Hysterosalpingograpy (HSG Or Tube Test)

Introduction.

HSG is an X ray test which is done to see the outline of the shape of the uterus and to check if the fallopian tubes are blocked or open.

It is a minor procedure in which a special dye is injected that fills the uterus and then spills through the open fallopian tubes.

When Should this test be done

- As a part of workup for infertility.

- Usually recommended when a couple has been trying for more than a year with no success and when other basic tests have already been done.

- It is done after the periods ends but before the expected ovulation usually on cycle day 8 or 9.

Procedure

- The procedure takes around 15-20 minutes and is usually done in x ray department. 

- The woman is made to lie on a bed that is positioned so that a x ray imager is above, that can take pictures during the procedure. 

- The gynecologist will do an internal examination and then places a speculum in the vagina.

- The cervix is visualized then cleaned and then a cannula like devise is placed into the opening of the cervix.

- Then through this cannula a liquid dye that contains iodine is slowly injected to fill up the uterus.

- This dye can be seen on the Xray as a white image. 

What Abnormalities can be detected on HSG

- Abnormalities like polyps or fibroids inside the uterine cavity can be seen.

- The shape of the uterus is outlined and any abnormal shape can be detected.

- The length of the fallopian tubes and if they are open by the spill of the liquid dye confirms the patency. 

Is it Painful?

Pelvic Inflammatory Disease

 Pelvic Inflammatory disease is a condition in which there is an infection in the female reproductive organs. the include the fallopian tubes, the ovaries, uterus and the cervix. 

This is a common condition and may affect like every 5 in 100 woman, 

What actually happens is that first there is infection in the vagina which later on travels up and affects other organs. 

Clinical features

Sometimes the symptoms are very mild and the patient may not even know that they have an infection, while some may experience mild to moderate lower abdominal and pelvic area pain. Other symptoms include:

On and off Fever

Foul smelling vaginal discharge

pain during sex

pain during urination

infertility 

bleeding in between periods usually after intercourse.

tiredness and fatigue

Causes: 

Many different bacteria can cause pelvic inflammatory disease but Chlamydia and gonorrhea infections are the most common causes. 

How does the infection enter your body: 

The most common way is through sexual intercourse. Others include after a miscarriage or child birth when repeated pelvic examinations are done or when instruments are used for any diagnostic or treatment purposes. 

Risk Factors are any woman of reproductive age group who is sexually active, having multiple sexual partners, having sex without using protection (condoms), excessive use of different vaginal wash products as these may alter the normal vaginal pH causing the growth of bacteria. 

- Use of intrauterine contraceptive devise is also one risk factor. 

Treatment:

- Antibiotics are given to treat the infection. Usually a combination of 2-3 antibiotics are prescribed. - - - Pain killers and anti inflammatory medicines are given to control and manage pain. 

- It is always better to treat the partner at the same time even though males may not have any symptoms, because untreated partner usually leads to recurrence of infection and symptoms. 

Complications

- Spread to the blood can be serious and life threatening as it leads to sepsis.

- Infertility a very common complication, as long standing infections damages the pelvic organs and also leads to tube blockage.

- Ectopic pregnancy

- Chronic pelvic pain and scarring and adhesions of pelvic and abdominal organs.

Vaginal Yeast Infection

 

Yeast or Fungal infection in the vagina is a very common condition affecting almost every 3out of 5 woman, in most cases it is generally a mild infection and can be easily treated but sometimes it keeps on reoccurring. 

Presenting Features

- Itching and irritation in the vaginal and vulvar region.

-Burning and discomfort at the time of intercourse. 

- Thick, white, cottage cheese like vaginal discharge which is usually not foul smelling. 

If the infection occurs more than 4 times in a year it is considered to be a complicated case.

Why Does It Occur? 

Normally in the vagina there is normal flora (normal healthy bacteria) that help prevent many infections, sometimes due to certain conditions this normal flora is reduced and this can lead to growth of fungus. Candida albicans is the most common fungal infection affecting the vagina. The conditions commonly leading to fungal infection are.

