INVESTIGATIONS AND EXAMINATIONS IN OBS AND GYN best for undergraduate

Basic investigation in gyn

1. OBSTETRICS AND GYNAECOLOGICAL INVESTIGATIONS AND EXAMINATIONS. MUKHOOLI SAMUEL WANDEKA SUPERVISED BY: DR . JOHN ZIMULA

2. INVESTIGATIONS INCLUDE THE FOLLOWING; CBC Blood grouping Renal function tests Liver function tests Urinalysis Reproductive hormonal profile PAP smear karyotype Intravenous pyelography Ultrasound scan X-ray hysterosalpingography

3. COMPLETE BLOOD COUNT(CBC) This is used to measure various components of blood which include red blood cells, white blood cells,platelets,hematocrit,differential count(neutrophils, lymphocytes, monocytes) A complete blood count may be indicated in: anemia, infection, bleeding disorders , malignancy, nutrition deficiencies and pregnancy related conditions. However the normal ranges of some of these parameters for example haemoglobin may change due to the physiological changes that occur in pregnancy.

4. CBC PARAMETERS THAT DEFINE ANEMIA IN PREGNANCY; 1 st trimester; HB<11g/dl Hct<33% 2 nd trimester HB<10.5g/dl Hct<32% 3 rd trimester Hb<11g/dl and Hct <33%

5. BLOOD GROUPING. This is used to determine the blood type and may be indicated in pregnancy planning, blood transfusion compatibility and neonatal hemolytic disease prevention. It includes various components such as; ABO blood group:A,B,AB,O Rh blood type.Rh- and Rh+ Other blood group antigens:kell,Duffy

6. RENAL FUNCTION TESTS(RFTs) This is used to evaluate kidney function and it is usually indicated in kidney disease, pregnancy related conditions forexample pre-eclampsia,diabetes mellitus and sometimes in urinary tract infections. Its components include; Serum creatinine:0.5-1.5mg/dl Serum urea:10-50mg/dl Estimated Glomerular Filtration rate (eGFR):90-120ml/min Urine protein to creatinine ratio<30mg/g

7. LIVER FUNCTION TESTS(LFTs) This is used to access liver function and may be indicated in liver disease, pregnancy related conditions for example HELLP syndrome and for monitoring medications. It includes the following components; Alanine transaminase(ALT):5-40U/L Aspartate transaminase(AST):5-40U/L Bilirubin:0.1-1.2mg/dl Alkaline phosphatase(ALP):30-120U/L Gamma glutamyl transferase(GGT):5-40U/L

8. URINE ANALYSIS. This is used to analyze urine and it may be indicated in urinary tract infections, kidney disease and pregnancy related conditions. Its components include; Urine proteins Urine glucose Other findings for example blood in Urine,epitherial cells,pus cells may signify various conditions.

9. Methods of urine collection Midstream collection Catheter collection Suprapubic bladder puncture

10. Midstream collection: The patient herself should separate the labia with the fngers of left hand. Asterile cotton swab moistened with sterile water is passed over the external urethral meatus from above down and is then discarded. With the vulvastill separated the patient is to pass urine. During the middle of the act of micturition, a part of urine is collected in a sterile wide mouth container.

11. Catheter collection: This should be collected by a doctor or a nurse. This is especially indicated when the patient is not ambulant or having chronic retention. Meticulous washing of the hands with soap and wearing sterile gloves are mandatory.

12. Catheter collection contn... The patient is in dorsal position with the thighs apart. The labia are separated using the fngers of 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 to be introduced with the proximal 4 cm remaining untouched by the fngers. With meticulous asepsis,the technique does not increase urinary tract infection.

13. Suprapubic bladder puncture 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 mLof urine is collected.

14. Contn... Whatever method employed in the collection of urine, the sample should be sent immediately to he laboratory to avoid multiplication of the organisms with time.

