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5th-95th centile being 23

sing oral contraceptives.

menstruation: bleeding at any time outside normal menstruation and any

variation outside the defined limits.
pre or postmenopausal bleeding.
90% occurs 1because of underestimation by some patients.


al appraisal of menstrual blood loss is uncertain


75% of menstrual flow is blood, the rest is made up of fragments of

Aggregation of endometrial tissue, red
blood cells, degenerated platelets and fibrin.
metrium contains large amounts of fibrin
the presence of clots in menstrual flow Excessive menstrual blood flow.
leukotrienes all play an important role in menstruation.
membranes and converted to arachidonic acid by phospholipase A2. Cyclo-oxygenase converts
arachidonic acid to unstable endoperoxides (PGG3 and PGH2) which are rapidly converted to by specific
synthetases into:
- potent vasoconstrictor and weakly pl

potent vaso
Thromboxane potent vasoconstrictor and platelet inhibitor.
site of synthesis.
intervals of more than 35 days.

norrhea: menstrual periods at

leeding usually excessive and prolonged

bleeding occurring at intervals of 21 days or less.

bleeding: uterine bleeding, usually not excessive, occurring at any time during the menstrual cycle other
than during normal menstruation.
7. Dysfunctional uterine bleeding (anovulatory bleeding)
al years.
rs many factors might
and physiologic.

8. Etiologic classification of anovulatory bleeding

pituitary axis; functional or chronic diseases; traumatic, toxic, and infectious lesions; polycystic ovarian
; psychotrophic drugs, drug addiction,
exogenous steroid administration.
ses: chronic illness, metabolic or endocrine
premature ovarian failure.
9. Perimenarcheal dysfunctional uterine bleeding (DUB)
associated with oligomenorrhoea, polymenorrhea or some irregularity of menstruation due to delayed
or failed ovulation with a failed luteal phase support.
prolonged leading to severe anaemia especially in truely anovulatory cycles.
persists the existence of PCO must be excluded and the teenager treated with cyclic hormones or oral
10. Menstrual disorders Reproductive Age
disorers involve marital and sex life, a detailed history might reveal significant events that precedes
anovulatory episodes.
mon finding: obesity, hirsutism, anovulatory cycles
(failure of follicular development), endometrial hyperplasia.
11. Abnormal vaginal bleeding Reproductive age
- sometimes mistaken for vaginal bleeding.
cervical polyps, cervical canc
hyper or hypothyroidism, Cushing syndrome, diabetes.

l disorders:
s: malnutrition and

12. Menstrual disorders Reproductive age

Frequently due to benign organic disease of the reproductive tract such as fibromyomas or pelvic

13. Menstrual disorders Reproductive age

suggestive of organic disease: carcinoma of the
(anovulatory cycles).
14. Menstrual disorders during perimenopause
failing ovarian function.
normal values occasionally ovulation occurs.

acyclical bleeding (metrorrhagia)

ith a
ome cycles are

15. Abnormal bleeding Postmenopausal bleeding.


vaginal and endometrial atrophy, vaginal, cervical and uterine cancers, urethral caruncle, cervical polyps,
uterine fibroids.
bleeding which can be confused with vaginal bleeding.
16. Vaginal bleeding Postcoital
penile bleeding: blood might come fr


17. Vaginal bleeding Drugs Certain drugs and medications can cause vaginal bleeding.
contraceptives(starting or

18. Abnormal vaginal bleeding Diagnosis

on and
pattern of bleeding;and associated gynaecological problems, including infertility or perimenopausal
Willebrandt disease, myxoedema,
thyrotoxicosis, Cushing disease, renal failure, etc.
ients plans and wishes: contraception, future
pregnancies, possible hysterectomy.
19. Abnormal vaginal bleeding Diagnosis
and pelvic examination essential (exclude pelvic masses).
D/C: mainly diagnostic but can also be therapeutic.

20. Abnormal vaginal bleeding Diagnosis

hyperplasia, endometriosis, tuberculosis).

seases), abdominal

(endometrial polyps,
ndometrium: proliferative or

permits visualisation of the uterine cavity.

65% D and C.
21. Abnormal vaginal bleeding Diagnosis
Haematological investigations
especially in cases of DUB: FBC, platelet count, clotting profile, bleeding time, clotting factors.

22. Principles of management

surveillance (vital signs, urinary output, central venous pressure).

ding: admission and

time, blood sugar, renal and liver function tests based on suspected pathology,
related complications and abdominopelvic masses.

23. Principles of management

associated with profuse blood loss:
Treat patients
ening blood loss
with transfusion: rare.
24. Management of chronic menstrual disorders
25. Principles of management
tives (DUB), antibiotics (PID), GnRH analogues.
26. Specific management
cervical cancers.
27. Conclusion
occurrence in different age groups (pubertal years, reproductive age and perimenopausal period).
Requires proper evaluation so that the underlying pathology can be diagnosed and specific treatment
surgery (in cases of advanced cancers).
28. Thanks for your attention.
Diseases of genital tract

-reproductive age group

with inc
incidence of pulmonary and extrapulmonary forms of tuberculosis including drug resistant forms.
intercourse with a partner suffering from tuberculous lesions of genitilia

-bovine org

-2%-ascends through the genital tract


ly a small no of cases


tubercular salphingitis

10. Tuberculous endosalphingitis

- frequent exacerbations

- fimbrial end is pouting,

with oil contrast

subacute,recurrent PID

e to recurrent attacks by pyogenic organisms wrong diag - hyperplastic oedematous patternlate stage


miliary tubercules

-attempt to separate adhesions



17. cervix
18. Vulva & vagina

-tubercles on surface, adhesions with tube

endAbscess in myometrium- rare

- caseating material collects


- ulcer/red papillary erosion bleed on touch

-shallow,undermined edges


- confirmed

- caseation, gaint cells, clusters of epithelial cells ,lymphocytic

- typical gaint
ion in case of prev sx foreign body reac

16. uterus
in uterine cavity- pyometra

Poor quality of ova may be responsible

21. Menstrual disorders

-amenorrhoeaamenorrhoea, pelvic ex- adnexal swelling22. pain

- amenorrhoea


23. Vaginal discharge

24. Abdominal mass

A doughy feel tb peritonitis FISTULA FORMATIONFollowing sx for abscess


immobile,sometimes tender -

26. HSG in asymptomatic-

- small,fixed -frozen pelvis

ion in filling density

-spred the infection

pouch and dilated distal end

lesion suff from infertility, menstrual disorders,pelvic mass




genital lesion
Chestxray-healed/active pulmonary infection
-week preceeding menstruation

timing of uterine curretage/less incidence of uterine infection



lcer- mimic ca


innoculation test-if positive-type the bcilli,report their drug sensitivity

- 10 org in clinical specimens compared to 10,000 for smea positivity
Genital tb- always paucibacillary

33. First day menstrual discharge


d amplification,
-not rule out tb




- lesion in

-CI reactivation of lesion

ing of tubes/calcified shadow of places
- irreg outline. honeycomb app/uterine synaechiae

diagnosis Laproscopy fluiddiscovered during diag lap for infertility
37. DIAGNOSIS The physician should Be conscious of entity
Unexplained infertility/amenorrhoea 2. Recurr episodes of pelvic infections,not responding with usual
course of antibiotics 3. Presence of pelvic mass with nodules in the POD
38. DD Pelvic mass-

disturbed ectopic pregnancy


41. general

cute exacerbations

during intercourse- prevent urogenital tb

42. chemotherapy
emergence of drug-

Ethambutol-prev treated/immunocompromised

on phaseisoniazid,rifampicin

- endometrium is examined at interval of six mnths

44. patient must be considered cured

examination becomes negetive


nd bacteriological

ity rate
drug regimens(CDC)