-Pregnancy

-Any immunocompromised state like acute or chronic illness, generalized body weakness etc. 

-Use of antibiotics

-Diabetes

-Taking oral contraceptive pills or any hormonal medicines

-Use of silk panties.

- Using scented pads or tampons.

- Excessive sweating in warm conditions.

-Staying in a wet panty for a long time. 

- Stress

Yeast infection is not sexually transmitted and can even occur in unmarried girls or those who are not sexually active. 

How To Treat

Most cases are treated by using a local antifungal cream or pessary that can be used for 1 to 6 days. 

Sometimes oral antifungal treatment is also prescribed. 

Avoid taking unnecessary antibiotics like for common cold etc

Get tested for diabetes and treat and control blood sugar levels

Postpartum Depression And How To Manage It

 

It is quiet common for the new mother to feel sad, worried, tired or fatigued. As many as 80 out of 100 mothers go through such feelings for a week or two after the birth of the baby. It is completely normal and they start to feel better and normal after a few weeks..

Postpartum depression is diagnosed when these symptoms are much severe and lasts longer. It can cause severe mood swings, and a mix of physical, emotional and behavioral changes.

The symptoms usually begins within the first few weeks after giving birth but sometimes may even begin earlier while being pregnant or later up to a year after birth. 

Suffering from postpartum depression does not mean that a mother does not love her baby or that she is a bad mother. It is just that she is suffering from a medical condition and needs counselling therapy and treatment. 

Symptoms may vary among different woman but a list of common symptoms include:

- Feeling low

-Lack of interest in daily activities

- Body aches and headache

-Lack of appetite

- Anxiety and irritability

- Not able to think or make proper decisions. 

- Feeling difficult to bond with the baby.

- No interest in friends and family,

What causes Postpartum Depression: Female body produces a lot of hormones during pregnancy but soon after delivery there is a sudden decrease of these hormones which causes changes in the chemical system of the brain leading to depression. 

How To Manage:

Depending on the severity and the type it can be treated with psychotherapy or antidepressant medications. 

It is important to seek medical help if symptoms of depression lasts longer than 2 weeks within 1 year of giving birth. 

-Get Support from friends and family. 

-Be open about your feelings and discuss it with your partner and your family. 

- Join support groups.

-Antidepressants may be prescribed to you by your doctor but they usually take 6-8 weeks to show improvement in symptoms. 

- Psychotherapy helps with more positive thinking approach. 

Positioning A Baby While Breast Feeding

 

Breastfeeding your baby is always encouraged but at times new mothers find it difficult and face a lot of problems which in the end results in giving up and switching to formula.

Proper positioning the baby is very important for breastfeeding and to prevent problems later on.

How to position a baby while breast feeding  depends on the choice and comfort of both mother and baby. No matter which position is used it is important to make sure that

-         The baby’s whole body is supported

-         Baby’s body is facing and is close to the breast

-         Baby’s neck is straight. (not turned or twisted)

-         Baby approaches the breast and nose is in line with the nipple.

While Breast feeding it is very important that

-Mother is comfortable and relaxed.

She should know and learn how to support the breast while feeding. Baby’s lips should be first touched with the nipple and then wait for the baby to widely open the mouth so that nipple along with areola goes in and baby starts sucking.

Five Possible Positions

1.   Cradle Position: The mother cradles the baby in her arm. The baby should be held close to the mother’s body, with the forearm supporting the baby’ head. For mother’s comfort she may want to support the cradling arm with a pillow or her other arm.

2.   Cross Cradle: The mother cradles the baby in her arm. Her hand is supporting the baby’s head and neck.

3.   Football Hold: The mother is sitting or leaning back and the baby is under her arm with feet pointing back. The mother support the baby’s head and neck with her hand and a pillow may be used to support the baby in this position.

4.   Side lying position: Mother is lying on her side and baby lies on its side facing the mother. Mother supports the baby’s head and neck with her hand or a pillow.

5.   Supine Position: The mother is lying on her back with the baby lying face down on the mother’s chest. Mother’s hand supports the baby’s head on her breast. This position is useful immediately after a c section.