15. Reproductive hormone profile. This measures various hormone levels for example fertility hormones, sex hormone levels and many others it may be indicated in infertility, menstrual disorders and polycystic ovary syndrome. It has various components of which some include the following; Follicle-stimulating hormone(FSH):1.5-12.5mIU/ml Luteinizing hormone(LH):5-20mIU/ml Estrogen(E2):20-800pg/ml Progesterone:2-25ng/ml Testosterone:10-50ng/dl and also H CG levels

16. PAP SMEAR This is usually done when screening for cervical cancer,endometrial cancer and can also be done for precancerous lesion detection.

17. Instruments used for collection of samples from cervix and vagina

18. procedure Cervix is exposed with a cuscos speculum without lubricant. Cervical scrapping is done using Ayres spatula ,the whole of the squamocolumnar junction has to be scrapped to obtain good material. Vaginal pool aspiration of the exfoliated cells in the posterior fornix is collected using a glass pipette about 15cm in length. Endocervical sampling is done using a cytobrush or with a moist cotton tip applicator

19. Procedure continuation Fixation and staining of the collected sample is done by spreading the sample immediately over a slide and at once put into the fixative ethyl alcohol (95%) before drying. After fixing for about 30minutes, the slide is taken out, air dried and sent to the lab with proper identification. The slide is then stained either with papanicolaou’s or Sorr’s method and examined by a trained cytologist.

20. Contn... Reporting system Normal/abnormal Abnormal-CIN/papilloma infection/invasive malignancy. Doubtful/inconclusive smear-repeat smear Papanicolaou classification-grading Normal cells Slightly abnormal-inflammatory change Cells suspicious of malignancy-biopsy indicated Few distinctly abnormal, possibly malignant cells Malignant cells seen-numerous

21. Limitations of pap smear Detect only 60-70% of cervical cancer and 70% of endometrial cancer Reliability depends on slide preparation and skill of the cytologist 10-15% false negative results False positive results in presence of infections Difficult if squamocolumnar junction indrawn as in post menopausal women (10days course of estrogen cream suggested) Post radiation cytology difficult- scarring and atrophy of the vagina

22. KARYOTYPING This is used for analyzing chromosomes. This is usually indicated in genetic diseases, chromosomal abnormalities and other pregnancy disorders for example molar pregnancy. This can be done through amniocentesis and chorionic villus sampling.

23. INTRAVENOUS PYELOGRAPHY This is used when visualizing the urinary tract. It's usually indicated in Urinary tract obstruction and kidney stones. It may also involve contrast agent injection and chest x-ray imaging of the urinary tract.

24. ULTRASOUND SCAN Ultrasound is a noninvasive imaging procedure that utilizes high frequency sound waves. It was first introduced by Ian Donald (Glasgow – 1950) in the field of medicine. Sonography is used widely in Gynecology either with the transabdominal (TAS) or with the transvaginal (TVS) probe. Because of safety, high patient acceptance and relatively low cost.

25. Ultrasound cont.… Transabdominal Sonography (TAS) is done with a linear or curvilinear array transducer operating at 2.5–3.5MHz. TAS requires full bladder to Displace the bowel out of pelvis. Full bladder serves as an acoustic window for the high-frequency sound waves. Ultrasound is very accurate (> 90%) in recognizing a pelvic mass but cannot stabilize a tissue diagnosis. Tissue resolution of <0.2 mm can be obtained with sonography.

26. Cont… TAS is best used for large masses like fibroid or ovarian tumor. Higher is the frequency of ultrasound wave, better is the image resolution but lesser is the depth of tissue penetration.

27. Cont… Transvaginal Sonography (TVS) is done with a probe, which is placed close to the target organ. There is no need of a full bladder. It also avoids the difficulties due to obesity, faced in TAS. TVS operates at a high frequency (5–8 MHz) . Therefore, detailed evaluation of the pelvic organs (within 10 cm of the field) is possible with TVS. But the drawbacks of TVS are mainly due to narrow vagina as in virgins, postmenopausal women or post-radiation vaginal stenosis.

28. Cont… Transvaginal Color Doppler Sonography (TV–CDS)—Provides additional information of blood flow to, from or within an organ (uterus or adnexae) . This flow can be measured by analysis of the wave form using the pulsatility index.