2 or more agentsincluding

46. DRUG Daily oral dose Nature Toxicity Comments Isoniazid 5mg/kg Max-300mg Bactericidal
Hepatitis,perip heral neuropathy Check LFT, Combine pyridoxine 50mg daily Rifampicin 10mg/kg Max600mg Bactericidal Hepatic dysfunction, Orange discolouration urine,febrile reaction avoid- ocp Monitor
liver enzymes Pyrizinamide 20-25mg/kg Max-2gm Bactericidal Hepatitis,huper uricaemia,GI
upset,arthralgia LFT, Active against intracellular dividing forms Ethambutol 15-20mg/kg Max-2.5gm
Bacteriostatic Visual disturbances,op tic neuritis,loss of visual activity Ophthalmosco pic prior to therapy
47. Itermittentdose shedule
Isoniazid-15mg/kg-3 times a week for 6 mnths
-30mg/kg-3 times a week6mnths


-30mg/kg-3 times a week for first 2 mnths

-600mg-3 times a week for

-15-aminosalicylic acid-




-tubercular tx
iachr pelvic pain causing
deteriorating health status

50. CIAccidental discovery of tubercular tubo ovarian mass on laprotomy in young pt.-abdomen is closed after
taking tissue for biopsy
51. Precautions-

52. Types of surgery-

ntinued 6wks after sx

be restored when tubal walls are damaged


provided endometrium normal

54. VULVAL TUBERCULOSIS Painful,tender ulcer

Cervical cytologycells,dyskaryotic cells


-ulcerated /hypertrophic
t cells,epitheloid

nfections of the female genital tract is causes by etiological agent such as Bacteria Fungus Parasite
3. BACTERIA Chlamydia trachomatis Gardnerella vaginalis Acinomyces israelii Virus infection Herpes
simplx virus(HSV) Human papilloma virus(HPV) cytomegalovirusCMV ) Fungal Infection Candida albicans
Parasite infection Trichomonas vaginalis Infections of the female genital tract
Chlamydia trachomatis
Chlamydia trachomatis is specialized
Gram Negative small bacteria an obligate extracellular pathogen
Chlamydia resembles viruses in being unable to reproduce outside of living cells.
Normal habitat of Chlamydia trachomatis can be found n the human genitourinary tract.
Its occur in two forms:
-infective extracellular elementary body
-the intermediated reticulate bodies /particle
5. Microscopy and cytological features Show infected the metaplastic squamous cells and endocervical
cells frequently affected.Parabasal cells sometimes involved The important features significant is intra
cytolplasmic inclusion that also show faint eosinophilic coccoid bodies The inclition bodies also can be
detect microspically by immunofluorescence or Giemsa stained prepared. Other features is
showreactive changes of squamous and columnar cells and multinucleation
Gardnerella vaginalis
Gardnerella vaginalis previously known as Haemophilus vaginalis

that causes vaginitis ,probably by acting with anaerobs such

as Bacteroids
the infection usually sexual trassmitted disease.
Gardnerella vaginalis infection usually associated with vaginosis
G.V is found in healthy women also causes
neonatal sepsis and bladder bacteuria.
Signs and symptoms
excessive malodorous vaginal discharge
vaginal pH greater than 4.5
a fishy ,amine like odour
Microscopy and cytological features
Microscopy show Gram positive ,non motile and non capsulated coccobaccilus or rod
Large number of coccobacilli can often be seen attached to epithelial cells known as clue cells.
The presence of clue cells (vaginal epithelial cells coated with masses of (coccobacilli)
significant of increase in number of obligate anaerobes such as Bacteroids in Vaginal flora.
Other organism of normal flora of vaginal and Lactobacilli are absent or scanty.
Acinomyces israelii
Acinomyces species form part of the normal microbial
flora of the mouth and female genital tract
Acinomyces israelii is Gram Positive bacilli non motile,non sporing
and the morphologically resemble the thin branches.
Facultative anaerobes that causes pelvic actinomycosis

Usually infection occurs at human with IUCD ,

Foreign body ,vaginal pessaries ,surgical clumps and
forgotten tampons associated with actinomycosis usually.
Acinomyces israelii causes actinomycosis a chronic granulamataus.
Microscopy and cytological features
amorphous deep purple clumps and dark in centre are seen
Also show a thin and thick filaments
9. Fungal Infection Candida albicans Candida albicans is the commonest cause of candidiasis(moniliasis)
The yeast is a common commensal of gastrointestinal tract . Candida albicans is a normal in habitat of
female genital tract Load of candida in FGT may causes irritants vaginitis Candidiasis is also associated
with prolonged broad spectrum antibiotic theraphy. Depression normal acidity of FGT condition candida
to invade epithelium favored by the administrationof broad spectrum antibiotics Women who use oral
contraceptive will develop this infection. Diagnosis confirm by microscopy and culture of discharges.
Candida yeast cells can be detected in unstained with germ tube and stained with Gram stain
Cytological features
Candida albicans can be icentified by the formation of pseudohyphae and spores.
candida have two form
Yeast-small pink spores
Pseudohyphae elongated and become long
Candida stains eosinophilic
Clear zone outside the hyphae and the spores
Smear show prodominent intermediated
Glycogen granules easily seen
Epithelial cells clumps in group and fungus usually seen at the end of clumps
Nuclei enlarged and may darker

Parasite infection
Trichomonas vaginalis
Trichomonas vaginalis is protozoan parasite that inhibit the vaginal in
women and the urethra in men and also in prostate sometimes.
T.V Transmitted with sexual intercourse from men to women and
also women to men.
In women,vaginal show foul smelling green yellow discharge
Vaginal pH also show alkaline
40-50% infected woman is asymptomatic
Cytological features of the TV parasite
Round oval and pear shape
Variable stained greenish-blue ,blue grey
Nucleus usually single and eccentrically occasionally binuclear ,
side by side lying
Occur single and irregular
Crowd epithelial cells(intermediated cells)
Motile identified by wet preparation of vaginal discharge
Staining with PAP
12. Cellular changes Abundant polymorph and cannonball cells. Squamous cells shift to the right in
maturation index Anucleated squamous cells and squamous cells smaller than usual (parakeratosis) A
background mucus may form a net like structure on the slide Perinuclear halos-clear zone around nuclei
Associated bacteria coccoid bacteria and leptophrix Nucler changes Enlargement of nucleus and
increase ratio of N/C Chromatin structure slightly granular and many small dark chromacentres
Nucleolus may be seen Binucletion and multiniclition may occur especially with endocervical cells
Nuclear degeneration nuclei loss (karyolysis)

