Gynecological disorders

gynecological disorders in pregnancy

1. in Pregnancy Gynecological Disorders in pregnancy Prepared by;Anila C.Eapen Assistant Professor Caritas college of nursing

2. ABNORMAL VAGINAL DISCHARGE There is an increased cervical secretions and vaginal transudate during pregnancy due to increased vascularity and hyperestrogenic state . The discharge is thick, mucoid in nature and non-irritating. Except improvement in personal hygiene, no treatment is required .

3. TRICHOMONAS VAGINALIS: Trichomonas vaginalis  is a parasitic protozoan that infects the urogenital tract of both women and men.  It is the most common sexually transmitted infection (STI) The infection is not increased during pregnancy. The clinical features remain the same as in non-pregnant state. Treatment consists of prescribing metronidazole ( Flagyl ) 200 mg thrice daily for 7 days. Metronidazole should be avoided in the first trimester. The husband should be treated simultaneously

4. MONILIA VAGINITIS: Vaginitis due to Candida albicans is relatively more common than Trichomonas vaginalis . Its growth is favored by the high acidic pH of vaginal secretions and frequent presence of sugar in the urine during pregnancy. It is more prevalent in diabetic pregnancy. Treatment is by use of miconazole vaginal cream, one applicator full, high up in the vagina at bedtime for 7 nights.

5. CERVICAL POLYP During pregnancy, there is increased vascularity and as a result any pre-existent polyp bleeds, confusing the diagnosis with threatened abortion in early months and constitutes extra placental cause of APH in later months. The diagnosis is confirmed by speculum examination . The polyp should be removed as in the non-pregnant state and should be sent for histological examination.

6. CARCINOMA CERVIX WITH PREGNANCY INCIDENCE: The incidence of invasive carcinoma of the cervix is about 1 in 2,500 pregnancies.

7. DIAGNOSIS:  Asymptomatic cases — Cytologic screening of all pregnant mothers is a routine during antenatal checkup in the organized sector.  Symptomatic cases — In cases of bleeding during pregnancy either in the early months simulating threatened abortion or in the later months constituting APH, the cervix should be inspected through a speculum at the earliest opportunity. If suspicion arises, a biopsy from the site of lesion confirms the diagnosis.

8. EFFECTS OF PREGNANCY ON CARCINOMA CERVIX : The malignant process remains unaffected. There may be a rapid spread following vaginal delivery and induced abortion. EFFECTS OF CARCINOMA ON PREGNANCY : There is increased incidence of (1) abortion, (2) premature labor , (3) secondary cervical dystocia , (4) injury to the cervix and lower segment leading to traumatic PPH, (5) lochiometra and pyometra , and (6) uterine sepsis.

9. TREATMENT

10. First trimester: Radical hysterectomy (with the fetus in uterus), pelvic lymphadenectomy and aortic node sampling are done. Oophoropexy at the time of hysterectomy may be done. Post operative irradiation following evaluation of prognostic factors

11. Third trimester: Radical hysterectomy, pelvic lymphadenectomy after classical cesarean delivery. Dissection may be easy, but bleeding is often more in pregnancy. Second trimester: Management decisions are more difficult.

12. LEIOMYOMA S WITH PREGNANCY INCIDENCE : The incidence of fibroid in pregnancy is about 1 in 1,000 and it depends on population characteristics.

13. EFFECTS ON PREGNANCY: It depends on their location. (1) May be none; (2) Pressure symptoms due to impaction — (a) bladder—retention of urine (b) rectum—constipation; (3) Abortion; (4) Malpresentation ; (5) Non-engagement of the presenting part; (6) Preterm labor and prematurity; (7) Red degeneration; (8) Placental abruption.

14. EFFECTS ON PUERPERIUM: (1) Subinvolution ; (2) Sepsis is common ( 3) Secondary PPH; ( 4) Inversion of uterus; (5) Lochiometra and pyometra .

15. Clinical features: ( 1) Acute onset of focal pain over the tumor ; (2) Malaise or even rise of temperature; ( 3) Dry or furred tongue ; (4) Rapid pulse ; (5) Constipation; ( 6) Tenderness and rigidity over the tumor ; (7) Blood count shows leukocytosis . The diagnosis is confused with acute appendicitis or twisted ovarian tumor. The diagnosis is often made only on laparotomy .

16. Treatment: Conservative treatment should be followed. Patient is put to bed. Ampicillin 500 mg capsule thrice daily for 7 days is given. Analgesic and sedative are frequently given. The symptoms usually clear off within 10 days

17. OVARIAN TUMOR IN PREGNANCY INCIDENCE: The incidence of ovarian tumor with pregnancy is about 1 in 2,000.

18. EFFECTS OF TUMOR  On pregnancy: There is increased chance of ( 1) impaction leading to retention of urine, (2) mechanical distress in presence of large tumor ( 3) malpresentation , ( 4) Non-engagement of the head at term.  On labor: There is chance of obstructed labor if the tumor is impacted in the pelvis.

19. DIAGNOSIS: Patient may remain asymptomatic or presents with the symptoms of ( a) retention of urine due to impaction of the tumor ( b) mechanical distress due to the large cyst © Abdominal examination reveals the cystic swelling felt separated from the gravid uterus

20. TREATMENT: DURING PREGNANCY  Uncomplicated — The best time of elective operation is between 14th week and 18th week, as the  Complicated — The tumor should be removed irrespective of the period of gestation .