29. Cont… Trans-rectal sonography: can be used where TVS cannot be used for example due to vaginal narrowing.   Saline infusion sonography (SIS): Infusion of normal saline into the uterine cavity and doing trans-vaginal (high resolution) sonography is helpful for the diagnosis of many uterine pathology. SIS catheter is inserted through the cervical os. Normal saline is infused slowly(5–10 mL) when the uterus is imaged with vaginal ultrasound.

30. Common indications of SIS are: Postmenopausal bleeding. Abnormal uterine bleeding. Recurrent miscarriage. Infertility.

31. use of ultrasound in Gynecology fertility workup ;Serial measurement of ovarian follicular diameter (folliculometry) and endometrial thickness are done using TVS. Mature follicle should measure between 18 and 20mm in diameter. The favorable peri-ovulatory endometrium should be between 7 and 11 mm thick. Ultrasound can provide presumptive evidence of ovulation. Following ovulation, internal echoes appear within ruptured follicle and free fluid is observed in pouch of Douglas

32. Cont… To detect correct timing of ovulation by folliculometry in conjunction with plasma estradiol. This helps in induction of ovulation, artificial insemination and ovum retrieval in IVF, sonographic guided oocyte retrieval in IVF and GIFT programs, is now accepted as the best method. Ectopic pregnancy can be detected on TVS as a tubal ring”, separate from the ovary in a patient with empty uterine cavity. TV–CDS is of more help to detect the vascularity of “tubal ring” when it is unruptured.

33. Cont… Pelvic mass can be evaluated as regard to its location and consistency. Uterine fibroid, ovarian mass, endometrioma, tubo-ovarian mass etc. can be delineated when there is confusion in clinical diagnosis. However, major limitation is due to its lack of specificity. .Oncology: TV-CDS can assess the vascularity of the mass . Low flow impedance with high flow velocity raises the suspicion of a malignant tumor.

34. Cont… Presence of papillary excrescences, mural nodules, septations, cystic lesion with solid components, snow storm appearance (hydatid-form mole) and ascites are the other sonographic features that can be seen on TVs.  Endometrial disease: Women with unexplained uterine bleeding, or postmenopausal bleeding are better studied with TVS. An endometrial thickness of less than 5 mm is considered atrophic.

35. Indications of First Trimester Ultrasonography . To Evaluate, Estimate or to Confirm intrauterine pregnancy. Suspected ectopic pregnancy, Vaginal bleeding (in all trimesters), gestational anomalies (anencephaly), Suspected molar pregnancy, Gestational age , Multiple pregnancy (chorionicity) , cardiac activity , e valuation of pelvic/adnexal masses (all trimesters)

36. Indications of Second and Third Trimester USG (ACR,2007) (For Estimation/Evaluation/Confirmation) G estational age , Cervical insufficiency, suspected multiple pregnancy, liquor volum e (poly/oligohydramnios) ,p lacenta Previa/abruption, suspected uterin e malformation, cases with premature rupture of membranes (PROM) ,f etal growth restriction (FGR) ,f etal presentation (breech, face) ,f etal well-being assessment , s creening feta differences , a s an adjunct to: amniocentesis, chorionic v ill us sampling (CVS), cordocentesis, fetal therapy, external cephalic version (ECV) ,u terine size: Either > dates or < date

37. X-RAY This is used to visualize internal structures.This is usually indicated in Urinary tract obstruction and other pregnancy related complications. It can either be a pelvic X-ray or abdominal x-ray.

38. Cont… X-rays are essential for investigation in pelvic malignancy, cervical cancer in particular, prior to staging. 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.

39. HYSTEROSALPINGOGRAPHY This is usually used for visualizing the uterus and the fallopian tubes. Its indicated for fertility evaluation and tubal patency testing. Its components may be Contrast agent injection or x-ray imaging of the uterus and fallopian tubes.

40. EXAMINATIONS. The examination includes: General and systemic examinations; Breast examination Abdominal examination Pelvic examination.