Ectopic Pregnancy - Pregnancy Which Occurs Outside The Uterus

 

Ectopic pregnancy

Ectopic pregnancy is defined as a pregnancy which occurs outside the uterine

cavity, the commonest site being the fallopian

tube. It may also occur, although  rare, in:

• ovary;

• cervix;

• abdominal cavity

Why Does Ectopic Pregnancy Occur

The ovum is fertilized in the fallopian tube and reaches the uterus in about five days. Anything that delays the passage of the fertilized ovum to the uterus can result in tubal pregnancy, such as

-intrauterine device (IUD) and progesterone-only pill (POP)

 Risk factors for ectopic pregnancy

Pelvic inflammatory disease (PID)

Previous pelvic surgery

Previous ectopic pregnancy

Intrauterine device (IUD)

Progesterone only pill (POP)

Depoprovera

Emergency contraception

Sterilization

Clinical features

The picture of ectopic pregnancy is:

Missed periods and a positive pregnncy test

Pain—typically constant and often unilateral due to spasm of the tubal muscle

Vaginal bleeding The bleeding is usually scanty, less than a normal period and dark brown in colour.

 Faintness or even shock with an acute rupture.

 How to Diagnose

Ultrasound is helpful. While it may not always show the embryo or its sac in the tube, findings may include:

• an empty uterus with thickened decidua;

• fluid (blood) in the pouch of Douglas;

• a multi-echo mass in the region of the tube.

Progesterone levels are commonly low because the pregnancy is failing.

Serum bhCG is usually lower than expected for gestation and on serial measurements increases by less than 60% over 48 hours.

 Laparoscopy is the ultimate investigation to make the diagnosis with direct vision

 

Differential diagnosis

The diagnosis is from any other acute abdominal conditions such as rupture of a viscus or acute peritonitis. The clinical picture is so typical that in most cases diagnosis presents no difficulty. Other diagnoses which may confuse are:

• inevitable miscarriage;

• bleeding with an ovarian cyst;

• pelvic appendicitis;

• acute salpingitis.

Treatment

The treatment of tubal pregnancy is removal of the pregnancy and sometimes the affected tube by laparoscopy or laparotomy. If the tube is patent and not seriously damaged, it may be possible to conserve it and thus leave the woman with a chance of conception later in life.

Laparoscopy techniques exist to:

• kill the embryo with a direct injection of methotrexate or mifepristone allowing absorption so requiring no surgery on the tube;

• incise the swollen tube over the ectopic pregnancy, aspirate the embryo, and achieve haemostasis (salpingostomy).

In a case of severe haemorrhage, the patient must be taken immediately to the operating theatre.

Little time should be wasted in attempting resuscitation which can prove useless and may only increase bleeding. 

An intravenous drip should be set up and a blood transfusion given as soon as possible.

In most cases the affected tube should be removed;

an exception may be made if the woman

desires children and the other tube is already missing

or seriously diseased. The disadvantage of conservation

is the increased risk of recurrence of

ectopic pregnancy.

 

• Medical treatment with methotrexate can be used if the hCG level is less than 5000 iu/l and the ectopic mass is less than 4 cm in diameter on ultrasound scan. There should be no symptoms or signs of rupture.

Introduction To Preimplantation Genetic Diagnosis (PGD)

Preimplantation genetic diagnosis (PGD) is an early form of prenatal diagnosis in which embryos created in vitro are analysed for well-defined genetic defects.
Defect-free embryos are then used for implantation.

Indications: It is used in

• those with high risk of genetic disease, e.g carriers of monogenic disease or chromosome structural abnormalities (e.g translocations) 
• who have repeatedly terminated pregnancies due to prenatal tests showing abnormality,
• who have concurrent infertility, 
• who have had recurrent miscarriage (as occurs with translocation carriers), and 
• for those with moral or religious objections to termination.
• It has also been used to screen for aneuploidy (PGD-AS) in those undergoing in vitro fertilization hoping to enhance chance of ongoing pregnancy (e.g in the case for women >37–40 years old).

