like delivery of large baby, physical trauma of
labor and birth stresses or bearing down before full dilatation of cervix can
strain the pelvic muscles and ligaments.
 Other factors: Pressure on the pelvic muscles due to Obesity ,chronic
coughing or straining and chronic constipation

 Risk Factors
 Large tumors
 Obesity
 Chronic coughing, constipation or straining
 Heavy lifting
 Previous pelvic surgery

 Clinical Manifestation :
 feeling of heaviness or pressure in the pelvis and discomfort during walking
 Feelings as if something is falling out of the vagina
 Pain in the pelvis, abdomen or lower back
 Pain during intercourse
 A protrusion or bulging out of tissue from the vagina
 urinary frequency or urgency

 Types of uterine prolapse
 Incomplete prolapse: Slipping or falling down of the uterus into the birth
canal
 If the prolapse is minor, it may become visible on straining due to incomplete
evacuation
 Complete prolapse: the uterus slips out of place that some of the tissue
drops outsides the vagina called complete prolapse.

 Staging of uterine prolapse:
 Stage I: descent of the uterus in the vagina above the level of the hymen.
 Stages II: descent to the level of hymen
 Stages III: descent beyond the hymen
 Stages IV: total eversion

 Diagnosis
 pelvic examination
 Laboratory to detect infection, hemorrhage
 Imaging studies : A pelvic ultrasound examination

 Prevention
 Maintain healthy body weight
 Perform Kegel exercises:to tone up the pelvic muscles.
 Eat balanced diet: helps to prevent constipation.
 Stop smoking: Chronic cough can put extra strain on pelvic muscle.
 Do not lift heavy load, use correct lifting techniques.
 Consider Estrogen replacement therapy after menopause.

 Management
 Vaginal pessary: This device fits under the cervix and holds the uterus in
place.
 Used as temporary or permanent treatment
 Surgical management:
 Repair: in women with child bearing age and haven’t completed their
families and insist on preservation of uterus.
 hysterectomy

 References
 Current obstetrics and gynecology 2007 edition.
 Williams gynecology 23rd edition.
 Essential obstetrics and gynecology volume1

Outline
9/25/2023
Objective
Etiology Of Fistula
Clinical Manifestations
Contributing Factors
Classification Of Fistula
Diagnosis Of Fistuala
Complication

Objectives
9/25/2023
After this session learner will be able to:-
Describe the contributing factors of obstetric fistula
Identify clinical manifestation
Elaborate diagnosis of obstetric fistula
Describe the management and complication
Identify the prevention of obstetric fistula

Brain storming
•What is fistula?

9/25/2023
 Definition
 Fistula is defined as an abnormal opening between two areas of the body
 A fistula usually develops between the bladder and vagina (vesico-vaginal
fistula or VVF)
 less commonly between the vagina and the rectum (recto-vaginal fistula or
RVF).

 Etiology
 unsuccessful primary repair of a third or fourth degree laceration
 unrecognized injury at the time of vaginal delivery, and
 episiotomy infection
 from surgical procedures involving the vaginal , perineum, anus, and
rectum.
 Recto-vaginal and ano-vaginal fistulas frequently result from obstetric
trauma.

clinical manifestations
9/25/2023
 uncontrollable passage of gas or feces from the vagina.
 malodorous vaginal discharge
 vaginal pain

Development of obstetric fistula
9/25/2023
The continual pressure during uterine contractions compresses maternal
tissue against hard bone on either side (mother’s pelvis and infant’s head).

 Contributing factors
 Early age at labor with pelvic immaturity
 Android or anthropoid pelvis
 Genital mutilation
 neglected obstructed labor
 Difficult operative delivery
 Pelvic immaturity
 Nutritional deficiencies

Diagnosis of fistulae based on:-
9/25/2023
Assessment of fistula site
Size and number of fistula
Degree of scarring
Relationship of ureteric orifices
The use of magnification, such as a colposcope, may be
helpful.

Dx cont…
9/25/2023
A few drops of methylene blue dye can be mixed with
lubricating gel and massaged into the anterior rectal wall.
Alternatively, an enema consisting of warmed saline and a
few drops of methylene blue dye can be instilled into the
rectum using a genitourinary syringe.

Methylene blue dye test
9/25/2023

Management
9/25/2023
 Surgery: Repair
 Route of Repair
 Vaginal
Abdominal
Combined (vaginal & abdominal)

Complications
9/25/2023
 incontinence of urine and/or stool
 Vaginal stenosis ,dyspareunia
 Pelvic inflammatory disease
 Malnutrition – often a result of neglect, depression and poverty

Psychosocial complications
9/25/2023
 Depression and anxiety
 Social isolation: >50% of women with obstetric fistula have been
abandoned by their husbands.
 Depression and grief related to infertility
 Inability to work
 Stigmatization

Fistulas and stillbirth
9/25/2023
Fistulas do not cause stillbirths, but if a woman has a
labor that is difficult and long enough to result in an
obstetric fistula, it is unlikely that her infant will survive the
delivery.
 It is estimated that in 95% of cases, if a woman
developed a fistula during childbirth her baby was not born
alive.

Primary prevention
9/25/2023
 Education and empowerment for women
 Delaying marriage and child bearing.
 Secondary prevention:-
 Birth preparedness and complication readiness, including
transportation and family decision making.
 Skilled attendance at every birth.

… prevention
9/25/2023
Monitoring of every labor with the partograph for early recognition of
obstructed labor.
 Ready access to high quality emergency obstetric care
 Community awareness raising and education about prevention and
treatment of obstetric fistula.

Tertiary prevention
9/25/2023
 Early recognition of developing or developed fistula in women who
have had an obstructed labor or genital trauma.
 Standard protocol at health centers for management of women who
have survived prolonged/obstructed labor to prevent further
damage.

References
9/25/2023
1. Prevention and Recognition of Obstetric Fistula Training Package.
2. Goh JWT, Krause HG. Female Genital Tract Fistula. Brisbane:
University of Queensland Press, 2004.
3. Arrowsmith S, Hamlin C, Wall L. Obstetric labour injury complex:
obstetric fistula formation and the multifaceted morbidity of maternal
birth trauma in the developing world. CME review article. Obstet
Gynecol Surv 1996; 51: 568–74.

quiz
1. What is GTD
2. How can we prevent obstetric fistula?

obgyne notes (1)-1.pptx

Recommended

Recommended

More Related Content

Similar to obgyne notes (1)-1.pptx

Similar to obgyne notes (1)-1.pptx (20)

Recently uploaded

Recently uploaded (20)

obgyne notes (1)-1.pptx