41. GENERAL EXAMINATION Palmar pallor, capillary refill Finger clubbing Pulse rate Blood pressure Axillary lymph nodes Cervical lymph nodes/masses Oral exam Conjunctival palor Jaundice Oedema

42. GYNECOLOGICAL EXAMINATION Breast Examination. This should be a routine especially in women above the age of 30 to detect any breast pathology, the important being carcinoma.

43. Breast quadrants;

44. Percentage of tumors per quadrant;

45. Local examination. Examination should be carried out in both sitting and supine position includes:- Inspection Palpation Lymph node examination

46. Inspection. Position With the arms by the side of the body- to assess the level of the nipples. With the arms raised straight above her head- lumps or dimple will be more marked. With the hands pressing on her hip- abnormal movement of the nipple or exaggeration of the dimples will be evident. With the patient bending forward from the wrist so that the breasts fall away from the body- failure of one nipple to fall away indicates abnormal fibrosis behind the nipple. Inspect systematically starting with the normal breast.

47. Nipple. Position- compare levels on both sides, elevation  cancer or inflammatory swelling due fibrosis. Size & shape prominent: underlying cyst or swelling  retracted: malignant, fibrosis Surface  look for cracks, ulceration, fissure or eczema and discharge

48. Areola. Look for:- Cracks Ulceration Fissure Eczema Discharge

49. Skin over the swelling . Look for :- Erythema Infiltration Ulceration Satellite nodules Skin dimpling Peau d'orange

50. Palpation. Position: sitting initially  recumbent position Look for:- Local temperature & tenderness Location [which quadrant] Size & shape Margin Consistency Fixation to skin, breast tissue, pectoral muscles & chest wall

51. Lymph node examination. Includes:- Axillary lymph nodes Supraclavicular lymph nodes Note:- Number Size Location Fixation to other nodes or underlying structures.

52. SELF EXAMINATION Breast self examination is always emphasized so as to know the breasts when normal and easily detect any new changes or deviations.

53. Inspection before a mirror Stand and face a mirror with your arms relaxed at your sides or arms resting on your hips; then turn to the right and left for a side view look. (look for any flattening in the side view

54. …continuation Bend forward from the waist with arms raised overhead Stand straight with arms raised over the head and move the arms slowly up and down at the sides. (look for free movement of the breasts over the chest wall) Press your arm firmly together at the chin level while the elbows are raised to shoulder level.

55. In palpation the breast should be: without masses, lumps, or tenderness Nipples should have no discharges Axillae should be smooth and nodes are non-palpable

56. Palpation: Lying Position Place a pillow under your right shoulder and place the right hand behind your head. This position distributes breast tissues more evenly on the chest. Use the finger pads (tips) of the three middle fingers (held together)on your left hands to feel the lumps. Press the breast tissue against the chest wall firmly enough to know hoe your breast fells. A ridge of firm tissue in the lower curve of each breast is normal. Use circular motions systematically all the way around the breasts as many times as necessary until the entire breast is covered. Bring your arm down to your side and feel under your armpit, where breast tissues are also located. Repeat the exam on your left breast using the right finger pads of your right hand.

57. General Guidelines: Male examiners should normally be chaperoned Texture: smooth to granular. During menstrual cycle and pregnancy Nodularity and tenderness often increase towards the end of the cycle and during menstruation. The patient should be undressed to the waist and seated with arms by side.

58. General overview; Breast size symmetry shape of breast skin color superficial veins Nipples everted, flat, or inverted (note if recent change or longstanding cracking or ‘eczema’ bleeding or discharge Milky (hypothyroidism, prolactinoma, drugs) Bloody (papilloma, Paget’s disease)

59. Nodules; Location (by quadrant or clock) Size in cm Shape Consistency Delimitation Tenderness Mobility

60. Various positions for examination;

61. Palpation techniques;

62. Lymph node palpation;

63. OBSTETRICS EXAMINATION. General examination Obstetrics include both traditional and leupold's manouvers.

64. General Examination Palmar palor, capillary refill Finger clubbing Pulse rate Blood pressure Axillary lymph-nodes Cervical lymph-nodes/masses Oral exam Conjunctival palor Jaundice Oedema

65. The traditional Obstetric exam Greet the mother, introduce your self and ask for her consent to perform the examination Tell mother to lie down in an anatomical position and expose from costal margin to symphysis pubis Ask for any areas of pain in the abdomen

66. The traditional Obstetric exam Take symphysial fundal length using a tape measure Palpate for the presenting part and make a logical conclusion Do fundal palpation a makes logical conclusion Add up findings of presentation and fundal palpation and concludes about the lie Perform lateral palpation and make conclusion about the fetal back and fetal position Auscultate for the fetal heart, palpate maternal radial pulse for comparison and count the fetal heart rate and make conclusion

67. Leupold maneuvers Fundal grip Umbilical grip First pelvic grip (Pawlick's grip). Second Pelvic grip

68. First maneuver: Fundal Grip While facing the woman, palpate the woman's upper abdomen with both hands. determine the size, consistency, shape, and mobility of the form that is felt. The fetal head is hard, round, and moves independently of the trunk while the buttocks feel softer, are symmetric , and the shoulders and limbs have small bony processes; unlike the head, they move with the trunk.

69. Second maneuver: Umbilical Grip attempts to determine the location of the fetal back. Still facing the woman, palpate the abdomen with gentle pressure using the palm of the hands. First the right hand remains steady on one side of the abdomen while the left hand explores the right side of the woman's uterus. This is then repeated using the opposite side and hands. The fetal back will feel firm and smooth while fetal extremities (arms, legs, etc.) should feel like small irregularities and protrusions

70. Third maneuver: ( first pelvic grip) ( Pawlick's Grip) Attempts to determine what fetal part is lying above the inlet, or lower abdomen. first grasp the lower portion of the abdomen just above the pubic symphysis with the thumb and fingers of the right hand. This maneuver should yield the opposite information and validate the findings of the first maneuver. If it is the head and is not actively engaged in the birthing process, it may be gently pushed back and forth. Although still used by some obstetricians, this maneuver is not recommended as it is more uncomfortable for the woman.

71. Fourth maneuver: (second Pelvic Grip) to determine fetal descent fingers are pressed in both side of the uterus approximately 2 inches above the inguinal ligaments, then press upward and inward. the fingers of the hand that do not meet obstruction palpates the fetal neck, as the fingers of the other hand meet an obstruction above the ligaments palpates the fetal brow. Good attitude if brow correspond to the side (2nd maneuver) that contained the elbows and knees. Poor attitude if examining fingers will meet an obstruction on the same side as fetal back (hyperextended head). also palpates infant’s anteroposterior position. If brow is very easily palpated, fetus is at posterior position (occiput pointing towards woman’s back).

72. Vaginal examination and pelvimetry Vaginal examination Inspection. Inspect for color of vaginal mucosa, warts, sores and swellings or any obvious vaginal discharge or bleeding. Palpation. palpate for warmth, and moisture of the vagina. palpate the cervix for position, thickness, dilatation, effacement, membranes if ruptured or intact. if ruptured feel for the presenting part , sagital suture for molding, station and color of the liquor on the gloved fingers at the end. Incases of cord prolapse feel for pulsation of the cord.

73. PELVIMETRY Two types 1. Clinical pelvimetry 2. Radiological pelvimetry However the method of focus in discussion is clinical pelvimetry.

74. THE IDEAL OBSTETRIC PELVIS Pelvic Inlet 1)Sacral promontory not tipped i.e. measures the obstetric conjugate Mid pelvis 2) Ischial spines are blunt means that the interspinous diameter > 10cms 3) Sacral curve should be concave Pelvic outlet 4) Pubic arch accommodates more than two fingers, that means that the subpubic angle is not acute i.e. > 90 degrees. 5) Intertuberous space should accommodate more than four knuckles, that means the intertuberous diameter is more than diameter > 10 cm.

75. THE IDEAL OBSTETRIC PELVIS • Normal pelvis: All the five parameters are normal • Borderline pelvis: one parameter is abnormal • Contracted pelvis: Two or more parameters are abnormal

76. THANK YOU References DC Dutta’s Textbook of Gynecology 7 th Edition, 2016. American college of obstetricians and gynecologists(ACOG )