Background: Pioneered in the early 1990's, PGD has resulted in >1200 pregnancies (pregnancy rate 24%), of which 5% of babies had some kind of abnormality.

PGD selection of embryos by HLA type so that a child born after using this technology can be used as a stem cell donor to save a sibling from certain conditions (eg with Fanconi anaemia, thalassaemia, or leukaemia) is controversial, but possible.

Some clinics select sex of implanted embryo e.g for ‘family balancing’.

Recurrent Miscarriage - Causes And Workup

Recurrent miscarriage (RM), which is defined as three or more consecutive miscarriages, is relatively uncommon – affecting about 1 to 2% of couples who conceive.

Three strands of evidence supports that Recurrent Miscarriage is a distinct clinical entity rather than one which occurs purely by chance alone.

1. First, the observed incidence of RM is significantly higher than that expected by chance alone (0.4%); 
2. second, a woman’s risk of miscarriage is directly related to the outcome of her previous pregnancies ; and 
3. third, in contrast to sporadic miscarriage, women with RM tend to lose pregnancies with a normal chromosome complement, suggesting the presence of a persistent underlying cause for pregnancy loss among these women.

Despite major advances in medicine the understanding of the cause of RM is sometimes not clear and even after comprehensive investigation, no cause for pregnancy failure is identified in approximately 50% of couples. This has led to the situation where women with RM have been, and continue to be, subjected to investigations and treatments based on trial and error approach. 

Contemporary investigative screen for recurrent miscarriage:

• Male and female parental blood karyotypes
• Lupus anticoagulant
• IgG and IgM anticardiolipin antibodies
• FactorV genotype
• FactorII genotype
• Activated protein C resistance
• Pelvic ultrasound to determine ovarian morphology and uterine anatomy
• Early follicular phase FSH
• Insulin resistance status

Spontaneous Miscarriage - The New Classification And Management

Introduction
Spontaneous miscarriage is one of the commonest complication of early pregnancy. It occurs in approximately 15–20% of all pregnancies.
It is important to take a good clinical history in every case of pregnancy loss and classify the type whenever possible.
Increasing knowledge about early pregnancy development, with the more widespread availability of measurement of serum Beta HCG (human chorionic gonadotrophin) , the advent of high resolution ultrasound and a clearer description of gestational age at pregnancy loss make for a more sophisticated assessment of miscarriage history.

Diagnosis
Role of ultrasound
The first demonstration of an intrauterine pregnancy by means of transvaginal ultrasound was reported in 1967. Major improvements in ultrasound resolution since then have revolutionized the assessment and management of early pregnancy problems.

Ultrasound plays a major role in maternal reassurance, where fetal cardiac activity is seen and is pivotal in the assessment of early pregnancy complications, such as vaginal bleeding. 

However, there are limits to ultrasound resolution of normal early pregnancy development.

• Expert advice concludes that the diagnosis of an empty gestation sac can only be made when the mean gestation sac diameter is greater than 20 mm, and that the crown–rump length must be 6 mm or greater before one can say for certain that fetal heart activity is absent. 
• If measurements are below these thresholds a repeat transvaginal ultrasound examination after at least a week should be offered . 

Ultrasound features such as a sac that is much smaller than expected from a certain last menstrual period; a sac that is low in the uterus or the presence of fetal bradycardia are strongly suggestive but

not diagnostic of impending miscarriage. In addition, the possibility of incorrect dates should always

be remembered by the alert clinician. Wherever possible, the term ‘missed abortion’ should be replaced by ‘delayed miscarriage’.

The impact of a diagnosis of a miscarriage should not be underestimated. It is recommended that ‘Early intrauterine death should be regarded as of equal significance to fetal death occurring at a later stage.’ It is therefore important that within an area where early pregnancy scans are performed, there is a quiet room for counselling, and staff working within this setting should have training in the emotional aspects of early pregnancy loss.

Modern classification of pregnancy loss type

The revision of early pregnancy nomenclature is both desirable and essential in raising the standard of reporting.