13. Virus infection Herpes simplx viruse(HSV) Herpes simplx viruse(HSV) belong to the family
Herpesvirus. The viruses is Double Stranded DNA that have two types HSV 1 and HSV -2 Infection
caused by HSV 1 included gingivostomatitis (ulceration of the gums and lining of the mouth) in young
children. An important infection caused by HSV-2 is genital herpes. The virus is sexually transmitted and
can causes painful ulceration of he genital tract and uro genital organs .HSV -2 has been associated with
cancer of the cervix .
14. Cytological features The cytologic appearance of HSV infection is easily recognized,HSV show
cytologic canges where the cells are characteristic by large multiple nuclei that are molded together
(arrowed) and show marginatin of chromatin and generally empty nuclei.large intranuclear inclusion are
also commonly seen it is important to different such as cell from binucleated cell that are common
found in associated with HPV infection .cytologically appearance of degeneration and necrotic cells in
which ghost of the nuclei can just be recognized . this necrotic cellular appearance have to be different
from those that associated with carcinoma. microscopically can show enlargement squamous and
metaplastic type cells and also multinucleation .Internuclear moulding present on the cells and the
blurring and show smudge cells that lost of chromatin structure . the chromatin also show the
degeneration of chromatin form distinct nuclear border. in the primary infection ,nuclei show typical
ground glass, overlapping and molding nuclei and in the re-current infection a large eosinophilic
intranuclear inclusions.
15. Characteristic of Human Papilloma Virus (HPV) Human Papilloma Virus (HPV) is a very common virus
(germ) that causes abnormal cells or growth of tissue on the skin of the body. HPV can cause abnormal
tissue changes on the feet, hands, vocal cords, mouth and genital (sex) organs. Over 60 types of HPV
have been identified so far. Each type infects certain parts of the body. In gynecology, we are concerned
about the types of HPV that infect the female organs Human papilloma virus(HPV) is double stranded
DNA virus . HPV have 60 types the important type is Type 6,11,31,42,45 and this type of HPV only
produce a low risk lesions. Type 16,18,31,35,39 cause high risk lesions of ano genital ,laryngeal
esophageal and lung in the service may causes high grade lesions progress to malignancy .
16. Cytological features Cytological features of Human Papilloma Virus (HPV) can see microscopically
from the cellular changes.thimportant cellular changes that perform the characteristic of Human
Papilloma Virus (HPV) is Koilocytosis, Parakeratosis ,Binucletion and multinucletion ,Dyskeratosis ,and
Hyperkeratosis Koilocytosis Many cell show perinuclear clearing of the cytoplasm with a hard margins to
the vacuole(arrowed) . The borderline of nuclear also changes.that increase cytoplasmic ratio, smooth
muscle outline and fine evenly dispersed chromatin. The Squamous cells also show peripheral well
defined dense cytoplasmic and surrounding clear perinuclerahalos . It is commonly in the type of
superficial and intermediated cells .Cytoplasmic staining amphophilic
17. Parakeratosis Parakeratosis mean of when the cell become smaller than normal cells.or Minture
squamous cell singly or in groups.the type of cells to differ is smaller than parabasal cells.The nucleus

show pyknotic nucleus and cytoplasm may be keratinized Binucletion and multinucletion Binucletion
and multinucletion always seen in mature squamous ,metaplastic cells and in parakeratotic cells. The
chromatin structure due to nuclear smudge and pyknotic. The Nuclear also enlargement and dysplastic
changes Dyskeratosis Enlargement of nucleus with chromatin clearing and incomplete nuclear envelope
and a result of degeneration superimposed changes.Cytoplasm also become darker Hyperkeratosis
Hyperkeratosis show anucleated squamous due to karyolysis.karyolysis is cytoplasm when nucleus are
disappear.(not have nucleus).Also show yellow and orange cytoplasm.
18. CytomegalovirusCMV) belongs to the family Herpesvirus Disease caused by CMV can occurs
conginental neonatal and childhood thatcan causes infection in epithelial tissue of salivary gland
,bronchus alveolar,renal tubes and endoservic . During pregnancy lead to conginental disease ,mental
diagnosed ,deafness and multiple other birth defectsRarely diagnosed with cervical-vaginal smear.
Cytological features CytomegalovirusCMV) microscopically characteristic by eosinophilic intranuclear
inclusion with single nuclei.CMV differ from HPV because multinucletion not occur. To confirm CMV case
must diagnosed by immunocytochemical method CytomegalovirusCMV
19. Normal flora of female genital tract is lactobacillus spp. Account for 95% of vaginal microorganism,
lactobacillus acidophilus. Maintain vaginal pH 3.8-4.2 from the production of lactic acid. Lactobacillus
also suppress the growth of gram negative and gram positive facultative and obligate anaerobes via the
production of hydrogen peroxide. The organism make up Normal flora of female genital tract is
corynebacterium, streptoccus,peptostreptococci and bacteroids. Infections in the female genital tract
are extermly common in clinical and cytophatology practice and include complication of
pregnancy,inflammation,tumor and hormonally.other high risk factor is IUCd user,oral
contraceptive,and via sexually. The main symptom of infections in the female genital tract is
diching,pruritus,dysuria and dysparaeunia . CONCLUSION
20. From the TBS (the Bethesda system) Infections of the female genital tract is categories of benign
cellular changes. The main focus of cervical/vaginal cytology traditionally been the detection of cervical
cancer precursor. However, various benign processes can also be recognized morphologically, and
diagnosis of these entities can make an important contribution to patient care. The Infections of the
female genital is causes by etiological agent such as Bacteria ,Fungus,viruses and parasite .
vaginal canal or a
graduallydescends of the uterus in the axis of the vagina takingthe vaginal wall with it.
4. Usually, prolapse is rated by degrees:
-degree prolapse: the cervix part of
-degree prolapse
-degrees prolapse: the
uterus protrudes through the introitus.

5. First degree prolapse

6. Second degree prolapse
7. Third degree prolapse
8. Etiology
abdominal pressure as a result of chronic coughing, lifting of heavy objects and obesity, place pressure
on the pelvic floor.
presumably to
female hormone estrogen plays an important role in maintaining the strength of the pelvic floor).
11. Clinical Manifestation
pty the bladder
pulling in t
12. Treatment
vice fits inside your vagina and holds youruterus in place. Used
as temporary or permanent treatment,vaginal pessaries come in many shapes and sizes.
14. Treatment (cont.)
prolapse. These proceduresinclude: surgery to repair the tissue that supports the prolapsed organ
surgery to repair the tissue around the vagina surgery to close the opening of the vagina surgery to
remove the womb (hysterectomy)
15. Collaborative Care
orough explanation of procedure,
sing edema (rectocele) independently,
at home a day prior procedure
nursing care:

Up to half of the normal female population will develope uterovaginal prolapse during their lifetime.
Twenty percent of these women will be symptomatic and need treatment .

As the population of the world continues to increase in age, the prevalence of pelvic floor dysfunction is
likely to increase.
3. : Structure and function of the pelvic floor
The pelvic floor functions to support the pelvic and abdominal viscera and help maintain control of their
It has two major components which are interdependent:
the muscle and facia.
4. Muscle:
Levator ani muscles consist of pubococcygeus , coccygeus and ileococcygeus muscles on each side which
together form a muscular floor to the pelvis.
The striated muscle of levator ani is under voluntary control but is a unique striated muscle in having a
resting tone.
5. Muscle:
Contraction of the muscles results in a forward elevation of the pelvic floor which is important in their
role in continence.
This forward elevation helps to increase the angulation between bladder and urethra anteriorly and
rectum and anal canal posteriorly . Increase in this angulation is one of the fundamental mechanisms
which aid continence
6. Muscle:
When the intra-abdominal pressure rises levator ani muscles contract and provide additional support
and outlet resistance to the bladder and rectum.
This reflex response to intra-abdominal pressure rises also requires an intact innervation.
Damage to the pelvic floor muscle innervation is likely to impair the pelvic floor muscle responses.
7. Fascia:
Fascia envelopes levator ani, attaches it to bone at its origin and holds the two muscles together in the
The urethra, vagina and rectum perforate this midline fascia.

Thus, the pelvic viscera are supported both by the levator ani muscle below and the fascial attachments
which are condensed in some areas and are often referred to as ligaments the uterosacral, cardinal
and round ligaments being examples.
8. Fascia:
any factor that influences the strength or integrity of pelvic floor fascia will influence the function of the
pelvic floor.
These factors may be congenital (such as hyperelasticity of the collagenous component of fascia ) or
environmental , such as stretching or tearing of fascia during childbirth or heavy lifting.
9. Pathophysiology of pelvic floor dysfunction Muscle
The striated muscle of the pelvic floor, undergoes a gradual denervation with age .
This denervation will result in a gradual weakening of the muscle over time .
Pelvic floor muscle denervation is increased by vaginal delivery , particularly if the active second stage of
labour is prolonged .
Caesarean section may offer some protection from this injury.
10. Pathophysiology of pelvic floor dysfunction Muscle
The site of pelvic floor muscle denervation during childbirth is unclear. It has been proposed that
stretching of the pudendal nerve at the ischial spine results in nerve injury .

In neurological diseases like multiple sclerosis , pelvic floor muscle may behave unpredictably ranging
from inappropriate relaxation causing incontinence to spasm resulting in voiding dysfunction.
11. factors have a significant influence on pelvic floor support: .

Congenital differences in collagen behaviour are clinically evident in women who have increased joint
Women with hyperextensible joints will develope uterovaginal prolapse at an earlier age. Such women
often excel at sports requiring increased joint elasticity (such as gymnastics) and they develop fewer
striae gravidarum during pregnancy because of increased skin elasticity.
13. : 2.AGE
The fascia of the pelvic floor will provide weaker support with advancing years.
Gynaecologists repairing the pelvic floor often recognize that the tissues used for building a repair are of
poor quality and are poorly vascularized.
The repair after surgery will heal with less strength and more slowly. The recurrence of prolapse seen
after surgery in one out of three cases must in some part be due to a deterioration of fascial strength
with age.
Most women recognize that their pelvic floor is different after vaginal delivery.
regaining the tone and shape of their anterior abdominal wall is also often a difficult challenge.
These changes are due to a combination of muscle and fascial changes. whether pelvic floor fascia
stretches or tears during pregnancy and childbirth.

The menstrual cycle, pregnancy and the menopause are the most significant endocrine events which
may influence pelvic floor fascia.
Women often declare that prolapsed symptoms are worse around the time of menstruation.
This is thought to be secondary to higher progesterone levels increasing fascial elasticity.
women examined at the time of menstruation will have a higher stage of prolapse than at other times of
the cycle.
During pregnancy, prolapse symptoms will be more evident in the first trimester but diminish as the
pregnant uterus enlarges out of the pelvis.

The prevalence of uterovaginal prolapse increases after the menopause

17. Uterovaginal prolapsed:
Prolapse is normally divided into anterior, uterine/vault, posterior compartments.
anterior vaginal wall prolapse is still commonly called a cystocoele and posterior prolapse a rectocoele
or enterocoele .

18. Symptoms:
Prolapse classically produces a sensation of fullness in the vagina or a visible or palpable lump at the
Low backache is a common symptom but is also commonly experienced by women who do not have
prolapse .

Vaginal atrophy , if present, will exacerbate many prolapse symptoms and should be treated as a first
priority with topical oestrogens unless clinically contraindicated .


Anterior vaginal wall prolapse may result in a range of urinary symptoms .
While women who have anterior prolapse may have stress incontinence, particularly if the urethra is not
well supported,
they may also have voiding dysfunction secondary to kinking of the urethra.
Voiding dysfunction may result in
1. frequency (due to incomplete bladder emptying),
2. hesitancy .

3. a poor urinary stream .

4 recurrent urinary infection with accompanying frequency, urgency and urge incontinence.
Posterior vaginal wall prolapse may be associated with a range of bowel symptoms .
Constipation is a common symptom in women and may contribute to obstructed defaecation.
Posterior vaginal wall prolapsed does not normally result in ano-rectal incontinence
Prolapse often does not interfere with normal sexual activity.
many women feel unhappy with the vaginal discomfort experienced through the sexual activity.

Some couples find that the loss of tone in the vagina leads to sexual dissatisfaction for both parties.

23. Classification:
1 Dislocation of the urethra the urethra is displaced
downwards and backwards off the pubis. It may be also dilated becoming an urethrocoele.
2 Cystocoele hernia of the bladder trigone .
3 Uterine prolapse descent of the uterus and cervix.
24. Classification :
4 Enterocoele or pouch of Douglas herniaa prolapse of the upper part of the posterior vaginal wall.
The hernia contains the peritoneum of the pouch of Douglas often with a loop of bowel.
5 Rectocoele a prolapse of the lower part of the posterior vaginal wall due to weakness of the
levatores ani; the rectum bulges into the vagina.

25. Uterine prolapse ( Three degree):

(a) First degree with a descent of the uterus , but the cervix remains within the upper vagina.
(b) Second degree uterine descent when the cervix reaches down to the vulva on straining, but does not
pass through it.
(c) Third degree or procidentia when the cervix and some or all of the uterus is prolapsed outside the
vaginal orifice
26. 3 rd degree vaginal prolapse ( procidentia)
27. Investigation of prolapse symptoms:
Abdominal examination should be performed to exclude an intra-abdominal mass.
Abimanual pelvic examination or ultrasound should exclude a pelvic mass and delineate the size of the
uterus and ovaries if present.
The patient should be examined in the horizontal position, conventionally in the left lateral position with
a Sims speculum .
If prolapse is not evident, even with a Valsalva manoeuvre, the patient should be examined in the
upright position.
Many women are only aware of their symptoms after a long period in the upright position. An early
morning clinic appointment may preclude detection of the prolapse. Some clinicians examine women in
the lithotomy position .
If a woman has significant urinary symptoms urodynamics may help define cause of symptoms .
if urodynamics indicate obstructed voiding there is a good prognosis for surgical repair of the cystocoele
resolving the voiding dysfunction .
An rectocoele may result in obstructed defaecation.

Proctography can give some insight into factors which may be contributing to difficulty with defaecation
and may help avoid unnecessary, unhelpful vaginal operations .
31. Treatment: of genital prolapse:
Some women elect for non-surgical treatment of their prolapse either because:
1 the prognosis offered for treatment is not sufficiently attractive
2 they are unfit for surgery
3 they wish to delay surgical treatment for other reasons.

32. Conservative treatment may involve :

1.Lifestyle advice:
This may include advice on diet and weight loss including avoidance of caffeine containing drinks , water
intake , fibre content , laxative use and modification of drug regimes , e.g. diuretics.
Avoidance of high-impact exercise and lifting may improve symptoms .
33. 2.Pelvic floor physiotherapy.:
While it is unlikely that advanced prolapse will be helped by pelvic floor exercises,
earlier stage prolapse may be improved sufficiently to avoid further intervention.
34. : 3.Vaginal pessary
Vaginal pessaries have been available in some form for 4000 years .
Currently in the UK the most frequently used pessary is the polypropylene ring pessary.
The most appropriate anatomical configuration for the ring pessary has not been defined but if there is
little or no posterior perineal support the ring pessary will often not be retained.
35. 3.Vaginal pessary
Pessaries such as the ring can normally allow sexual intercourse without problems .

Space occupying pessaries such as the shelf pessary preclude normal sexual relations and are therefore
unsuitable for sexually active women.
The shelf pessary may be particularly helpful for uterine or vaginal vault prolapse .
Careful examination, at least every 6 months is advisable and topical oestrogens may reduce the risk of
ulceration and erosion.

36. Vaginal pessary

Over the last 100 years surgery has been considered to be the treatment of choice for uterovaginal
prolapse .
a desirable outcome should include more than a satisfactory anatomical result. Functional outcome may
be more important to the patient.

38. Anterior vaginal wall prolapsed :

In 1909, White described the vaginal repair to repair a cystocoele .
Four years later Kelly described the anterior vaginal repair with a central placation of the pubocervical
fascia .

The Kelly operation became the treatment of choice for anterior prolapsed partly because of the
simplicity of the procedure .

39. Complications :
1.5% developed stress incontinence and 5% detrusor overactivity postoperatively.
2.Long-standing voiding problems occurred in less than 1%.
3.Post-operative pyrexia developed in 10%

The use of support materials in primary repairs would certainly not appear to be justified.
40. Posterior vaginal wall prolapsed :
The classical posterior vaginal repair involves not only plication of the fascia underlying the vaginal skin
but also a central plication of the fascia overlying the pubococcygeus muscle even including the muscle

41. Uterine prolapsed:

The current conventional approach to uterine prolapse when awoman no longer wishes to have children
is a 1. vaginal hysterectomy with any additional repair to the vaginal walls as appropriate.
The vaginal vault is then supported by reattaching the uterosacral/cardinal ligaments to the vagina .
42. 2.The Manchester repair :
is now less popular but also employed the cardinal ligaments brought together anterior to the cervix
which was amputated as part of the operation.
The use of the uterosacral/cardinal ligaments has the fundamental problem that it is the weakness of
these ligaments that has contributed to the development of the prolapse.
43. 3.Uterine conservation:
There is no evidence that uterine conservation, either by abdominal sacrohysteropexy or sacrospinous
hysteropexy provides a lower risk of prolapsed recurrence.
44. Vaginal vault prolapsed:
Vaginal vault prolapse occurs in approximately 5% of women after hysterectomy .
Most studies indicate that an equal proportion of women have had an abdominal or a vaginal
hysterectomy which, given that abdominal hysterectomy is performed more frequently than vaginal,
suggests that vaginal hysterectomy predisposes to vault prolapse .
45. vault prolapse
Failure to treat extensive vault prolapse may lead to ulceration and less commonly bowel extrusion.
Vaginal vault prolapse may be treated surgically by a vaginal sacrospinous colpopexy or
an abdominal (or laparoscopic) sacrocolpopexy .

46. vault prolapse

Colpocleisis :
the vaginal lumen is completely occluded, may be used rarely in women who are unfit for major surgery
and in whom conservative measures have failed.
Strips of vaginal skin are removed from anterior and posterior vaginal walls and the two are sutured
together .

Genital Injuries Prepared by : Racha Elkassem Prepared to : Dr. Mageda Mourad

2. Outline Definition Classifications Anatomy and Physiology Causes Signs and
Symptoms Risk factors Diagnostic procedure Complications Treatment Prevention & Risk for
reoccurrance Nursing management References
3. Female genitalia External female genitalia


5. CLASSIFIED INJURIES TO BONY PARTS i) Injury to Symphysis Pubis ii) Injury to Sacro-coccygeal Joint
iii)Injury to Sacro-iliac Joint INJURIES TO SOFT TISSUE i) Injury to Vulva ii) Perineal Tears iii)Laceration of
Vagina & Cervix iv)Rupture of Uterus
6. The vagina It is the fibromusculo membranous sheath communicates uterine cavity with exterior
at the vulva. It extends from the vestibule upwards and backwards upto the vaginal part of the cervix.
Walls anterior (7cm), posterior (9cm) and 2 lateral walls44. The lower third, resembles, figure of H,
middle third is like transverse slit and upper thirdis rounded in shape.
7. Structures: Mucous coat: lined by the stratified squamous epithelium without any glands. Sub
mucous layer consists of loose areolar tissue. Muscular layer consists of inner circular and outer
longitudinal. Fibrous coat from endopelvic fascia.
8. CERVIX The cervix is a constricted part of uterus separated from the body by the constriction part
known as the isthamus and behind by the transverse ridge considered as torus uterinus. This contains a

cervical canal, which communicates the uterine cavity with the vagina. It extends downwards and
backwards from the isthamus, protrudes through the anterior wall of vagina which divides the cervix
into supravaginal and vaginal parts.
9. Structure of the cervix: Serous coat: from the peritoneum which covers the posterior surface of
supravaginal part. Muscular coat: disposed smooth muscle. Some parts produced from collagenous
and elastic fibrous tissue. Mucous membrane: by columnar epithelium and stratified squamous
10. Ligaments of cervix Laterally by a pair of Mackenrodts ligaments. Posteriorly by a pair of
uterosacral ligaments. These ligaments have unstriped muscles and leashes of blood vessels and
lymphatics. On each side, the lymphatic drainage into external iliac, obturator lymph nodes, internal
iliac groups and sacral groups.
12. Anatomy and Physiology A. Pelvic floor: Pelvic floor is a muscular diaphragm that separates the
pelvic cavity above from the perineal space below. It is formed by the levator ani and coccygeus
muscles, and is covered by parietal fascia. The levator ani muscles on either side arise from posterior
surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine.
13. The levators sweep from the lateral pelvic wall downwards and medially to fuse with the opposite
side in the midline and form a pubo-coccygeal raphe. Fibres of Levators are inserted from before
backwards and fuse with muscle fibres of urethra, the vaginal walls, perineal body, anal canal,
anococcygeal body and the lateral borders of coccyx. Functions: To support the pelvic viscera. To
maintain effective intra-abdominal pressure. To facilitate anterior rotation and downward and forward
propulsion of the presenting part during parturition. Serves as a support and voluntary sphicter of
urethra, vagina and anal canal.
14. B. Urogenital diaphragm: The urogenital diaphragm is external to pelvic diaphragm and includes the
triangular area between the ischial tuberosities and the symphysis. It is made up of deep transverse
perineal muscles, sphincter urethrae and internal and external fascial coverings.
15. C. Perineum: Perineum is a diamond-shaped space that lies below the pelvic floor. it is bounded by:
16. This area is divided into two triangles by transverse muscles of perineum and base of urogenital
diaphragm: Anteriorly- Urogenital triangle. Posteriorly- Anal triangle Most of the support of
perineum is provided by pelvic and urogenital diaphragms.

17. Perineal Body: The median raphe of levator ani between the anus and vagina, is reinforced by the
central tendon of the perineum. Bulbocavernosus, superficial transverse perineal and external anal
sphincter muscles also converge on the central tendon. These muscles contribute to perineal body,
which provides much support to perineum.
18. PERINEAL TEAR Gross injury is due to MISMANAGED 2ND STAGE OF LABOUR More common in
PRIMIGRAVIDA than MULTIGRAVIDA . Due to extension of episiotomy, posteriory it involves the anal
sphincter from back & obliquely upwards into the lateral vaginal wall ETIOLOGY: - OVER STRETCHING OF
19. Causes and Predisposing Factors: Obstetric injuries:
babies Non-obstetric injuries: rape, molestation, fall, accidental injuries like RTA, bull horn injuries etc.
20. Degrees of Perineal tear:
degree- trauma involves the anal
- extends into the rectal lumen, through the rectal mucosa. A rare type of
tear is central tear of the perineum when the head penetrates first through the posterior vaginal wall,
then through the perineal body and appears through the skin of the perineum. It usually occurs in
patients with contracted outlet.
22. First & second degree tears :Spontaneous tears originate near the midline of the perineum, but
when they are traced upwards they are invariably found to extend into one / other posteriolateral
vaginal sulcus.
helpful to catch the upper edge of
care must be taken to unite the lateral vaginal walls to the
loose posterior tongue.
meatus. Later, pt. is unable to void urine because of muscle spasm consequent on the bruising around
the urethra & bladder neck.
23. Third degree tears:
anal canal is closed by interrupted or continuous catgut sutures (No.0) placed so that the suture avoids
the bowel mucosa. Disadvantage appearance of small rectovaginal fistula at the upper end of the
24. Symptomatology: Immediate: Bleeding Traumatic PPH - hemorrhagic shock. Perineal
Pain Perineal hematoma Urinary retention due to painful perineum Urinary incontinence Anorectal
dysfunctions like fecal incontinence Delayed: 1. 2. 3. 4. 5. 6. Infected perineum- perineal abscess
Uterovaginal prolapse Urinary incontinence (stress and urinary fistula) Fecal incontinence ( rectovaginal

fistula) Dyspareunia Feeling of slack vagina during coitus Bleeding Disruption of anatomical
26. Repair of perineal tear : First degree: Sometime doesnt require suturing or can use one or two
interrupted suture. Second degree: The vaginal mucosa is to be sutured first. The first suture is placed
at or just above the apex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures
with chromic catgut no. Ofrom above downwards till the fourchette is reached. The sutures should
include the deeper tissues to obliterate the dead space.
27. A continuous suturing may cause shortening of the posterior vaginal wall. Complete perineal tear:
The rectal and anal mucosa is sutured from above downwards by interrupted sutures. Muscle walls
including the pararectal fascia are then sutured by interrupted sutures. The torn ends of the sphincter
ani externus are sutured with figure of eight stitch by another interrupted suture. Perineal skin by
interrupted suture
29. Complications if left untreated: Infection Hemorrhagic Shock Cosmetic disadvantage 3rd and
4th degree tears if left untreated may lead to fecal incontinence.
30. Episiotomy It is an incision on the perineum & the posterior vaginal wall during the second stage of
labor It should be performed just before the crowning of head in second stage of labour. It is
commonly performed for spontaneous vaginal delivery , about 2/3rd of primigravida , 1/3rd of the
31. Objective: To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus
spontaneous or manipulative. To minimize over stretching & rupture of the perineal muscles & fascia
To reduce the stress & strain on the fetal head. Indications: In elastic or rigid perineum. Anticipating
perineal tear big baby, face to pubis delivery, breech delivery, shoulder dystocia. Operative delivery:
forceps delivery, ventouse delivery. Previous perineal surgery: pelvic floor repair, perineal
reconstructive surgery.
32. Types
are encountered & repair is very simple. Disadvantage: extension of incision includes the anal sphincter
or canal itself.
considerable difficulty may be encountered in securing an accurate realignment of the divided

rting at the midpoint of the fourchette or posterior commissure. It has
the advantage to the damage to the sphincter.
in the midline until a point is reached 2-3 cm from the anterior margin of the anus.
35. Median Merits : -the muscles are not cut - blood loss is least. - repair is easy. - postoperative comfort
is maximum. - healing is superior. - Wound disruption is rare. - Dypareunia is rare. Mediolateral - relative
safety from rectal involvement from extension. - if necessary, the incision can be extended.
36. Demerits : - Extension, if occurs involves rectum. -Apposition of the tissues is not so good. -Blood
loss is little more. - Not suitable in - Relative increased manipulative delivery or in incidence of wound
abnormal presentation or disruption. position. - Dyspareunia is more
37. Advantages Maternal Reduction in the duration of second stage. Reduction of trauma to the pelvic
floor muscles. Fetal it minimizes intracranial injuries.
38. The structures involved during mediolateral episiotomy are :
perineal branches of pudendal vessels and nerves.
39. Timing of the repair of episiotomy
blood loss from the
implantation site because it prevents the development of extensive retroplacement bleeding.
manual removal must be performed
40. Post operative care: Clean wound with clean water after each urination and defaecation. Keep
area dry Apply clean pads Analgesics if needed Peri-care and peri-light Suture removal on 7th 10th post op day if silk is applied. F/U after 6 wks if no complication
41. Complication Immediate: 1. Extension of the incision: involves rectum, mainly in median episiotomy
or occipito posterior. 2. Vulval haematoma. 3. Infection. 4. Wound dehiscence: infection is the primary
cause of wound disruption. 5. Injury to anal sphincter. 6. Rectovaginal fistula.
42. Cont-d Remote: Dyspareunia due to narrow introitus. Chance of perineal lacerations. Scar
43. Prevention of perineal tear: Well support of the perineum at the time of delivery of head
Delivery by early extension is to be avoided Spontaneously forcible delivery is to be avoided To
deliver the head in between contraction To perform timely epsiotomy To take care during delivery of

44. Periurethral Tears Vaginal tears can also occur at the region around the urethra - the opening
through which urine comes out. These are then called ' Periurethral tears'. The problem with these type
of tears is that there may be profuse bleeding from even a small tear since the region has a large blood
45. Causes The commonest cause for a periurethral tear is a sudden extension of the fetal head at the
time of delivery. Normally, the fetal head is in a position of flexion with the chin touching the chest. At
the time of delivery, after crowning occurs, the head is born by extension. A gradual extension will not
put much presure on the anterior or upper part of the vagina. But a sudden extension will cause a
sudden pressure on upper vaginal area resulting in a periurethral tear.
46. How to prevent It is important for the doctor or midwife to press gently on the fetal head at the
time of delivery and guide it to a slow and gradual extension at the time of birth.
47. Treatment Periurethral tears need to be stitched carefully under proper light. If not repaired well
or if it is not diagnosed after the delivery, it can bleed continuously for quite some time and cause many
other problems It is advisable for the woman to use cold packs on the site of the tear for at laeast 7-10
days to hasten healing. Using anti-inflammatory painkillers like Ibuprofen aslo helps. Thankfully, during
the course of a pregnancy the body is primed to heal quickly. The immune system is more efficient than
usual and therefore wounds will heal within a few weeks after childbirth
48. Complications if not treated Continuous Bleeding Infections in the tear Severe pain and
inflammation Urine Retention due to inability of the woman to pass urine through the inflamed urethra
49. Vaginal lacerations

nvolves middle or upper third of the vagina but not associated with
derlying tissues and give rise to

haemorrhage, which is controlled by appropriate suturing.

continuous sutures using chromic catgut no. 0.
51. Cervical tear The cervix is lacerated in over half of vaginal deliveries. Most of these are less than
0.5cm. Deep cervical tears may be extended to the upper third of vagina. In rare instances, the cervix
may be entirely or partially avulsed from the vagina, with colporrhexis in the anterior, posterior or
lateral fornices.
52. Cont-d Rarely, cervical tears may extend to involve the lower uterine segment & uterine artery &
its major branches & even through the peritoneum. Cervical lacerations upto 2 cm must be regraded
as inevitable in childbirth. Such tears heal rapidly. In healing, they cause a significant change in round
shape of the external os before cervical effacement & dilatation to that of appreciable lateral elongation
after delivery.


54. Diagnosis A deep cervical tear should always suspected in cases of profuse haemorrhage during &
after third stage labour, if the uterus is firmly contracted Extent of the injury can be fully appreciated
only after adequate exposure & visual inspection of cervix.
55. Treatment Deep cervical tears require surgical repair when the laceration is limited to the cervix or
extends into the vaginal fornix, results are obtained by suturing the cervix. Either interrupted / running
absorable sutures are suitable
56. complication
57. Wound healing Healing by primary intension occurs in clean incised wounds such as surgical
incision. It produces a clean, neat, thin scar. Healing by secondary intension refers to a wound which
is infected, discharging pus or wound with skin loss.
58. Factors influencing wound healing 1. General:

Blood dyscrasis.
59. Cont-d 2. Local:

ion - protein deficiency, vitamin c and

Anaemia , Jaundice, Diabetes,

bodies tissue reaction and inflammation, necrosis

61. spontaneous or traumatic rupture of the uterus ie., the actual separation of the uterine
myometrium/ previous uterine scar, with rupture of membranes and extrusion of the fetus or fetal parts
into the peritoneal cavity. Dehiscence - partial separation of the old uterine scar; - the fetus usually
stays inside uterus and the bleeding is minimal when dehiscence occurs
62. Rupture uterus
64. RISK FACTORS: Women who have had previous surgery on the uterus (upper muscular portion)
Having more than five full-term pregnancies Having an overdistended uterus (as with twins or other
multiples) Abnormal positions of the baby such as transverse lie. Use of Pitocin (oxytocin) and other
labor-induced medications (prostaglandin) Rupture of the scar from a previous CS

delivery/hysterectomy. Uterine/abdominal trauma Uterine congenital anomaly Obstructed labor;

maneuvers within the uterus Interdelivery interval (time between deliveries)
65. PATHOPHYSIOLOGY Pathologic retraction ring occurs, strong uterine contractions w/o cervical
dilatation tearing sensation Complete rupture Incomplete rupture Rupturing of endometrium,
myometrium and perimetrium Rupturing of endometrium and myometrium Uterine contraction stops
Localized tenderness and persisting aching pain over the area of the uterine segment Bleeding into the
peritoneal cavity
66. Swelling of the abdomen: Retracted uterus Extrauterine fetus Hemorrhage from torn uterine
arteries Bleeding to the vagina Decreased blood volume Decreased venous return Decreased BP
Increases gas exchange to oxygenate better the decreased blood volume Decreased cardiac output
Heart attempts to circulate remaining blood volume Vasoconstriction of peripheral vessels, increased
heart rate
67. Cold, clammy skin Increased respiratory rate Uterine perfusion is decreased Continued blood loss
will continue to fall BP Fetal distress Decreased brain perfusion Decreased kidney perfusion Decreased
LOC (lethargy, coma) Decreased urine output Renal failure Death of Mother and fetus
68. ASSESSMENT: evaluate maternal vital signs note an increase in rate and depth of respirations, an
increase in pulse , or a drop in BP indicating status change assess fetal status by continuous monitoring
speak with family, and evaluate their understanding of the situation observe for signs and symptoms
of impending rupture -lack of cervical dilatation -tetanic uterine contractions - restlessness - anxiety severe abdominal pain - fetal bradycardia - late or variable decelerations of the FHR)
69. SIGNS AND SYMPTOMS Clinical Manifestations: Developing Rupture Abdominal pain and
tenderness Uterine contractions will usually continue but will diminish in intensity and tone. Bleeding
into the abdominal cavity and sometimes into the vagina. Vomiting Syncope; tachycardia; pallor
Significant change in FHR characteristics usually bradycardia (most significant sign) Difficulty
identifying fundal height Vaginal bleeding Maternal hemorrhage and shock Absent fetal heart tones
70. Violent Traumatic Rupture Sudden sharp abdominal pain during or between contractions.
Abdominal tenderness Uterine contractions may be absent, or may continue but be diminished in
intensity and cord bleeding vaginally, abdominally, or both Fetus easily palpated in the abdominal
with shoulder pain Tenses, acute abdominal with shoulder pain Signs of shock Chest pain from
diaphragmatic irritation due to bleeding into the abdomen.

73. Planning and Implementation

74. Deficient Fluid Volume

in an IV fluid as prescribed. Use a large gauge catheter when
starting the IV for blood and large quantities of fluid replacemnt.
Foley catheter, and moniter urine output hourly or as indicated.
as indicated.
75. Fear
or woman may have.

aintain a quiet and calm atmosphere to


for them to express feelings.

76. Decreased cardiac output Administer supplemental oxygen, blood/fluid replacement, antibiotics,
diuretics, inotropic drugs, antidysrhythmics, steroids, vassopressors, and/or dilators as ordered.
Position HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation
Activities such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing which may
stimulate Valsalva response should be avoided; administer stool softener as indicated.
77. Ineffective Tissue Perfusion

-12 L/min or as ordered to provide

o assess respiratory status, observing for

hyperventilation and electrolyte imbalance.

pattern because progressive changes may indicate profound shock.
78. Risk for Infection Observe for localized signs of infection. Cleanse incision or insertion sites daily
and PRN with povidone iodine or other appropriate solutions. Change dressings as needed or
indicated. Encourage early ambulation, deep breathing, coughing and position changes. Maintain
adequate hydration and provide. Provide perineal care.
79. MEDICAL MANAGEMENT Immediate stabilization of maternal hemodynamics and immediate
caesarean delivery Oxytocin is given to contract the uterus and the replacement . After surgery,
additional blood, and fluid replacement is continued along with antibiotic theory.
80. SURGICAL MANAGEMENT Caesarean Section Laparotomy Hysterectomy
81. NURSING MANAGEMENT Continually evaluate maternal vital signs; especially note an increase in
rate and depth of respirations, an increase in pulse , or a drop in BP indicating status change. Assess
fetal status by continuous monitoring. Speak with family, and evaluate their understanding of the
situation. Anticipate the need for an immediate caesarean birth to prevent rupture when symptoms

are present. Provide information to the support person and inform him or her about fetal outcome, the
extent of the surgery and the womans safety. Let the pt express her emotion without feeing
82. FGM Female Genital Mutilation compromises all procedures involving partial or total removal of
the external female genitalia or other injury to the female genital organs for non medical reasons (WHO,
UNICEF, UNFPA, 1997)..
83. Procedures *Type III- Also known as Infibulation. *Type IV- All other harmful procedures to the
female genitalia for non-medical purposes, for example: pricking, piercing, incising, scraping and
84. Health Risks health benefits. damages healthy genital tissue and interferes with a womans natural
bodily functions.
85. Health Risks Immediate Complications Severe pain Shock Hemorrhage Tetanus Sepsis
(bacterial infection) Urine retention Open sores
86. Cont-d Long Term Consequences Bladder and urinary tract infections Cysts Infertility
Need for later surgeries Childbirth complications Newborn deaths Decreased sexual pleasure
87. International Organizations

Congenital malformation of the reproductive organs

Fallopian tube and ovary
2. Absence of vagina Congenital absence of vagina is also known as "Rokitansky- Mayer Hauser Kuster Syndrome". Patients with this syndrome have a normal female karyotype. They typically present
at the age of menarche or later because of primary amenorrheoa. Rarely is the abnormality discovered
at birth. On physical examination findings include a normal vulva with absent vagina or vagina
represented by a dimple. There is usually absence of uterus and cervix. The ovaries are normal and there
is normal cyclical ovarian function as reflected by circulating hormone levels and ovulation and the
fallopian tubes may or may not be normal but complete absence is rare.
3. Clinical features Absent vagina Absence of menstrual period Absent uterus and other
reproductive organ Kidney abnormalities Skeletal abnormalities Hearing loss
4. Diagnosis Since outward genitalia appear normal, vaginal agenesis is not usually diagnosed until
puberty. Typically, an adolescent girl 15 to 18 years old consults a pediatrician or gynecologist when her
period does not start. The condition may also be discovered in infancy or childhood while investigating
kidney, skeletal or other abnormalities, such as the absence of an anal opening. Ultrasound reveals if

the uterus and ovaries are present and the presence and location of kidneys. MRI shows a more
detailed picture of the reproductive tract and kidneys.
5. Treatment Most young women are treated in their late teens or early 20s. Others may wait until they
are older and sexually active. Treatment is not urgent, but it is usually necessary before sexual
intercourse. Self dilation: some patients can create a vagina without surgery using self dialation. In this
treatment, the patient presses a small rod (dialator) against the skin or the small vagina for 15 to 20
minutes per day. This is often done after bathing, when skin is more pliable. Progressively larger dilators
are used to expand the vagina. Several month may be required to obtain the desired result.
6. Cont.. Surgery (vaginoplasty): Surgery (vaginopalsty) is used to create a functional vagina. These
treatments are usually delayed until the patient possesses the maturity to handle follow up dilation.
Skin graft(McIndoe procedure)- The McIndoe procedure) is the most commonly performed vaginal
plasty. The procedure uses the skin graft from the buttock(which leaves only a disfigurement). The
surgeon makes an incision where the vagina would normally developed and inserts the graft to create a
vagina. A mold is placed in the newly formed vagina for seven days.
7. Cont Counseling: it is often useful for a patient to speak with a counselor about her condition.
After treatment patient can have a normal sex life. Although it is not common some patients have
normal uterus and can bear children. Typically, vaginal absence patients have undersized uterus and
cannot become pregnant. However, if their ovaries are healthy, which is often the case, affected woman
can have children by INF of their own eggs with the pregnancy carried by a surrogate mother.
8. Uterine Malformation A uterine malformation is a type of female genital malformation resulting
from an abnormal development of the Mllerian duct(s) during embryogenesis. Symptoms range from
amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the
nature of the defect.
9. Prevalence The prevalence of uterine malformation is estimated to be 6.7% in the general
population, slightly higher (7.3%) in the infertility population, and significantly higher in a population of
women with a history of recurrent miscarriages (16%).
10. Types of uterine malformation Class I: hypoplasia/agenesis (absent uterus). Combined agenisis of
the Uterus, cervix and upper portion of vagina. The condition is also called Mayer-Rokitansky-KusterHauser syndrome. The patient with MRKH syndrome will have primary amenorrhea. Patients have no
reproductive potential aside from medical intervention in the form of invirto fertilization of harvested
ova and implantation in a host uterus.
11. Class II: Unicornuate uterus (a one-sided uterus). Only one side of the Mllerian duct forms. The
uterus has a typical "penis shape" on imaging systems. Unicornuate Uterus If a woman has a
Unicornuate uterus, she will have a single uterine cavity with a cervix and one fallopian tube coming off

of the uterus. In this malformation, the uterus only forms half-way. The other side of the uterus may
have a rudimentary horn. An ultrasound can be used to find a Unicornuate uterine malformation.
Further diagnostic test used to confirm this diagnosis are; hysteroscopy, ultrasound, and laparoscopy.
Excision of rudimentari horn by Surgical procedure.
12. Cont. Unfortunately, a woman with this malformation can have much risk if she becomes
pregnant. There is a great risk of pregnancy loss and preterm labor. Also, there is a chance of the woman
having an ectopic pregnancy. The common miscarriages due to this malformation are caused by
abnormalities in the blood supply of the uterus. The reason that there is a great risk for preterm labor is
due to space restrictions in the Unicornuate uterus. Furthermore, for the woman with the rudimentary
horn, she will have greater risks associated with pregnancy. This horn will cause a lot of space restriction
which could result in ectopic pregnancy. This is the reason that most doctors recommend surgery to
remove the rudimentary horn.
13. Class III: Uterus Didelphys: A woman with a didelphic uterus has a duplication of the uterus and a
duplication of the cervix. In this malformation, there are two uterine cavities and two cervixes
accompanying each cavity. It is not recommended that a woman have surgery to connect the two
uteruses together. Women with this malformation may be asymptomatic. The malformation is normally
found with a pelvic examination. There are two common complaints of women that have a didelphic
uterus. There are complaints of dysmenorrheal (uterine pain during menstruation) and complaints of
dyspareunia (painful sexual intercourse).
14. Cont Class IV: The bicornuate (heart-shaped) uterus has a marked indentation and is separated
into two different cavities. This malformation is a result from the uterus forming improperly in the
womans early prenatal development. The way that a woman can confirm that she has a bicornuate
uterus is by having an ultrasound or by the use of laparoscopy. The primary risk with having a bicornuate
uterus is preterm labor and cervical insufficiency. The cervical insufficiency could cause the woman to
have a miscarriage during the second trimester of pregnancy. The good news is that there is a chance
that the baby can still survive. Furthermore, in some cases, a woman with this type of uterine
malformation can carry the baby to full term with no complications. It just varies from person to person.
15. Class V: Septated uterus (uterine septum or partition). A woman with a septate uterine
malformation will have the problem from which the septum separates the uterine cavity into two
separate cavities. The septum will arise at the top of the uterine cavity and then extend down to the
cervix and the vagina. It is normally recommended that a woman with this malformation have a simple
out patient surgical removal of the septum. There is a risk of miscarriage associated with a septate
uterine malformation. Furthermore, there is a chance of preterm labor. Doctors can normally find a
septate uterine malformation with the use of an ultrasound. However, to confirm the diagnosis, the
woman will need to have a hysteroscopy performed.

16. Class VI(arcuate uterus):The arcuate uterus has a depression at the fundus. A woman with an
arcuate uterus can carry a baby to full term pregnancy. However, this condition is associated with a
higher risk for miscarriage and premature births. The best way for a woman to find if she has this
malformation is through transvaginal ultrasonography, hysterosalpingography, MRI, or hysteroscopy. In
most cases, the woman will not have any reproductive problems. For those that do have reproductive
tribulations, there is the option to have a hysteroscopic resection performed.
17. Cont. Class VI: DES uterus. Several women were treated with diethylstilbestrol(DES), an estrogen
anolouge prescribed to prevent miscarriage from 1945-1971. The drug was withdrawn once its
teratogenic effects on the reproductive tracts of male and female foetus were understood. The uterine
anomaly is seen in the female as many as 15% of women exposed to DES during pregnancy. Female
fetuses who are affected have a variety of abnormal findings that include uterine hypoplasia and a Tshaped uterine cavity. Patients with uterine abnormalities may have associated renal abnormalities
including unilateral renal agenesis.
18. Diagnosis Physical examination TAS and TVS Hysterosalpingography(HSG) MRI and CT scan
19. Clinical features Gynaecological impact
occur in bicornuate uterus.
20. Obstetrical impact


21. Management During pregnancy When the diagnosis of uterine malformation is made at the
beginning of pregnancy, the treatment can be only preventive(setting at rest, sonographic monitoring of
the fetal growth and the cervical competence). Cervical cerclage should be proposed only in the case of
proved cervical incompetence observed in 1/3 to of uterine malformations. Abdominal mertoplasty
could be done either by excising the septum or by incising the septum. The success rate of abdominal
metroplasy in terms of live birth is 5-75%. Nowadays hysteroscopy metroplasty is done for this
22. Abnormalities of the fallopian tube The fallopian tubes may be unduly elongated, may have
accessory ostia or diverticula. Rarely, the tube may be absent on one side. These conditions may lower
the fertility or favour ectopic pregnancy.
23. Abnormalities of Ovaries The congenital anomaly of the ovaries includes congenital absence of ovary
and developmental overian cyst. Accessory ovary (division of original ovary into two) also comes under
this condition. Rarely, supernumerary ovaries may be found in the broad ligaments.