UTERINE anomalies,prolapse, ovarian cyst.pptx

OG

1. introduction Obstetric and gynecology are closely interrelated disciplines. Disorders of the genital tract can complicate pregnancy and adversely affect its outcome. Mullerian defect from tubes, uterus, cervix and upper part of vagina. It has varying presentation ranging from primary amenorrhea to menstrual disorder, infertility and pregnancy complications like BOH, Ectopic etc.

2. UTERINE MALFORMATION

3. Definition of uterine malformation A Uterine malformation is the result of an abnormal development of the Mullerian ducts during embryogenesis. The most common types of uterine abnormalities are caused by incomplete fusion of mullerian ducts.

4. INCIDENCE   It varies between 3 and 4%. The incidence is found to be high in women suffering from recurrent miscarriage or pre term deliveries (5- 20 %).

5. CAUSES Failure of development of one or both mullerian ducts : The absence of both ducts leads to absence of uterus, including oviducts. There is absence of vagina as well. Primary amenorrhea is the chief complaint.  Failure of recanalization of the Mullerian ducts : Agenesis of the upper vagina or of the cervix – this may lead to hematometra as the uterus is functioning.

6. Failure of fusion of mullerian ducts : In majority, the presence of deformity escapes attention. In some, the detection is made accidently during investigation of infertility or repeated pregnancy wastage. In others, the diagnosis is made during D & E operation, manual removal of placenta or during cesarean section.

7. Types of uterine anomalies Arcuate uterus-32.8% Septate uterus- 33.6% Bicornuate uterus- 20.0% DES exposed uterus-0.8% Unicornuate & uterine dedelphys - 33%

8. UNICORNUATE UTERUS OR UTERUS UNICORNIS (10 %)   There is a failure of development of one Mullerian duct. Only one side of the Mullerian ducts forms and there is a single uterine cavity with a cervix and one fallopian tube coming out of the uterus.

9. Unicornuate uterus contd ….. Types Unicornuate with rudimentary horn communicating Non communicating With endometrium Without endometrium

10. Unicornuate uterus contd ….. Women with unicornuate uterus have an increased incidence of infertility Endometriosis Dysmenorrhoea Implantation in the normal size hemiuterus is associated with increase incidence of Spontaneous abortion Preterm delivery Intrauterine fetal demise

11. Clinical features and reproductive outcome Clinical features Heamatometra Endometriosis Preterm labour-43% IUGR Malpresentation Ectopic-4.3% Pregnancy in accessory horn-2% Ruptured uterus Reproductive outcome Live birth rate-43.7% Abortion-35 to 43% Preterm delivery- 27% Term delivery- 31%

12. Diagnosis and management Hysterosolphingography USG-3D or high resolution MRI - shows banana shaped uterus Intravenous urogram (IVU ) or renal sonography Surgical Management Laproscopy - indicated for excision of rudimentary horn which has endometrium Cervical encirclage - is mandatory if patient conceives

13. UTERINE DIDELPHYS (DOUBLE UTERUS-8%)   There is complete lack of fusion of the mullerian ducts with a double uterus, double cervix and a double vagina. This anomaly is distinguished from bicornuate and septate uteri by the presence of complete non fusion of the cervix and hemiuterine cavity.

14. Uterine didelphys contd … Women with this type of uterus suffer dysmenorrhea and dyspareunia . Premature births and malpresentation are common. Twin pregnancies are commonly associated with didelphic uterus .

15. Clinical features, complication& reproductive outcome Clinical features Asymptomatic- failure of tampons to obstruct menstrual flow. Hematometrocolpos Hematometra Hematosalphinx endometriosis Complication Preterm delivery Fetal growth restriction-10% Breech presentation-43% Cesarean delivery-82% Outcome Term delivery-20% Ectopic- 2.3% Abortion- 20% Live birth- 68% Preterm delivery-24%

16. UTERUS BICORNIS (26 %) - Bicornuate uterus)  There is varying degree of fusion of the muscle walls of the two ducts.  Uterus bicornis bicollis - There are two uterine cavities with double cervix with or without vaginal septum. Uterus bicornis unicollis - There are two uterine cavities with one cervix. The horns may be equal or one horn may be rudimentary and have no communication with the developed horns

17. UTERUS BICORNIS (26%) - Bicornuate uterus) contd …. Marked increase in miscarriage that likely due to the abundant muscle tissue in the septum Pregnancy losses in the first 20 weeks were reported. 70% for bicornuate Clinical features Asymptomatic Abortion-28% Preterm delivery-25% Live birth-63% Outcome Increased incidence in infertile population Term pregnancy rate-60% Live birth-65%

18. UTERUS BICORNIS (26%) - Bicornuate uterus) contd …. Diagnosis Hysterosalphingography Ultrasonogram -during luteal phase shows 2 endometrial cavities with a deep dimple in the fundus . MRI- ideal Intercornual distance->105 degree Myometrial tissue is seen in bicornuate uterus<75degree Management Metroplasty - is reserved only in recurrent abortion Strassmann procedure eithet by laproscopy or laparotomy .

19. SEPTATE UTERUS (35 %) A septum separates the uterine cavity into two separate cavities. The septum will arise and then extend down to the cervix and vagina. This develops when the two mullerian ducts have fused, but the partition between them persisted splitting the system into two parts. It is the most common form of malformation and cause for abortion. There is chance of preterm labor, if pregnancy progresses.

20. SEPTATE UTERUS (35 %) contd ….. Clinical feature: Dyspareunia Dysmenorrhoea Primary or secondary infertile Poor reproductive performance Investigation Hysterosalphingogram Ultrasonogram 3D ultrasonogram MRI

21. SEPTATE UTERUS (35%) contd ….. Management Hysteroscopic - septal resection under laparoscopic guidance using microscissors , electro cautery , laser, versal point. Stop dissecting- when both cornuate are seen in the same plane. - apparance of vascularity - move the scope from one side to other. Post operative management Estrogen may be used. Complication Uterine perforation Hemorrhage Cervical incompetance Residual septum

22. SEPTATE UTERUS (35%) contd ….. Out come Spontaneous abortion Live birth Term deliveries Pre term labour Ectopic Metroplasty increase incidence of live birth to 82%

23. ARCUATE (18 %) It has depression at the fundus . This malformation is only a mild deviation from the normally developed uterus. A woman with an arcuate uterus carries a baby to a full-term pregnancy. However, this condition is associated with a higher risk for miscarriage and premature births. .  

24. ABSENT UTERUS OR UTERINE AGENESIS This is the most severe kind of uterine malformation. There is failure of uterus, cervix and vagina to develop. A girl with this malformation will experience puberty with the absence of menstruation. The women will have a small dimple in the place where the vagina should be at.

25. DES - RELATED ABNORMALITY It is due to DES (Diethylstilbestrol) exposure during intrauterine life. Varieties of malformation are included. Eg : Vagina -adenocarcinoma, adenosis. Cervix - cockscomb cervix, cervical collar. Uterus- hypoplasia, T-shaped cavity, Fallopian tube - cornual budding, abnormal fimbriae.

26. CLINICAL FEATURES Gynecological : Infertility and dyspareunia are often related in association with vaginal septum. Dysmenorrhea in Bicornuate uterus or due to cryptomenorrhea. Menstrual disorders (menorrhagia, cryptomenorrhea) are seen. Menorrhagia is due to increased surface area in Bicornuate uterus.

27. Obstetrical: Mid trimester miscarriage which may be recurrent. Rudimentary horn pregnancy may occur due to transperitoneal migration of sperm or ovum from the opposite side. Cervical incompetence Increased incidence of malpresentation: transverse lie in arcuate or subseptate, breech in bicornuate, unicornuate or complete septate uterus.

28. Preterm labor, IUGR, IUD. Prolonged labor - Due to incoordinate uterine action. Obstructed labor - obstruction by the non-gravid horn of the bicornuate uterus or rudimentary horn. Retained placenta and postpartum hemorrhage where the placenta is implanted over the uterine septum.

29. DIAGNOSIS Ultrasonography. Hysterosalpingography which allows evaluation of the uterine cavity and tubal pregnancy. MRI Scan. Hysteroscopy.

30. COMPLICATIONS Dysmenorrhea. Hematometra. Complications during pregnancy and labour - late miscarriage, preterm labor, uterine rupture, malpresentation, obstructed labor. Fertility is unaffected except for uterine agenesis.

31. MANAGEMENT Surgical intervention depending on the type of abnormality or enabling a viable pregnancy. Rudimentary horn should be excised to reduce the risk of ectopic pregnancy. Unification operation (bicornuate or septate uterus) is, therefore, indicated in unexplained cases with uterine malformation. Abdominal metroplasty could be done either by excising or incising the septum. Hysteroscopic metroplasty is more commonly done. Resection of the septum can be done either by resectoscope or by laser.

32. ADVANATAGES - HYSTEROSCOPY i . High success rate(80-89%) ii. Short hospital stay. iii. Reduced postoperative morbidity. iv. Subsequent chance of vaginal delivery is high compared to abdominal metroplasty where C- section is mandatory. v. Unicornuate uterus has very poor outcome for pregnancy (40%) No treatment is generally effective vi. Uterus didelphys has best possibility of successful pregnancy (64%).

33. NURSING MANAGEMENT Assess the condition of the women by collecting health history, menstrual history and obstetrical history. Based on the severity of the condition plan for interventions. Educate the couple about the best possible treatment of uterine malformation . Assure the couple about chances of fertility or pregnancy except for the case of uterine agenesis. Allow the client exploring all possible options for family. Help the couples in overcoming dilemmas, deciding the right fertility treatment. Counsel and encourage the couple for child adoption in case of infertility.

34. Help the couple to deal with emotional stress. Advice the mother to avoid fertility impairing medication. To relieve dysmenorrhea, provide hot application. Administer analgesics to relieve pain. Educate the woman to practice light exercise and maintain nutritious diet such as fiber diet after surgical treatment.

35. Uterine prolapse

36. Definition of uterine prolapse Prolapse of uterus refers to a collapse, descend or change inn the position of the uterus in relation to surrounding structure inn the pelvis. - Shaws textbook

37. 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 condition. Incidence 1 in 250 pregnancies Associate condition Prolapsed uterus occur due to weakness of muscles that hold the uterus inn place Cystocele Urethrocele Enterocele Rectocele Relaxed perineum

38. Degrees of prolapse Prolapse of the uterus may be one of three types, depending on severity First degree Second degree Third degree First degree The uterus sags downward from the normal anatomic position into the upper vagina. The external os remains inside the vagina. Second degree The cervix is at or outside the vaginal introitus , but the uterine body remains inside the vagina. Third degree This type is also referred to as complete prolapse or prociidentia . The entire uterus descends to lie outside the introitus .

39. Effects on prolapse On pregnancy There is increased chance of Miscarriage Discomfort due to increased ailments Premature rupture of the membranes Chorioamnionitis During pregnancy Early rupture of the membranes Cervical dystocia Prolonged labour due to non-dilatation of cervix and obstruction due to sagging cystocele and rectocele . During puerperium Subinvolution Uterine sepsis.

40. treatment During pregnancy The symptoms are mostly pronounced in early pregnancy If the cervix is outside the introitus The cervix is to be replaced inside the vagina and is position by a ring pessary . The pessary is to be kept until 18 th -20 th weeks of pregnancy. When 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 20cm. To relieve edema and congestion of the prolapsed mass, it should be covered by gauze soaked with glycerine and acriflavine . The treatment is continued until 18 th -20 th weeks of pregnancy till the prolapse mass is reduced in size and replaced inside the vagina. Thereafter, the patient is allowed to walk about. If the cervix remains outside the introitus even in the later months It is preferable to admit the patient at 36 th week.

41. During labour The patient should be in bed, not only to prevent early rupture of the membranes but also to facilitate replacemetn of the prolapsed cervix inside the vagina. Intravaginal plugging soaked with glycerine and acriflavine , not only helps in reduction of cervical edema but also helps inn reduction of cervical edema but also facilitates its dilatation. Prophylactic antibiotic- incase of PROM or when the cervix remains outside, should be administered. 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 deeply engaged with the cervix remaining thin but undilated , delivery may be faclilitated by Duhrssen’s incision at 2 o’ clock and 10 o’ clock positions followed by ventouse extraction or forceps application.

42. If the head is high up and or the cervix remains edematous , thick or undilated , cesarean section is a safe procedure. PUERPERIUM The patient should lie flat on the bed. If the mass remains outside, it should be covered with gauze soaked in glycerine and acriflavine . If subinvolution is evident, a ring pessary may be put in until involution is completed. Prophylactic antibiotic is administered.

43. prevention Maintain a healthy body weight. Exercise regularly( for 20-30 minutes, 3-5 times per week), including kegal exercise, which may be done upto 4 times a day. Eat healthy diet balanced in protein, fat and carbohydrates. Stop smoking, this reduces the risk of developing a chronic cough, which can put extra strain on the pelvic muscles. Consider estrogen replacement therapy after menopause. Use correct lifting techniques. Chroonic straining such as chronic constipation, should be avoided.

44. Ovarian cyst Defintion An ovarian cyst is semi-solid or fluid filled sac within the ovary. Etiology Most ovarian cysts occur as part of the normal workings of the ovaries. These cysts are generally harmless and disappear without treatment in a few months. Cysts caused by abnormal cell growth and aren’t related to the menstrual cycle. They can develop before and after the menopause. Condition that cause ovarian cyst Endometriosis PCOS

45. Polycystic ovary syndrome PCOS is a condition that causes lots of small, harmless cysts to develop on the ovaries. The cysts are small egg follicles that do not grow to ovulation and are the results of altered hormone levels. Types of ovarian cyst Functional ovarian cyst Pathological cyst Functional cyst Cysts that develop as part of the menstrual cycle and are usually harmless and short-lived. These are the most common type of ovarian cyst.

46. During pregnancy Any type of ovarian cyst can occur during pregnancy. But simple cyst and dermoid cyst. Incidence Ovarian cysts during pregnancy are usually benign, but around 10% of cysts below 30 years are malignant and this proportion actually rise with age. Investigation History collection Physical examination Ultrasound scan, CT Scan, MRI Blood test: CA 125-to screen for ovarian cancer. Pregnancy test: a positive pregnancy test result may suggest the patient has a corpus luteum cyst. Laproscopy

47. Pathological ovarian cyst Cysts that occur due to abnormal cell growth, these are much less common. Dermoid cyst Cystadenomas Endometriomas Signs and symptoms Abdominal bloating or swelling. Painful bowel movements Pelvic pain before or during the menstrual cycle. Painful intercourse Pain in the lower back or thighs. Breast tenderness Nausea and vomiting.

48. In pregnancy It is detected incidently at the antenatal clinic. During routine ultrasound. Torsion is more likely to occur. During early second trimester or puerperium when there is relatively more space in the abdominally cavity. Pregnancy is usually undisturbed by the ovarian cyst unless torsion or other complication. Labour is unaffaced unless the cyst is deeply impacted in the pelvis thereby causing obstruction. Depends upon size, sonographic apearance symptoms, An ovarian cyst may undergo torsion or rupture during the pregnancy and can cuase acute abdominal symptoms. When the patient presents with acute symptoms laparotomy should be undertaken regardless of the duration of the pregnancy.

49. Contd …. If the ultrasound features suggests complex mass with high suspicious of malignancy laparotomy should be undertaken as soon as possible.(or) cystectomy ( cyct >5cm) If an asymptomatic cyst is discovered, it is prudent to wait until after 14 weeks gestation before removing it. ( this avoids the risk of remaining a corpus luteal cyst upon which the pregnancy might still be dependent at an earlier stage). Aspiration, unilocular cyst>10cm transvaginally or abdominally. Often it is possible to keep a close eye by serial ultrasound examination during the pregnancy and plan surgey at 6to 8 weeks after delivery.

50. Ovarian cyst Complex or simple cyst >5cm- sever pain/ torsion / pressure symptoms- surgery, aspiration if simple cyst rescan in 4 weeks MRI in suspicious- rapid increase in size or high ?malignancy .- surgery , aspiration if simple cyst Simple cyst<5cm No further action Not increase in size- rescan 6 week postnatal

51. complications Infertility Ovarian torsion Rupture Ovarian cancer

52. CONCLUSION G ynecological problems affect the female reproductive system. Every woman suffers from some gynecological disorders at some points in her life. Early diagnosis is important to prevent sequelae of delayed diagnosis.

53. SUMMARY So far we have discussed about definition, incidence, types, clinical features, diagnosis complication and management of uterine anomalies, prolapse , ovarian cyst.

54. Journal application The impact of congenital uterine Babnormalities on pregnancy and fertility. Yadegiri et al(2021) The review clearly showed that although these disorders are generally not lethal(death or damage), they critically impact the patients reproductive health. The fertility rate of patients with uterine congenital abnormalities depends on the severity of the condition. Reproductive endocrinologists and infertility specialists must be considered as active parts of the interdisciplinary treatment team for such patients. ART practices are reasonably successful at managing fertility problems of women with these abnormalities.

55. Journal application Management of pelvic organs prolapse during pregnancy Vargas B.A.M et al (2022) Pregnancy using a pessary is the best option to improve maternal symptomatology and minimize gestation risk, there is no contra indication for vaginal delivery . Management of ovarian cyst during pregnancy Bhagat.N ., et al(2022) MRI also use in pregnancy to better delineate ovarian lesions. Simple cyst <6cm can be safely managed conservatively, with surgery reserved for larger, ovarian cyst can be managed laproscopically between 14 and 16 week gestation.

56. TEACHER REFERENCE: Dc Dutta (2004) 6 th edition text book of gynecology, Jaypee Brothers Text book of Medical publishers (P) ltd. New Delhi. Nima Bhaskar (2017) 2 nd edition Midwifery and Obstetrical Nursing EMMESS Medical Publishers Bangalore. Kumari N (2014) A Text Book of Midwifery & Gynecological Nursing, S. Vikas company medical publishers, Jalender city, Annamma Jacob (2015) A comprehensive text book of Midwifery & Gynecological Nursing,4 th edition, Jaypee Brothers Text book of medical publishers (P) ltd. New Delhi. https://en.m.wikipedia.org/wiki/Uterine_malformation

57. STUDENT’S REFERENCE: Dc Dutta (2004) 6 th edition text book of gynecology, Jaypee Brothers Text book of medical publishers (P) ltd. New Delhi.