A Brief Introduction to Infertility

Definition of Infertility:

A. Primary infertility
1. Female partner has never been pregnant
2. Couple unable to conceive after unprotected intercourse for at least 1 year

B. Secondary infertility
1. Female partner has had at least one prior conception
2. Couple unable to conceive after unprotected intercourse for at least 1 year

Scope of Problem:
Approximately 15% of couples are unable to achieve a pregnancy within 1 year of attempting conception.Fertility declines are evident at least a decade prior to the menopausal transition.

Evaluation of the Infertile Couple:
A. History and physical
1. Menstrual cycle frequency and length
2. Gravidity, parity, pregnancy outcomes
3. Coital frequency and sexual dysfunction
4. Duration of infertility
5. Surgical history, particularly pelvic/abdominal
6. Medications, allergies
7. Tobacco, alcohol, drug history
8. History of sexually transmitted diseases
9. Family history of birth defects, reproductive difficulties, spontaneous abortions, early menopause, mental retardation
10. Symptoms of thyroid disease, pelvic pain, galactorrhea, hirsutism, dyspareunia
11. Physical examination includes weight, body mass index (BMI), thyroid and breast examinations, signs of hyperandrogenism/hirsutism, pelvic tenderness, and vaginal/uterine/cervical abnormalities.

Ovarian Cysts - A Brief Discussion

Introduction

Usually ovarian cysts are non-neoplastic sacs on an ovary that contain fluid or semisolid material. Although these cysts are usually small and produce no symptoms, they require thorough investigation as possible sites of malignant change.

Common ovarian cysts include follicular cysts, lutein cysts (granulosa-lutein [corpus luteum] and theca-lutein cysts), and polycystic (or sclerocystic) ovarian disease. Ovarian cysts can develop anytime between puberty and menopause, including during pregnancy. Granulosa-lutein cysts occur infrequently, usually during early pregnancy. The prognosis for nonneoplastic ovarian cysts is excellent.

Pathology
Follicular cysts are generally small and arise from follicles that overdistend instead of going through the atretic stage of the menstrual cycle. When such cysts persist into menopause, they secrete excessive amounts of estrogen in response to the hypersecretion of follicle-stimulating hormone and luteinizing hormone that normally occurs during menopause.

Granulosa-lutein cysts, which occur within the corpus luteum, are functional, nonneoplastic enlargements of the ovaries caused by excessive accumulation of blood during the hemorrhagic phase of the menstrual cycle.

Theca-lutein cysts are commonly bilateral and filled with clear, straw-colored fluid; they’re commonly associated with hydatidiform mole, choriocarcinoma, or hormone therapy (with human chorionic gonadotropin [HCG] or clomiphene citrate).

Polycystic ovarian disease is part of Stein-Leventhal syndrome and stems from endocrine abnormalities.

Signs and symptoms
Small ovarian cysts (such as follicular cysts) usually don’t produce symptoms unless torsion or rupture causes signs of an acute abdomen (abdominal tenderness, distention, and rigidity)

Uterine cancer

Cancer of the endometrium, or uterine cancer, is the most common gynecologic cancer. It usually affects postmenopausal women between ages 50 and 60; it’s uncommon between ages 30 and 40 and extremely rare before age 30. Most premenopausal women who develop uterine cancer have a history of anovulatory menstrual cycles or another hormonal imbalance.

Incidence
Uterine cancer has an incidence of 1% to 2% in the United States.

Causes
Uterine cancer seems linked to several predisposing factors:

• low fertility index and anovulation
• abnormal uterine bleeding
• obesity, hypertension, or diabetes
• familial tendency
• history of atypical endometrial hyperplasia
• estrogen therapy (still controversial).

Pathology

Generally, uterine cancer is an adenocarcinoma that metastasizes late, usually from the endometrium to the cervix, ovaries, fallopian tubes, and other peritoneal structures. It may spread to distant organs, such as the lungs and the brain, through the blood or the lymphatic system. Lymph node involvement can also occur. Less common uterine tumors include adenoacanthoma, endometrial stromal sarcoma, lymphosarcoma, mixed mesodermal tumors (including carcinosar- coma), and leiomyosarcoma.