21. DURING LABOR: (1) If the tumor is well above the presenting part, a watchful expectancy hoping for vaginal delivery is followed; (2) If the tumor is impacted in the pelvis causing obstruction, cesarean section should be done followed by removal of the tumor in the same sitting.

22. DURING PUERPERIUM: On occasion, the diagnosis is made following delivery. The tumor should be removed as early in puerperium as possible. Following operation the specimen is sent for histological examination.

23. RETROVERTED GRAVID UTERUS Retroverted uterus, either congenital or acquired, is considered as a normal variant of uterine position. Retroversion is either pre-existing or may be due to pregnancy. The incidence is about 10% during first trimester of pregnancy

24. (A) Direction of the cervix following incarceration; (B) Anterior sacculation ( sonography or MRI is needed to detect anatomical alterations)

25. Note the direction of the cervix—in pelvic tumor with pregnancy

26. CHANGES FOLLOWING INCARCERATION Changes in the uterus: (1) The cervix is pointed upwards and forwards and is placed even on the upper border of the symphysis pubis; (2) Rarely, the uterus continues to grow at the expense of the anterior wall called anterior sacculation while the thick posterior wall lies in the sacral hollow

27. Changes in the urethra and bladder: Urethra: Marked elongation along with the bladder base due to stretching of the anterior vaginal wall by the cervix. There is retention of urine. The causes of retention are: (1) Mechanical compression of the urethra by the cervix; (2) Edema on the bladder neck; (3) The woman passes small amount of urine with increased pressure (strain) even when the bladder is full (paradoxical incontinence).

28. Bladder changes: As a result of retention of urine, the bladder gets distended and becomes an abdominal organ reaching even upto the umbilicus. If the retention is not relieved, the following may happen: (1) The bladder walls become thickened due to edema; (2) Severe cystitis, pyelonephritis with uremia supervenes; (3) Intraperitoneal rupture may occur in grossly neglected cases resulting in infective peritonitis; (4) Obstructive nephropathy in a severe case may occur.

29. Effects on pregnancy: ( 1) Miscarriage; (2) If pregnancy continues with anterior sacculation , there is increased chance of (a) Malpresentation (b) Non-engagement of the head, (c) Preterm delivery and prematurity, and (d) Rupture of the uterus during labor.

30. GENITAL PROLAPsE IN PREGNANCY Pregnancy is not uncommon in first-degree uterine prolapse with cystocele and rectocele . Pregnancy is, however, unlikely when the cervix remains outside the introitus and continuation of pregnancy in third degree prolapse is an extremely rare event. The incidence of prolapse is about 1 in 250 pregnancies

31. Uterine prolapse in pregnancy with hugely edematous and hypertrophied cervix

32. EFFECTS ON PROLAPSE:  Vaginal discharge may be copious  There is chance of incarceration

33. EFFECTS  On pregnancy: There is an increased chance of: (1) Miscarriage; (2) Discomfort due to increased ailments; (3)Premature rupture of the membranes (4) Chorioamnionitis .

34.  During labor: There is an increased chance of: Early rupture of the membranes ;( 2) Cervical dystocia ; (3)Prolonged labor due to non-dilatation of cervix and obstruction due to sagging cystocele and rectocele ; (4) Operativeinterference .  During puerperium : (1) Subinvolution ; (2) Uterine sepsis.

35. treatment

36. DURING PREGNANCY:  If the cervix is outside the introitus — The pessary is to be kept until 18th–20th week of pregnancywhen the body of the uterus will be sufficiently enlarged to sit on the brim of the pelvis. The pelvic floor is too much lax — The patient is to lie in bed with the foot end raised by about 20 cm.  If the cervix remains outside the introitus even in the later months, it is preferable to admit the patient at 36th week.

37. DURING LABOR  Th e patient should be in bed,  Intravaginal plugging soaked with glycerine and acrifl avine not only helps in reduction of cervical edema but also facilitates its dilatation.  Prophylactic antibiotic,  Manual stretching of the cervix or pushing up the cystocele or rectocele past the presenting part during uterine contractions facilitates progressive descent of the head.  If the head is high up and/or the cervix remains edematous, thick or undilated , cesarean section is a safe procedure.

38. PUERPERIUM: (1) The patient should lie flat on the bed; ( 2) If the mass remains outside, it should be covered with gauze soaked in glycerine and acriflavine ; ( 3) If subinvolution is evident, a ring pessary may be put in until involution is completed; (4) Prophylactic antibiotic is administered.

39. THANK YOU

40. MORBID ANATOMIC CHANGEs IF LEFT UNCARED FOR FAVORABLE : In the majority, spontaneous rectification occurs. As the uterus grows, the fundus rises spontaneously from the pelvis beyond 12 weeks. Thereafter, the pregnancy continues uneventfully. UNFAVORABLE: In the minority, spontaneous rectification fails to occur between 12 weeks and 16 weeks. The developing uterus gradually fills up the pelvic cavity and becomes incarcerated. The probable causes of incarceration are: (a) Projected sacral promontory; (b) Uterine adhesions; (c) Pelvic tumor; (d) Idiopathic (majority).