Introduction to Endometriosis

Endometriosis  is defined as the presence of endometrial tissue outside the lining of the uterine cavity. Such ectopic tissue is generally confined to the pelvic area, most commonly around the ovaries, uterovesical peritoneum, uterosacral ligaments, and cul-de-sac, but it can appear anywhere in the body.
This ectopic endometrial tissue responds to normal stimulation in the same way the endometrium does. During menstruation, the ectopic tissue bleeds, causing the surrounding tissues to become inflamed. This inflammation causes fibrosis, leading to adhesions that produce pain and cause infertility.
Active endometriosis usually occurs between ages 30 and 40, but may be seen before age 20. Severe symptoms of endometriosis may have an abrupt onset or develop over many years. This disorder usually becomes progressively severe during the menstrual years; after menopause, it tends to subside.

Causes
The mechanisms by which endometriosis causes symptoms, including infertility, are unknown. The main theories to explain this disorder are:

• transtubal regurgitation of endometrial cells and implantation at ectopic sites
• coelomic metaplasia (repeated inflammation may induce metaplasia of mesothelial cells to the endometrial epithelium)
• lymphatic or hematogenous spread to account for extraperitoneal disease.

Signs and symptoms
The classic symptom of endometriosis is acquired dysmenorrhea, which may produce constant pain in the lower abdomen as well as the vagina, posterior pelvis, and back. The pain usually begins 5 to 7 days before menses, reaches its peak on days of bleeding, and lasts for 2 to 3 days. It differs from primary dysmenorrheal pain, which is more cramplike and concentrated in the abdominal midline. The severity of pain doesn’t necessarily indicate the extent of the disease.

Male Infertility

Male infertility may be suspected whenever a couple fails to achieve pregnancy after about 1 year of regular unprotected intercourse. 

Between 40% and 50% of infertility problems in the United States are totally or partially attributed to the male.

Causes
Factors that cause male infertility include:

• varicocele, a mass of dilated and tortuous varicose veins in the spermatic cord
• semen disorders, such as volume or motility disturbances or inadequate sperm density
• proliferation of abnormal or immature sperm, with variations in the size and shape of the head
• systemic disease, such as diabetes mellitus, neoplasms, liver or kidney disease, or viral disturbances, especially mumps orchitis
• genital infection, such as gonorrhea, tuberculosis, or herpes
• disorders of the testes, such as cryptorchidism, Sertoli-cell–only syndrome, varicocele, ductal obstruction (caused by absence or ligation of the vas deferens or infection), hydrocele (collection of fluid in the testes), or infection (orchitis and epididymitis).
• genetic defects, such as Klinefelter’s syndrome (chromosomal pattern XXY, eunuchoidal habitus, gynecomastia, and small testes) or Reifenstein’s syndrome (chromosomal pattern 46XY, reduced testosterone, azoospermia, eunuchoid-ism, gynecomastia, and hypospadias)
• immune disorders, such as autoimmune infertility and allergic orchitis
• endocrine imbalance (rare) that disrupts pituitary gonadotropins, inhibiting spermatogenesis, testosterone production, or both; such imbalances occur with Kallmann’s syndrome, panhypopituitarism, hypothyroidism, and congenital adrenal hyperplasia
• chemicals and drugs that can inhibit gonadotropins or interfere with spermatogenesis, such as arsenic, methotrexate, medroxyprogesterone acetate, nitrofurantoin, monoamine oxidase inhibitors, and some antihypertensives. sexual problems, such as erectile dysfunction, ejaculatory incompetence, and low libido.

Other factors include age, occupation, trauma to the testes, and tight-fitting clothing that constricts the scrotum and affects sperm production.

Brief Summary of Abortion

Abortion is the spontaneous or induced (therapeutic) expulsion of the products of conception from the uterus before 20 weeks gestation (fetal weight less than 500 g [17½2 oz]). 

Up to 15% of all pregnancies and about 30% of all first pregnancies end in spontaneous abortion (miscarriage). At least 75% of miscarriages occur during the first trimester.

Causes
Spontaneous abortion may result from fetal, placental, or maternal factors. 

Fetal factors usually cause abortions before the 12th week of gestation and include:

• defective embryologic development resulting from abnormal chromosome division (most common cause of fetal death)
• faulty implantation of the fertilized ovum
• failure of the endometrium to accept the fertilized ovum.

Placental factors usually cause abortion around the 14th week of gestation, when the placenta takes over the hormone production necessary to maintain the pregnancy. These factors include:

• premature separation of the normally implanted placenta
• abnormal placental implantation.

Maternal factors usually cause abortion during the second trimester and include:

• maternal infection, severe malnutrition, and abnormalities of the reproductive organs (especially an incompetent cervix, in which the cervix dilates painlessly and bloodlessly in the second trimester)
• endocrine problems, such as thyroid dysfunction or a luteal phase defect
• trauma, including any surgery that requires manipulation of the pelvic organs
• phospholipid antibody disorder
• blood group incompatibility
• drug ingestion.

Special considerations in Patients with Abortion/Miscarriage

Before an abortion, perform the following:
Thoroughly explain all procedures to the patient.
After the patient uses the bedpan, inspect the contents carefully for intrauterine material. (The patient shouldn’t have bathroom privileges because she may inadvertently expel uterine contents.)

After spontaneous or elective abortion, perform the following:

• Note the amount, color, and odor of vaginal bleeding. Save all the pads the patient uses, for evaluation, and provide perineal care.
• Administer oxytocin and an analgesic as ordered.
• Obtain vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, every hour for 2 hours, then every 4 hours for 24 hours.
• Monitor urine output.
• Caring for a patient who has had a spontaneous abortion includes emotional support and counseling during the grieving process. Encourage the patient and her partner to express their feelings. Some couples may want to talk to a member of the clergy or, depending on their religion, may wish to have the fetus baptized.
• The patient who has had a therapeutic abortion also benefits from support. Encourage her to verbalize her feelings. Remember, she may feel ambivalent about the procedure; intellectual and emotional acceptance of abortion aren’t the same. Refer her for counseling, if necessary.
• Before the patient is discharged, perform the following:
• Tell the patient to expect vaginal bleeding or spotting and to immediately report excessive bright-red blood or bleeding that lasts more than 10 days.
• Advise the patient to watch for signs of infection, such as a temperature higher than 100.5° F (38° C) and foul-smelling vaginal discharge.

Brief Summary of Polycystic Ovarian Syndrome

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders.These patients have a steady state of relatively high estrogen, androgen and LH levels rather than the fluctuating levels seen in ovulating women.

Definition
There are two definitions or diagnostic criteria that are commonly used:

 - In 1990 a consensus workshop sponsored by the NIH(National Institutes of Health)/NICHD(National Institute of Child Health and Human Disease) suggested that a patient has PCOS if she has all of the following:

• Oligoovulation
• Signs of androgen excess (clinical or biochemical)
• Other entities are excluded that can result in menstrual irregularity and hyperandrogenism.

 - In 2003 a consensus workshop sponsored by ESHRE(European Society for Human Reproduction and Embryology)/ASRM(American Society for Reproductive Medicine) in Rotterdam indicated PCOS to be present if any 2 out of 3 criteria are met.

• Oligoovulation and/or anovualation manifested as oligomenorrhea or amenorrhea
• Excess androgen activity (clinical or biochemical evidence)
• polycystic ovaries (as seen on gynecologic ultrasound)

Pathophysiology
Increased level of estrogen comes from obesity due to conversion of ovarian and adrenal androgen to estrone in body fat. High estrogen level suppresses FSH and causes relative increase in LH. Constant LH stimulation of ovary results in anovulation, multiple cysts and theca cell hyperplasia with excess androgen production.

Approach to Patient With Amenorrhoea

It is common in general practice that patients may come with amenorrhoea and it needs a proper diagnostic approach.

Primary Amenorrhoea
Defined as when a girl have never started menstruation and sexual characteristics have not developed by the age of 14 years OR no menstruation by age 16 years when growth and sexual development is normal.

Causes
1. Outflow Abnormalities: Mullerian agenesis, transverse vaginal septum, androgen insensitivity, imperforate hymen.

2. Ovarian Disorders: Gonadal dysgenesis due to chromosomal abnormalities e.g Turner’s syndrome

3. Pitutary Disorders: Prolactinoma

4. Hypothalamic disorders: Kallman’s syndrome.

Secondary Amenorrhoea
Defined as absence of menses for more than 6 months in a previously menstruating woman.

Causes

1. Always consider the possibility of pregnancy.

2. Stress

3. Starvation , anorexia or excessive exercise.

4. Hypo/ Hyperthyroidism

5. Hyperprolactinaemia

What Is Chemical Pregnancy ?

Introduction:
A chemical pregnancy is actually a very early miscarriage which takes place at a time when ultrasound scan could not show a gestational sac. The only evidence that indicates that the woman got pregnant is that she gets a positive pregnancy test which was done at a very early time.

The excitement of getting a positive pregnancy test usually ends up with getting a period shortly after or b y a negative test when the test is repeated.

Pathophysiology:
A chemical pregnancy occurs when an egg is fertilized but it does not implant on the uterine wall. As a result of fertilization the pregnancy hormone beta HCG starts to be produced in the body. Measuring this hormone in the blood or urine is the first documentation of being pregnant and since a number of pregnancy tests available in the market today can detect this hormone at a very early stage the woman thinks she is pregnant but since the implantation fails this very early miscarriage occurs at a time just around the expected time of periods and without the gestational sac being formed.

Causes:
There are a number of possible cause and is very common and usually goes unidentified since not all woman take a pregnancy test that early.

• Inadequate uterine lining.
• Low hormone levels
• Luteal phase defect
• Infections
• Chromosomal abnormalities in the fertilized ovum
• Unknown reasons

Dysmenorrhea Or Painful Menstruation

Dysmenorrhea, or painful menstruation, is a condition characterized by varying degrees of crampy, lower abdominal pain and other symptoms such as nausea, vomiting, urinary frequency, low back pain, diarrhea, fatigue, thigh pain, nervousness, dizziness, sweating, and headache.

The pain typically begins just after menses and lasts for about 1 to 2 days, but it can also begin 1 to 2 days before the onset of menses and can last up to 4 days into menstruation.

Epidemiology: At least 40% to 60% of adolescent girls suffer some degree of discomfort during menstruation, with about 15% reporting severe symptoms and 14% reporting that they frequently miss school as a result of menstrual symptoms.

Most affected teenage girls have primary dysmenorrhea not associated with pelvic or other pathologic conditions; however, causes of secondary dysmenorrhea always should be considered when the patient is evaluated.

Primary dysmenorrhea: is common menstrual cramps that are recurrent (come back) and are not due to other diseases. Pain usually begins 1 or 2 days before, or when menstrual bleeding starts, and is felt in the lower abdomen, back, or thighs. Pain can range from mild to severe, can typically last 12 to 72 hours. 

Pathophysiology: Increased amounts of prostaglandins E2 and F2 in the endometrium of women with

dysmenorrhea lead to smooth muscle contractions along with other symptoms such as vomiting and diarrhea. This biologic explanation correlates with the clinical observation that women who have anovulatory cycles usually do not have dysmenorrhea. Adolescent girls typically develop dysmenorrhea 1 to 2 years after menarche, correlating with the onset of ovulatory cycles.

Approach To A Patient Presenting With Dysmenorrhea: The assessment of a teenager with dysmenorrhea should include the following:

• Complete menstrual history

• Timing of cramps or pain

• Missed school or other activities

• Ability to participate in social events

• Presence of nausea, vomiting, diarrhea, dizziness, or other symptoms

• Medications used, including doses

• Factors that improve or worsen symptoms

• Family history of dysmenorrhea or endometriosis

Ask: