Diagnostic aids in G naecology FN Pap’s Smear F\ 1, Write a short note on Pap’s smear. [DU- 1 What is Pap’s smear? [DU-L4sa, at Peres AED Ja, SU-11 JU, 08/06/03/02 Ja} + What is the interpretation of a standard Pap’s smear Fen [pu-iee) ‘Ans : Pap’s Smear iE So cancer screening test where cells are taken from the squamo-columnar junction of the cervix «5. altxtgy introduced by Dr George Fapenicoleon, 2 — paces eee ate (at 18 years) she should have done at yearly interyal ' ne cee ‘rove negative results, it should be done at 3 to 5 years interval upto «Preparation ‘© Abstinence from coitus for 24 hours prior to the procedure No intravaginal medication (vaginal tablet etc) for one week prior to the test No lubricant should be used during the procedure © 12 day of the cycle is ideal time for smear taking © Evidence of infection if any to be treated before taking the smear © Procedure Done in out-patient procedure «Empty bladder With good illumination, the Cusco’s bivalve speculum is to be inserted with cervical os «Scraping ofthe squamo-columnar junction or transformation zone isto be done with Ayet’s spatula By rotating through 360 degree © The ayer’s spatula and the speculum are to be removed ‘© Thin smear is to be made on glass slide | Fringe should be fixed immediately by immersing it in equal parts of absolute alcohol and ether for 30 minutes © The slide along with the fixative is sent to the laboratory The slide can be preserved for 3 months u’s grading ‘Normal Presence of borderline atypical cells—probably due to infection. No evidence of malignancy Cells suspicious of malignancy Presence of few malignant cells Presence of large number of malignant cells [Ref : Prof, Nurjahan : 7th : 365, 369-370, Dutta : 7th : 91] jout any lubricant to locate At ce + Cytology means microscopic study of the cells, Ctpnormal cell is detected in cytology or cervix i clinically suspicious despite negative cytologi finding then cervix should be examined by colpcscopy. pite negative cytological then indicates the need and site for cervical biopsy, © Colposcopy Mtabenaney can be excluded by hist iological examination of tissue taken from the abnormal area. [Ref : Prof. Nurjahan : 6" : 365, 368]«A385 years old lady reported with VIA positiv W «Mention the management seps ot Via pontine eee (RUCTESL gement of VIA +ve w Ans 1. Colposcopy & colpo: : scopy guided biopsy is to be done in cases with VIA +vewomen 2. Ifeoh psy is tobe done i “ ee Ey uided biopsy shows cervical intraepithelial neoplasia , treatment is to be done ‘ ay I Observation with Pap's smear follow up at 6 months or HPV DNA test at 12 months T+ Commonly treated with Large loop (electrosurgical) excision of transformation zone (LLLETZ) * CINIIL Treated by local ablative methods * Cryotherapy * Cold coagulation 5 ea * Electrodiathermy © Laser vaporisation - If colposcopy shows negative results, VIA is tobe repeated after 3 years. (Follow up at 6 months & 2 yrs) Colposcopy 1. Define colposcopy [DU-16/14/12Ja] ‘* What do you mean by colposcopy? [DU-13Ja] ‘Ans : Colposcopy Colposcopy is an optical method for visualisation of lower genital tract under bright illumination at a ‘magnification between the naked eye examination and lower power of microscope. [Ref: Prof, Nurjahan : 7th : 768] Fig : Colposcopy 2. What are the indications of Colposcopy? [DU-16/14/12Ja, RU-19May] Ans : Indications of colposcopy 1, VIA- Positive 2. Evaluation of women with abnormal pap smear Evaluation of women even with normal Pap smear in suspicious cervix, post coital bleeding & presence "of leukoplakia in cervix, vagina & vulva Evaluation of persistent excessive vaginal discharge, pruritus vulvae Identification and management of sub-clinical human papilloma virus infection (HIV) Conservative management of intraepithelial neoplasia of cervix Identification and management of vaginal extension of cervical neoplasia Follow up after treatment of intraepithelial and invasive carcinoma Post radiation follow up [Ref:: Prof. Nurjahan 7th : 769]chapter 10: Diagnostic nids in Gynaecology 49 Culdocentesis t 5 1, Write short note on culdocentesis. [SU-OSM] ns : Culdocentesis Culdocentesis i uldocentesis is the transvaginal aspiration of peritoneal fluid from the cul-de-sac or pouch of Douglas. {Ref : Dutta : 8th : 95] Indications 1. In suspected disturbed ectopic c “ opic pregnancy or ther causes producing haemoperitoneum ae cases of pelvic abscess e {Ref : Dutta : 8th : 95] Ultrasonography in Gynaecology 1. What is Ultrasonography? ‘Ans : Ultrasonography ‘Ultrasonography is a painless, non-invasive, diagnostic tool for almost any pelvic as well as abdominal abnormality. [Ref. Prof. Nurjahan : 7th : 720] 2, Enumerate the USG in gynaecology. [SU-16/15Ja] Ans: of Ult a] 1. Transabdominal Sonography (TAS) 2. Transvaginal Sonography (TVS) 3, Transvaginal Colour Doppler Sonography (TV-CDS) ‘4, Three dimensional sonography (3-D sonography) 5. Harmonic imaging [Ref : Dutta : 8th : 98] 3. What are the uses of Ultrasonogram in Gynaecology? [DU-18JU, ‘SU-20May/Ja, 19/185U, 18NOV] ‘© Write down the role of Ultrasonography im gynaecology [CU-12 Ja, ‘SU-19/18Ja, 18JU] © What information you can get from Gynaecological Ultrasonography. {CU-08/07/05/01 Ja] + What are the importances of USG in Gynaecological practice? [DU-0SS, ‘04Ja} ‘Ans : Indication / Role / Use of USG in gynt 1. Ovarian follicle development surveillance in infertility work up ¢. Suspected hydatidiform mole 2. Evaluation of abortion cases 7. Detection of pelvic mass 3. ectopic pregnancy 8. Diagnosis of fibroid uterus 44. Suspected uterine abnormality 9. Diagnosis of ovarian tumour 5. IUCD localization 10, Detection of polycystic ovarian disease [Ref : Prof. Nurjahan : 7th : 721) 4. Write short notes om Ultrasound in gynaecology. [SU-17/Ja] ‘Ans : Write down from above answers. 5. Name some imaging techniques used in gynaecology. [SU-20May, 1510, 13Sa] F Wits down imaging techniques used in gynaecology. [SU-20/19/16/15Ja} SPs gore the name of four imaging techniques in gynaecology. (CU-19JU] Ans ‘hnigu 1, X-ray 2 Unrasono Pe minal Sonoeaphy (TAS) ¢ Transvaginal Sonography (TVS) © Three dimensional sonography (3-D sonography), $. Positron Emission Tomography (PET) (Ref: Dutta : 8th : 97.98]Pelvic Infection W +f Defence of the Genital Tract TF What are the defence mechani Write down the defence m rr of genital tract? [DU-13/11/09/08 JU, RU-I9NOV, 18NOV/Ja, 16Ja, 15/08 JU) Pee re he eaanak egtanism of female ental tract [DU-18IU, RU-12 J, SU-20170U, 2018] lefence mechanism of female genital tract. [DU-20May, 17JU, RU-13/1 Ja] Describe the natural defence mechanism of tract. [DU-19/14JU, CU- th CIES : 1¢ female genital tract. [DU-19/ Describe the defence mechanism of female geni genital tract, [SU-20May, 19JU, 16/14/13Ja, 15/14/11/08 JU] Write 5 defence mechanism of genital tract. [SU-15/10Ja, 10 JU] " Descirbe the defence mechanism of vulva. [SU-12 Ja] Write 5 defence mechanism of vagina. [SU-10 Ja] ‘Ans : Defence mechanism of the genital tract 1. Vulva a. Inherent resistance to infection b. Secretion of the apocrine glands which is fungicidal c. Closure of the introitus by apposition of the labia 2. Vagis ‘a. Closure by apposition of its anterior and posterior walls __ b. A well developed stratified squamous epithelium, devoid of glands cc. Vaginal acidity d. Vaginal flora : Gram positive anaerobic lactobacillus keeps ‘vaginal p" in check by production of | lactic acid . The mucosal immune response-antibodies, phagocytic cells and cytokines 3. Cervix: '.. Functional closure of the cervix by mucus which is sai to be bact b. Racemose type of glands 4, Uterus ‘a. Cyclic shedding of the endometrium Closure of the uterine ostium of the fallopian tube with slightest inflammatory reaction in the endometrium 5, Fallopian tube | ‘a. Integrated mucus plicae and epithelial cilia « tf Persialsis ofthe rube and also the moverent ofthe cilia are towards the uterus [Ref : Jeffcoate : 9th 365 ; Dutta : 8th 105-106] 2. What is the p'” of vagina at different age? [RU-13Ja, 08 JU] ‘Ans : P™ of vagina at different age of vagina Age yee 10 days) Acidie (5) Ne ‘Neutral or alkaline (6-8) {childbearing period ‘Acidic (4-5) [Postmenopause_ ‘Neutral (6-7)x Sunny Amit's Gynaecology Nice to know ° Colposcopie findings * Normal findings Normal squamous epithelium (A) ‘© Columnar epithelium (B) * Transformation zone (C) ‘+ Abnormal findings * Acetowhite area (AW) * Punctation (P) ‘© ~Mosaicism (M) * Iodine negativity (1) * Unsatisfactory Entire transformation zone not seen © Other findings ‘Condyloma, ectopy and papilloma are of importance. a: Sctopy and papi a Tepe aero ECE SEE] 3. Write a short note on colposcopy. [CU-I9NOV, RU - 11JU] ‘Ans : Write down from above answers Cervical Biopsy 1. Write a short mote on cervical biopsy [RU-05 Ja] Ans : Cervical biopsy Cervical biopsy means taking cervical tissue for histopathological study to exclude pathology e.g carcinoma of the cervix, cervical tuberculosis etc. Cervical biopsy is the most common operation done on the cervix. It can be done under GA, udendal block or deep sedation. © Indications Invasive cervical carcinoma Any ulcerative, granular, nodular or papillary lesion of the cervix Positive pap smear Schiller-positive area Post coital bleeding Abnormal colposcopic findings Chronic cervicitis MOyaeNe ° Types Cervical biopsies are of four types : 1, Punch biopsy 2. Wedge biopsy 3. Ring biopsy 4, Cone biopsy ‘© Complication . inte Tamla or secondary Memos 2. Sepsis mor re = ; ical stenosis giving rise to cervical dystocia in subsequent zi Cieniy doo to loss of cervical mucus glands quent labour 3. Cervical incompetence leading to second trimester abortion, Pre-mature labour etc (Ref. Prof, Nurjahan : ‘Tth : 502, 504)13/108) 2} What is VIA? [DU-t3/125a,CU-10 Jes RUT ayy J Wilt short note on VIA [RU-19J8 11/8208 Whats the interpretation of VIA? [DU- * How VIA is interpreted? [CU-10 Ja] ‘Ans : VIA. ic acid : 5% acetic a Visual inspection of cervix after application of 3 sn To few mts, acetic acid solUti>® "normal area on visualisatioy When cei epee 03.5% ely pm oi, temporarily tur white and reveal a = a : at ee oe invasive lesion and asymptomatic early invasiy , ; high grade pre-invas '* Objectives : To identify earlier the cancer, * Indications . 1. Age 30 years and above every 3 years if VIA negative 2. Abnormal discharge 3. Irregular P/V bleeding = 4. Post-coital bleeding 5. Unhealthy looking cervix Application of 3-5% freshly prepared acetic acid solution for few minutes Look for acetowhite area at the transformation zone © Interpretation 1 2 Bs 4. Exposure of cervix by Cusco’s speculum 5. 6 Description No acetowhite lesion Distinct opaque acetowhite area Qeriows growth or user in the eerviy (Acco area may not be visible because of lee i“ cetowhite © Advantages J: Itis simplier and cheaper than other tests, 5. Realtime screening test, © Disadvantages 1, Low specificity. 73%-91% (com 2. High test positive rate (10-3594) 3. Over investigation and overtreatment of vig Positiy, 4. Essentially leads to detection of ecocervicl ny o°¥€ Women ical diseases 5." Appropriate survellance oe stand ons Pared to cytology) Ref: Prof. Nutiahan ae‘Sunny Amir's Gynaeeg EE |G % own? [CU-04 'M, RU-04S, ‘SU-08! 78 é ee ‘and how defence mechanism breaks d i a body defence is low? [SU-20Ja] jSU-175U] + When defence mechanism of female genital rat become weak ? ‘Ans : Loss of defence mechanism 1d after the menopause when. during childhood anc When - 1. With age : The cae eepithelium, less glycogen and lactobacilli ng vagina has thin nerabl P mpproaches . when its p®approac inal acidity is lowered by the alkaline 2. During menstruation : Absence of cervical plug and vaginal acidity is lo ‘menstrual discharge 3. Following abortion and childbirth Because of Raw placental site Breaks in the epithelial linings of the cervix and vagina ‘* The tissues are bruised and devitalised Vulva, vagina and cervix are wide open 4 Lower vaginal acidity by lochia and liquor discharge ; ; Low general resistance of the patient (by the strain of pregnancy and possibly by anaemia and manriien [Ref: Jeffcoate : 9th : 366 ; Dutta : 8th: 105] Pelvic Inflammatory Disease 1. Define pelvic infection. Classify pelvic infection. |RU-I8NOV/Ja] Ans : Pelvic infection : Pelvic infection may be defined as infection of the uterus, uterine tubes, adjacent parametrium and overlying pelvic peritoneum. sf pelvic ink Pelvic inflammatory disease (PID) Pelvic infection following delivery and abortion Pelvic infection following gynaecological procedures Pelvic infection following Intrauterine devices (IUD) Secondary to other infections-appendicits [Ref : Dutta ; 8th : 106] 2, Define pelvic inflammatory disease (PID) (DU-1S8Ja, 11/08 JU, CU-17Ja, RU 20May, 19NOVIIs 18/17/15/14/135U, 16/15/12/11/10/09 Ja, SU: 13Ja, 11 JU] ° vic inflammatory disease An Pelvic ee disease (PID) is a clinical syndrome associated with ascending spread of mict™ ‘organisms vagina or cervix to the endometrium, fallopian tul iguous structures, 9 ee pian tubes and/or conti [Ref Jeffeoate : 91h: 41) OR PID is a spectrum of infection and inflammation of the u it * ally involving Of cco pss a gil tps pay wi [Ref : Duna : i: 104CG ‘Sunny Am 76 su-20/19NOV1 6. Mention importance /role of imaging technique in GynseeolOBY: Ans. Im) Fo 7. Write short notes on Examination under ai I ‘+ What are the diseases necessary to EUA before definitive management ? ‘© What is the importance of examination under anaesthesia in management Ans. EUA (Examination under anaesthesia) ‘+ Examination under anaesthesia (EUA) is indicated where bimanual examination formative 1 It is cheaper and quite in with X-ray : Either pl using contrast media, has got its place = ither plain or using cot ‘minimal risks of irradiation uation Ultrasound : Establishes a definite place in diagnostic evel a for both the diagnostic & therapeutic purpose. asis and depth. CT scan: Useful in the diagnosis of lymph node melastasit Scr microa ‘endometrial cancer . It may be employed in selected cast ‘metastatic lesions in the brain or liver. MRI : Superior to CT or ultrasound. It is specially helpful t0 ‘tumour. It is safe in pregnancy. A [Ref : Dutta : 8: 102) d procedures are useg n, Ultrasound gu pth of myometrial invasion in \denoma of pituitary op differentiate post-treatment fibrosis ang 5. PET: Helpful to differentiate normal tissues from cancerous one. esthesi [cU-19Ja} {of carcinoma cervix? [CU-20NOV} in not be conducted Properly either because of extreme tendemess or inadequate relaxation of abdomino-pelvic muscles or non-cooperative patient. . It should be done routinely in all cases of uterine malignancy for clinical staging .It is extended freely to ‘examine virgins or in cases with pediatric gynaecological problems ‘* Whenever this examination is carried out , anaesthesia must be sufficient to ensure complete relaxation of the abdominal muscles. To obtain the maximum information, the examination should generally include measurement of the cavity of the uterus and endometrial sampling. + In ease of following disease examination under anaesthesia (EUA) is necessary before definitive management : ‘Carcinoma cervix (staging purpose) Vesico-vaginal and Recto-vaginal fistula Pelvic abscess Fibroid polyp Vaginal bleeding during childhood ( to exclude the presen cat eociestandl eter fea lal ra atc ae ao of tno on odie and (Dutta : 8th : 103, 286, 351, 357 — e bch, 357 237, Jeffcoate : 9*: 12, OO yeepe juated by : {CU-O8JU) Regarding colposcopy aaa! scopy [RU-A3Ja] —__] a. {has no magnificntpe | is T [a._| Visual inspection of cervix after acetic acid rete T | b._| HPV testing (human papilloma & a fa fesbony Pe z : [anaesthesia neem smiears | F [e._| Hysteroscop | a jiposcopy- [RU-16Ja] The 7 : & sal ‘Examination of cervix and vagina ts 1b. | Diagnosis of CIN onl; ‘Indoor procedure : a "No anaesthesia needed F [e. | Trained personnel not n448, Pelvic Pain |. Write down the causes oacte lower abdominal pain na young marred woman, [DUS] * What are the diferential diagnosis of acute abdomen in gynaecology? [CU-OSS, 91°07 ° What are the common gynaecological causes of acute abdomen? [CU-06 S, SU-07 Jal ‘+ Name 5 important causes of acute abdomen. |SU-12 Jal Ans. Causes of acute / severe lower abdominal pain © Gynaecological 1. Ruptured ectopic pregnancy 6. Dysmenorthoea 2, Ruptured chocolate cyst 7. Ruptured corpus luteum or follicular cyst 3. Torsion of the ovarian tumour 8, Haematometra or pyometra 4. Acute PID 9, Following hysterosalpingography (HSG) 5. Abortion 10, Intracystic haemorrhage ‘+ Non-gynaecological 1. Appendicitis 5, Rectus sheath haematoma 2. UTI, Pyelonephritis, 6. Mesenteric lymphadenitis 3. Renal calculus 7. Pancreatitis 4, Intestinal obstruction [Ref : Dutta: 8th: 466) ice to know ‘Common Gynaecological Causes of Lower Abdominal Pain 1, Endometriosis (Severe pain during menstruation, gradually increases with flow of blood ) 2. Adenomyosis (Severe pain during menstruation ) 3. Chronic pelvic pain (Pain during menstruation & intermenstrual pain is also present ) 4. Abortion (Pain is associated with amenorthoea and sign symptoms of pregnancy or positive pregnancy test ) 5. Ectopic pregnancy (Sudden severe agonizing pain with fainting attack and associated with short petiod of amenorshoca with sign symptoms of pregnancy or positive pregnancy test ) 6. Cystitis (No relation with menstruation. Suprapubic pain is associated with other sign symtoms of UTI like burning sensation during micturition ) 7. Degenerated fibroid or polypoidal fibroid (Usually fibroid is painless, but pain occurs when fibroid undergoes degeneration and in case of intracavitary polypoid fibroid when uterus tends to expel it) [Ref : Case Series of Obstetrics & Gynaecology : Prof. Rashida Begum :226-227] 2. How will you investigate a case of acute abdomen? [SU-12 Ja] ‘© Write down the investigations to diagnose a case of acute abdomen in gynaecology. [SU-07 Ja] Ans. Investigations to diagnose acute abdomen in gynaecology. 1. USG of lower abdomen including uterus and adnexa -«$. Blood : TC, DC, ESR, Hb%, PCV 2. Plain x-ray abdomen 6. CT scan & MRI 3. Urine for immunogolical test of pregnancy 7. Laparoscopy 4, Urine R/ M/E, culture & sensitivity test [Ref: Dutta : 8th: 466-467] 3. A lady came with sudden severe lower abdominal pain, How will you proceed to manage her? [DU-( ‘Ans. Management protocol of sudden severe lower abdominal pain 1. If definite diagnosis a. Immediate laparotomy i, Haemoperitoneum MI ‘Twisted ovarian cyst ii, Ruptured tubo-ovarian abscess iv, Tubal ectopic rupture b. Institution of medical therapy i, Urinary tract infection ili, Gastroenteritis ii, Pelvic inflammatory disease 2. Doubtful diagn a. To be subjected to diagnos b. Observation sonography or CT scan or MRI or Laparoscopy [Ref : Dutta: 8th : 467]Nice to know * Causes of low backache 1. Uterine displacement a. Prolapse b. Retroversion 2. Chronic pelvic infection 3. Endometriosis 4 ligament fibroid, pelvic malignancy) 4, Neoplasm (cervical or broat py secre pees ay ee ae appendages) 1. Ovarian ‘a, Ovarian neoplasm b. Ovarian cyst ¢. Endometriomas . Tubo-ovarian mass 2. Uterine ‘Myoma (broad ligament) 3. Tubal pathology a, Ectopic pregnancy b. Hydrosalpinx ¢. Tubai neoplasms 4, Gastrointestinal a. Diverticulitis . Appendicular mass (right) $. Genitourinary Pelvic kidney © Causes of dyspareunia (difficult and or painful coital act) © Male causes 1. Impotence 2. Premature ejaculation 3, Congenital anatomic defect of the penis 4. Lack of technique of coital act + Female causes © Superficiat ‘Narrow introitus Tough hymen Bartholin’s gland cysts Tender perineal scar Vulval infection Urethral pathology © Vaginal 1. Vaginitis 2. Vaginal septum 3. Tender scar following gynaecological operation or delivery 4. Secondary vaginal atresia 5. Tumour 6. Vaginal atrophy (menopause) © Deep ayaene Endometriosis Chronic cervicitis Chronic PID Retroverted uterus peene _Prolapsed ovary in the pouch of Douglas [Ref Dutta 8th 471, 4& Operative Gynaecology a operation. [RU-17/11 Ja] 1, Name 3 emergency gynaecolog Ans: Eme ol 1. D&C 2. Laparotomy followed by salpingectomy (Ruptured ectopic preganncy) : 3. Laparotomy followed by cystectomy / ovariotomy / salpingo-oophorectomy (Twisted ovarian tumour) Nice to know ‘Common gynaecological day surgery cases 1. Dilatation and curettage Termination of pregnancy (D & E) . Biopsy procedures ‘Examination under anaesthesia Endoscopic procedures : ‘a, Diagnostic hysteroscopy, laparoscopy . Laparoscopic sterilisation operation ¢. Ovarian drilling diathermy 4. Transcervical resection / ablation of endometrium. waer [Ref : Dutea: th 49 2. Mention 2 minor & 2 major gynaecological operations. [CU-20May, 19Ja] Ans. Major Gynaecological operation : ‘Abdominal hysterectomy Vaginal hysterectomy Laparotomy Myomectomy Fothergill’s operation Repair of vesico-vaginal fistula ih 2. 3. 4. 5, 6. 1 2. Cauterization & 3. Cryosurgery 4. Cervical biopsy 5. Polypectomy 6. Marsupialization 3, Mention the name of 2 anaesthesia used in minor gynaecological operations, [CU-19Ja] ‘Ans. Anaesthesia used in minor gynaecological operations : 1, Local anaesthesia (Lidocaine, prilocaineetc ) 2. Epidural anaesthesia 3, Short acting general anaesthesia (Inj. Ketamine) 4, Paracervical block% Amir's Gynac Ec 3. Write down the post-operative management following major gynaecological S¥rE°#- ‘Ans. Post-operative management following major gynaecological surgery ym and kept under 1. After recovery from anaesthesia the patient should be shifted to the recovery root Pt observation for 2 hours for early detection of any complications Nothing by mouth till bowel sound returns in2: 1 ratio at 30 drops/mi eae 3 deve sete en 394 dextrose in saline of total 3000 ml in 1 ratio at 30 drops/nin Parenteral antibiotic z ie Tn pethidine 75 mg and Inj, phenergan (promethazine HCI) 25 mg IM should be given when patient ‘comes round and at 8 hourly intervals for 24 hours Continuous catheterisation {All the vital signs should be monitored £ hourly (suchas pulse, BP respiration and urine outpa) Fluid intake and urine output chart shotild be strictly maintained to avoid dehydration, hypovolemia or fluid overload 5 9. Early ambulation should be encouraged after 24 hours. Deep breathing and leg movement are advised to prevent deep venous thrombosis. (Ref: Prof: Nujahan : 7th: 489] 4, Write down the postoperative follow up of a patient following a major gynaecological surgery.[DU-20May} Ans. P follow up of a patient following a major gynaecological surgery : 1. Vital signs (Pulse, blood pressure, temperature &respiration ) 2. Level of consciousness 3. Urine output 4. Oxygen saturation and heart rate using pulse oximeter 5. Tongue for hydration 6. Presence and site of any pain 7. Abdominal palpation for localized tendemess, peritonism or distension. Bowel ‘sound should be checked for return of peristalsis and exclude obstruction or ileus. Enquiry is to be made about the passage of flatus.The abdominal wound should be check for inflammation, bruising or discharge. If drains are present these should be checked. 8. A gentle pelvic examination to exclude a haematoma or collection , if there are any concems about bleeding or infection after vaginal surgery. 9. Vaginal bleeding if any 10, Serum electrolytes 11. Blood gas analysis (in case of patient on ventilator ) 12. Cardiac monitor . {Ret : SRB's Manual of surgery : 6" : 1135, Gynaecology by Ten Teachers : 20" : chapter 17, ‘Dutta : 8 : 491, Prof. Nurjahan : 9" : 489,542} 5. What might be the possible complications after major gynaecological surgery? [RU-20May, SU-06M] ‘+ Name the urinary complications of major gynaecological surgery. [DU-17Ja] ‘Ans. Common postoperative complications following major gynaecological surgery ‘Shock Haemorrhage Pyrexia Urinary complications a. Retention of urine €. Incontinence of urine b. Anuria 4. Cystitis, urethritis and pyelonephritis 5. Post-operative vomiting 6. Abdominal distension and pain 7. Paralytic ileus 8. Intestinal obstruction 9. Peritonitis 10. Wound infection and wound disruption 11. Thrombosis (superficial & deep venous thrombosis) & pulmonary embolism 12, Pulmonary complications : ARDS, post-operative bronchitis, bronchopy ee ral eee Sa i neumonia, pulmonary collapse, oo (Ref: Jeffcoate : 9th : 1123-1136]37: Special Topics yu ‘Ata glance Vaginismus Vaginismus is defined including the levator a cnapte adductor musi Hirsutism is the excessive Central part of the body (male pattern ie = Hypertrichosis pattern) that worries a female ‘© Hyperandrogenism effect of hyperandrogenemia ee Psychogenically mediated involuntary spasm ofthe vaginal muscles ft H Suniel scles and/or the thi rowth of androgen dependent sexual hair (terminal hair) in facial and Hypertrichosis is the excessive growth of non-sexual (fetal lanugo type) hair in normal location _| Hyperandrogenism is a state of increased serum androgen level with or without any biological | © Virilism Vi lism is defined as the presence of any one or more of the following features : ‘© Deepening of the voice ‘Temporal balding Amenorthoea Increased muscle mass Enlargement of clitoris (clitoromegaly) © Breast atrophy ‘© Galactorrhoea Galactorrhoea is the secretion of a milky fluid which is inappropriate (unrelated to child birth) [Ref : Dutta : 8th : 477, 481, 486] Gynaecological Emergency 1. What are the common gynaecological emergencies? [DU.07 S, Cl07S, RU-05S. + What are the gynaecological emergency?{RU-10 Ja, 09 20, SU-AA4AN a — + Mention the name of five gynaecological emergencies. [DU-08 JU, RU-20May, 20NOV, 07Ja] |-20NOV, 19May] Name three gynaecological emergency. [RU-20NOV, Write short notes on Gynaecological emergencies. [SU-17Ja] Ans. Common gynaecological emergencies Ruptured ectopic pregnancy ‘Twisted ovarian tumour Retention of urine Septic abortion : Torsion of subserous pedunculated fibroid Puberty menorrhagia with severe anaemia Ruptured chocolate cyst Mult noyeene le Choice Questions (MC jischarge 2, Common causes of vaginal itching are -[DU-14Ja] Abnormal Vaginal Dis a. | Trichomoniasis al discharge - [DU-14JU] Chlamydi Ts not always pathological Decreases with use of OCP. Candidiasi ‘Always associated with itching Bacterial vaginosis aa E =)5)5]=]5 efele |= i-fungal Sa sm of cervical malignanc) E.coli infectionT chapter 3 of e 4 4, A 40 year old lady came to you with inte you investigate and treat hor, TRU 10 gyy mer abdominapa with per vaginal discharge. How can ‘ans: Differential diagnosis 1, Submucous fibroid 2. Myomatous polyp 5. Incomplete abortion 3. Foreign body in uterus (1UCD) 6. Retained products of conception 4. Missed abortion 7. Ca cervix associated with pyometra and haematometra Investigation 1. USG of lower abdomen " 4. Le 2. Biopsy and histopathology Parmer Routine investigations (TC, DC, ESR, Hb%, Urine, 3. Hysteroscopy RUMIE, RBS, Chest X-Ray, ECG) Treatment: According to cause Lower Abdominal Mass lower abdomen? [DU-06 Ja, CU-07Ja, SU-08 Ja] diagnosis of lump in lower abdomen, [RU-14/11 JU, SU-07 Ja} A 30 years old women presented with feeling of a lump in the hypogastric region. Mention 4 important differential diagnosis. [CU-19NOV] 28 year old lady presents with a lump in lower abdomen. What are the D/D? [DU-12 Ja] A35 years old lady having a lump in the lower abdomen. Give the differential diagnosis forthe case. [RU-19Ja] ‘A20 yrs old lady came with a lump in the lower abdomen. What are the possible causes? (SU-11 JU] Ans. Causes of mass /lump in lower abdomen Fibroid uterus Ovarian tumour Tubo-ovarian mass Haematometra and haematocolpos Endometriotic cyst Pregnancy = Non gynaecological eauses : +” Full bladder eae [Ref : Prof. Nurjahan : 7th : 36] 1, What are the causes of « Write down the differenti sayaeene i lady of 30 years presents with a lump in the lower abdomen? [DU-06 Ja] | investigations "ould be done in a 20 years old lady with a lump in the lower abdomen? [SU- Ans. Management of a lady of 30 years with lower abdominal Diagnosis © Clinical features ; 1. Duration of the abdominal mass of growth 3 Whether the mass pint or not 4, Menstrual history 5, Associated symptoms © Investigations Ultrasonography Plain X-ray abdomen Plain X-ray KUB region Pregnancy test CT scan MRI ayeene meat / Treatment according 0 aus®(ete Derr a 7: fe Hysterectom 19May, 1350, RU-199] 1, Define hysterectomy. |CU Ans. Hysterectomy Hysterectomy is the operation of removal of uterus, 2. What are the types of hysterect leer eee my? [CU - 19May| [Ref Dutta : 8th: 498] Hysterectomy eee Vaginal eae Vv ah ode ae \ nakeal Tal reds Ref: Prof, Nurjahan : 7th : 526, 521) Nice to know ‘Types of laparoscopic hysterectomy 1, Laparoscopic hysterectomy 3. Laparoscopic supracervical hysterectomy 2. Laparoscopic assisted vaginal hysterectom; 4,__Laparoscopic radical hysterectomy Ref: Prof. Nurjahan : 7th : 526] Scenario 1. A lady of 40 yrs old underwent TAH with BSO 10 days back presented with high fever. {RU-18Ja} a. What might be the possible causes? b. How will you rroceed to investigate her? ©. Give the treatment protocol. ‘Ans. a. Possible Causes : i, Wound infection ii. UTI ii, RTT er rr”:—“=#EES reveal organism) ii, RBS iv. Ultrasonography of whole abdomen, ¥. Yay abdomen in erect in A/P view including aesanserre of diaphragm vi. Pus from the infected wound for C/S vi. Blood culture ¢. Treatment protocol : i. Antipyrtic (paracetamol for fever and tepid sponging ii. I.V fluid (correction of dehydration) iii. Injectable antibiotic covering the gm (+)ve, gm (-)ve and anaerobic organisms should be started and may change after getting C/S report iv. Maintain intake output chart v. Catheterization vi. Regular dressing. If granulation tissue appears, secondary suturing can be done. vii. If all the measures fails, lapartomy may be done. Abdominal Hysterectomy 1. Define abdominal hysterectomy: Ans, Abdominal hysterectomy through the abe in means removal ofthe uterus through the abdomen, “Abdominal hysterectomy 1 hysterectomy? (Ref: Prof. Nurjahan : 7th : 521] 2. What are the types of abdor! 7 0 ‘ Ans, ‘Types of abdominal hysteresiomy 3, Radical or Wertheim’s hysterectomy 1 Toa tery (Ref : Prof. Nurjahan : 7th : $21) . Sutcaper 38 : Operative Gynaecology 6) 455 pre-operative and Post-operative Management 1, Write down the pre-operative 2un9NOV ABOBTUA7IA Preparation of a patient before a major gynaecological surgery: [DU- «How will you prepare a patient bet 20May, SU-20NOV,07Ja} fore major gynaecological surgery. [DU-19/16/08Js, CU-19NOV,07S4, RU- ‘What are the pre-operation investi Pre gations for i hu tne et ar Ss ee ns should be done before abdominal hysterectomy ? [CU-14JU] What investigations you igations you want to do before doing laparotomy of malignant ovarian tumour ? [RU-20NOV] [A.45 years old women presents wi Reese ietmeeee DU ie fibroid uterus with progressive menorrhagia. How will you prepare her ‘ans. Pre-operative prey eparation of surgery. [RU-1 i wGcaeT a atient for major. ical syrs ils history (general, medi i , DS os sical rare ‘and complete physical examination ‘The nature of operation Complications of operation Modification depending on the finding during operation Successful outcome of operation ‘Alternative forms of treatment available Informed written consent 3. Pre-operative investigations Blood for TC, DC, ESR & Hb% £ Chest X-ray PA view Blood grouping & Rh typing g. ECG (Age above 40 years) Blood for fasting & 2 hours post prandial sugar —‘h. HBSAg Blood urea & serum creatinine i. Serum electrolytes & IVU in special cases Urine R/ M/E “The patient should be admitted at least 48 hours prior to operation On the preceding night of operation, the patient should be given light diet and 5 mg diazepam Nothing by mouth:from 10.00 P.M before the day of operation senonetna simplex should be given early in the morning on the day of operation ‘The abdomen should be cleaned and shaved 5 At east one unit of eross-matched blood has to be kept ready before operation 10. All vital signs of the patient are to be checked 11. Patient has to be sent to OT at 8.00 A.M with OT list 12, Preoperative preparation of patient in operation table TV fluid should be given with 5% dextrose s Prophylactic IV antibiotic Spinal or general anaesthesia should be give. Pe patent should bein supine position (vagina operation in ithotomy position) ~ronieptie dressing isto be given with povidone iodine and hexirol nei to be emptied by Foley's catheter il operation is over (In vaginal operation. catheter is to be put into the bladder after operation ifneeded) fore surgery by using sterile linen, towel and legging [Ref : Prof. Nurjahan : 7th : 487-488] 2. Why itis important to take consent before 8 y surgical procedure ? [CU-19NOV] i aoe arn of consent before sursial DOSS c ns, Importance of inderstand the risks and bene‘its of the procedure and decide " ra aont i important in helping padent 10 peegegmeaose eae pease i z 3 o s z i z p peel treat or operate upon a patient hut consent is assault in 1aw, even if it is beneficial and camine, tem Orne patient may recover damaacs, , 3 in ne in ete reunion 1 pai before asking for his consent to a particular : arged for * Negligence Uperation, be may Be MESS pint wiout consent he may be charged for * Battery” 4, Ifa doctor intent [Ref : The Essentials rp orensic Medicine and Toxicology : 33: 50, Clinical Surgery in General: RCS Course Manual : 4" : 157)458 Sunny Amir's Gynaecology Ata glance * Total hysterectomy: Removal of the entire uterus A Subtotal hysterectomy Removal of the body or corpus of the uterus leaving peer ee offs Panhysterectomy Removal of the uterus along with ae ‘of tubes and ove Extended hysterectomy : Panhysterectomy with removal of cuff of vagina ’ Radical hysterectomy — : Removal of the uterus, tubes and ovaries of both the Hap sagt of vagina, adjacent parametrium and the draining lymph nodes o! [Ref: Dutta: 8th: 498] 3. Define TAH. [SU-20JU] ‘Ans. Total Abdominal Hysterectomy (TAH) en i nally , it is called Total abdominal hyst ‘When the entire uterus is removed abdominally i is c ny A a 4. What are the indications of abdominal hysterectomy? [DU — 09/ 08 Ja, CU — 085, RU - 13/09 JU, SU-18Ja] ‘© What are the common indications of abdominal hysterectomy? [CU-13JU, SU-19/17/14JU} ‘* Name five common indications of abdominal hysterectomy. [CU - 13/10Ja, 12JU, SU-10Ja] ‘Mention five common indications of total abdominal hysterectomy. [DU-20May, 19JU, SU-18JU} ‘Write 4 important indications of abdominal hysterectomy. {CU-18NOV, SU-15/09 Ja] What are the common indications of total abdominal hysterectomy? [DU — 12 Ja, RU-19May, 18NOV, 17/13Ja, SU-20/11JU} ‘© What are the indications of total abdominal hysterectomy? [DU-19May/Ja, 16/09JU; RU-19Ja] ‘© Mention some common indications of Hysterectomy operation. [DU-17JU] ‘© Mention 2 indications of each Hysterectomy. [CU-17JU] Ans. Indications of total abdominal hysterectomy/ abdominal hysterectomy 1 uterus 2. Dysfunctional uterine bleeding, 3. Chronic pelvic infection 4. Endometriosis, 5. Adenomyosis 6. Benign ovarian tumour with age more than 45 years 7. Hydatidiform mole with age more than 40 years and / or parity more than three 8. Chronic inversion of the uterus ‘© Malignant conditions 1, Endometrial carcinoma 3. Carcinoma of the cervix upto stage Ila 2. Ovarian malignancy © Traumatic : Perforation of the uterus © Obstetric causes 1. Ruptured uterus 4, Infected uterus 2. Uncontrolled postpartum haemorrhage 5. Diseased uterus such as multiple myoma 3, Morbid placental adhesion [Ref: Prof. Nurjahan : 7th : 521] Nice to know 5 rectom © Total 1. DUB 3. Tubo-ovarian mass 2. Fibroid uterus 4. Endometriosis * Subtotal 1. Difficult tubo-ovarian mass 2. Endometriosis (rectovaginal septum) 3. Obstetric causes + Panhysterectomy : Indications for total hysterectomy in perimenopausal age # Extended : Endometrial carcinoma Radical : Carcinoma cervix stage | and I {Ref Dutta : 8th : 499]h 460 Sunny Amir's Gynaecology 5. What are the complications of total abdominal hysterectomy (TAH). [DU - 19JU/May, 16/095U, 145a, CU ~ 11Ja, RU-19May, 1SJU, 12Ja, SU-20JU] ‘What are the complications of total abdominal hysterectomy? [RU — 12 Ja] Mention the post-operative complications following TAH. [SU - 11 JU] ‘Write § per-operative complications uf total abdominal hysterectomy. [SU — 10 Ja] Give the post-operative complications of abdominal hysterectomy. [DU - 18JU, CU -20May, 19NOV, SU — 11JU| ‘What are the complications of abdominal hysterectomy? [DU-18Ja, 15JU, CU-12JU, 13a, RU 11 JU] Mention 6 important complications of abdominal hysterectomy. [CU-19May, 18NOV] Name 5 important com I hysterectomy. [CU-13JU] Mention 4 important complications of total abdominal hysterectomy. [DU-14JU] Enumerate the major complications of abdominal hysterectomy. [CU-12JU] ‘What are the common complications of TAH. [DU-20May, RU-I8NOV] Mention some common complications of Hysterectomy operation. [DU-17JU] ‘Ans. Complications of abdominal / tot dbdominal hysterectom © Per-operative complications 1, Haemorthage 2. Injury to the bladder, ureter and intestines 3. Anaesthetic complications such as cardiac arrest © Post-operative complications © Immediate 1, Haemorthage ‘© Reactionary haemorrhage usually occurs within first 24 hours ‘© Secondary haemorrhage occurs within 7-14 days 2. Paralytic ileus and intestinal obstruction © Delayed 1. Cystitis, pyelitis ete 2. Wound infection, wound dehiscence and burst abdomen 3. Deep vein thrombosis and pulmonary embolism 4, Genito-urinary fistula 5. Vault haematoma, vault abscess ‘© Remote 1. Vault granuloma and vaginal discharge 2. Incisional hernia 3. Vault prolapse 4, Stump carcinoma in case of subtotal hysterectomy [Ref : Prof. Nurjahan : 7th : 524-525] 9. Im which sites ureter likely to be damaged abdominal hysterectomy ? [CU-20May] Ans. The common sites of ureteric injury in abdominal hysterectomy : 1. Infundibulopelvic ligament 2. By the side of the cervix (clamping the cardinal ligament along with descending cervical artery) 3. Vaginal angle as the ureter traverses along the anterior fornix 4, During pelvic peritonization (ureter lies in the posterior leaf of the peritoneum) [Ref : Dutta: 8: 12] Nice to know The chances of ureteric injury are more in cases of endometriosis, pelvic inflammation or broad ligament tumour. Injury is more common during reclamping than primary clamping ‘In Radical hysterectomy direct injury to the ureter is not common. Sloughing necrosis may occur due to stripping the ureter off the peritoneum —» devitalization-> sloughing, [Ref : Dut“ ‘sunny Amir's Gynaecology es of non-descent vaginal hysterectomy over abdominal hysterecto There is no incision and no incisional scar, removal of uterus through Less operative time Less intra-operative bleeding, Less post-operative morbidity Early discharge and short hospital stay No extra setup cost, only conventional instruments are required No incision and no incisional hernia. | [Ref : Case series of Obstetrics & Gynaecology : Prof. Rashida Begum : 345-346) tural passage ns 2. 3, 4, Sh 6 7. 3. Write down the indications of vaginal hysterectomy. [DU - 20NOV, CU - 09JU, SU-18Ja], ‘Ans. Indications of vaginal hysterectomy 1. Third degree utero-vaginal prolapse 2. Second degree prolapse in aged women F 3. Utero-vaginal prolapse associated with diseased aterus such as DUB, small fibroid when the uterus is less than 10 weeks size : 4, Incase of diseased uterus even not associated with prolapse where the uterus is less than 10 weeks size [Ref:: Prof. Nurjahan : 7th : 536) Nice to know ‘Contraindications of vaginal hysterectomy ‘Associated pelvic inflammatory disease 2. Endometriosi 3. Previous pelvic surgery with associated adhesion 4. 5 fibroid 5. Diseased uterus with size more than 10 weeks 6. Previous pelvic radiation Disadvantages of vaginal hysterectomy 1. More skill and experience are needed on the part of the surgeon 2. Exploration of abdominal and pelvic organs cannct be done 3. Difficult in cases with restricted uterine mobility, limited vaginal space and associated adnexal pathology , 4, Limitation in cases with : uterus > 12 weeks of size, presence of pelvic adhesions or previous history of laparotomy with adhesions [Ref: Prof. Nurjahan ; 7th : 536-537, Dutta : 8th : 503] 4, What are the advantages of vaginal hysterectomy? ‘© What are the advantages of vaginal hysterectomy over abdominal hysterectomy? [RU-19NOV, 15JU] Ans. Advantages of vaginal hysterectomy/advantages of vaginal hysterectomy over abdominal hysterectomy ‘Can be effectively done in obese patients Post-operative complications are less Less morbidity and mortality Less post-operative pain and less need of analgesia Less hospital stay Early resumption of day-to-day act ‘No abdominal incision and scar PAW RENE [Ref: Dutta : 8th : 503] 5, How will you prepare a patient for vaginal hysterectomy? (SU ~ 10JU] © How will you prepare a patient for vaginal hysterectomy on next day? [CU— 12 Ja} Write down the pre-operative preparations of vaginal hysterectomy. [CU - 07 Ja, SU—06S , 02 Ja] ‘Ans. Pre-operativ ion of vaginal hyst See in the chapter "Operative Gynaecology” (Pre-operative preparation)4 464 Sunny Amir's Gynaecology 3. What are the. ‘complications of radical hysterectomy 2[RU-16JU} ‘+ What are the immediate & late complications of radical hysterectomy? [DU - 08 JU] © What are the complications of ‘Wertheim’s hysterectomy? Ans. Complications of Wert 's / Radical by om Immediate . Haemorthage . Haematoma ‘Shock |. Injury to the bladder, ureter, bowel and the large vessels Abdominal distension, paralytic ileus and peritonitis Sepsis «= Late 1. Bladder atony 3. Dyspareunia 2. Ureteri fistula 4. Lymphocyst formation [Ref : Prof. Nurjahan : 7th : 525-526] Dilatation & Curettage (D&C) 1, Define D & C. [DU-16JU, 13a, RU-16/14/09JU] Ans: Dilatation & Curettage (D & C) Dilatation of the internal os of the cervix and curettage of the endometrial cavity is called D&C. [Ref : Prof. Nurjahan : 7th: 491] D&E&C D:: Dilatation of the internal os of the cervix Evacuation of the products of conception CC: Curettage of the endometrial cavity 2. What are the indications of D & C? [DU-20Ja, 19May, 18NOV/Ja, 16JU, 13JU/Ja, 092,08M, CU-06Ja/M, RU-16/14/09/08JU, 10a, SU-20May/Ja, 16/13/12/11 Ja] © Enumerate common indications of D&C. [DU-15/10Ja| © What are the common indications of D, E&C. [RU-19NOVI ‘© Write down five indications of dilatation & curettage [CU-11Ja] * Write down 4 indications of diagnostic D & C. [SU-09Ja] ‘© What are the therapeutic indications of D & C. [CU-20May, RU-12Ja] ‘* Write down the diagnostic & therapeutic indications of D, E&C. [SU-15JU} © Write down 3 indications of D&C. [SU-15Ja] Ans: Indications of D & C © Diagnostic 1. Menstrual disturbance to exclude pathology e.g incomplete abortion, endometrial polyp, ‘endometrial carcinoma, choriocarcinoma, DUB ete . 2. Infertility to see the evidence of ovulation 3. In postmenopausal bleeding to exclude pathology e.g endometrial carcinoma, polyp etc © Therapeutic 1. Incomplete abortion 3. DUB to control bleeding 2. Missed abortion 6. Endometrial polyp 3. Inevitable abortion less than 12 weeks size 7. Displaced 1UCD 4, Hydatidiform mole «© Combined 1, DUB 2, Endometrial polyp (Ref: Prof. Nurjahan : 7th : 491-492]Chapter 38: 10, How will you manage a case of, Operative Gynaecology ue a Seconday + How will you treat a case of excessive Py anne Thage following abdominal hysterectomy?[DU — 06 Jal Write down the m: ieMeNt of secondar, seeding 14 days after TAH? [RU 12 Ja] hi ;. (CU-14Ja ‘Ans. Management of second: morrh; a Seectered nal hysterectomy. (Cl 1 Secondary haemorrha, lominal hysters 1, Hospitalisation WBC Occurs between 4 days after operation and is due to sepsis. 2. Bed rest 3. In case of mild bleeding a. High vaginal swab for culture and sensitivit f ity test b. Broad spectrum antibiotic orally (according to C/S report) 4. In case of moderate to severe bleeding 1, What are the types of vay WV fluid Blood is sent for Hb%, & Rh typing, Blood transfusion to CaS — IV broad spectrum antibiotic Send the patient to OT & examination under anaesthesia is done If the bleeding is from the vault, haemostasis by interrupted suture using vieryl under GA. In case of intraperitoneal haemorrhage, laparotomy his to be done along with resuscitative procedure.If the uterine artery is involved, anterior division of the internal iliac artery has to be tied to secure haemostasis. mpapse [Ref: Dutta : 8th : $02] Vaginal Hysterectomy I hysterectomy? ‘Ans. Types of vaginal hysterectomy, 1 2. Total Radical [Ref: Prof. Nurjahan : 7th : 526] 2. What is LAVH & NDVH ? [CU-19NOV] LAVH ( Laparoscoy assisted vaginal hysterectomy) . can Ans. LAVH ( Lapa ysterectomy (LAVH) is of gretest benefit in those conditions in whic isted vaginal Laparoscopy assisted vaginal oN jn ye — hysterectomy to a vaginal procedure and not to convert a It should be used t0 conven! Oo Scopic one. The late is asosited with increased operating time, cost vaginal hysterectomy J uncture sites in such a situation. ; i and pain at abdomine! Pil vases of endometriosis , known pelvic adhesions LAVE is ideally sult were a vaginal procedure would not be possible disease oF endometrial CANCE": srnent of the pelvis and division of pedicles up to the level of the re wscedue ca then safely to be done from below. i ‘formed depending upon the degree up to which surgery is carried out Several types Hn pi and reseton of eadometiss, detachment of aexa, blader roscopically, ©-8 adhesio NY fore proceeding tothe vaginal hysterectomy. leparefom or urine artery ligation Delon ; [ Ref: Jeffooate : 8%: 832] pelvic inflammatory also indicated in Stage ; 1 p NDVH ( Non-desceat seo eresne without genito-werine prolapse , it is called non-descent vaginal inal hy When vagi = terectomy: joned un Indiceans Same ss metioned indications of vaginal hysterectomy except genitourinary prolapse. 5. Cervix flushed with vaginal wall ntraind! 6. History of fistula (VVF/RVE) repair Te Ute Oe) : 7. History of caesarean section 2, Adnexal path? ee nal 3. Limited vag 4. RestrictedChapter 38 : Operative Gynaecology L$ 459 Nice to know * Advantages of Abdominal h 1. Scope of wide expl bladder etc) ysterectomy oration of the abdominal and pelvic organs (ovaries, appendix, gall Tubo-ovari F Caeentian oly an be el tte and simultaneously once sure proces appendectomy) mayb performed when needed can be done by a relatively less experienced surgeon with average skill * Disadvantages of abdominal hysterectomy Difficult to perform 100 obese patients 2. Pe i Sa complications are slightly high. There is increased incidence of we ‘onitis, fever, pulmonary and vascular complications lore postoperative pain and more need of analgesia 4, More hospital stay 5. Delayed resumption in day-to-day activities 6. Morbidity and mortality are more compared to a vaginal hysterectomy 7. Presence of abdominal scar [Ref Dutta : 8th : 503) 5. How will you prepare a patient for total abdominal hysterectomy (TAH)? [RU-17/13Ja] ‘Ans. Pre-operative preparation of abdominal hysterectomy perative Gynaecology” (Pre-operative preparation) See in the chapter " 6. Write down the structure cut in 1",2™ and 3% clamp during TAH. [SU - 10 Ja] - —— 09 Jal ‘Ans. Structures cut in 1%, 2" and 3% clamp during TAH © First Clamp Fallopian tube, ovarian ligament and round ligament «Second Clamp : Uterine vessels {Third clamp: Mackenrodt’s and utersacraligament [Ref : Prof. Nurjahan : 7th : 522-523] +, Write down the postoperative management of ‘abdominal hysterectomy. [CU - 07/02 Ja, RU~01 S] t Write down the post operative order folowing ‘otal abdominal hysterectomy in your routine OT. [SU-17Ja] |Ans. Post-operative management of 8 jinal hysterector i found appears 1. Nothing by mouth till bowel sun. : 2 ae Mud (5% dextrose water and 52% dextrose in saline of total 3000 ml in 2 $ 1 ratio at 30 drops/ min) | antibiotics Q ene 75 mg and Inj. Phenergan 25 ™B ree Tey emt ECO Ini hourly intervals for 24 aoe « 5. Continuous catheterisation Close monitoring of the patient bleeding, abdominal tenderness oF 7. When bowel sound solid and then soli hours (5 days in vaginal hysterectomy) regarding pulse, BP, temperature, lung and heart conditions, vaginal distension and urine output uld be allowed to have liquid diet for 24 hours and subsequently semi- appear, she sho a owed, Parental antibiotics are tobe replaced by oral ones [Ref Prof, Nurjahan : 7th : 489, 542]coapter 38 © Therapeutic : Operative Gynaecology 465 OR 1. Infertility 2. Abnor 4. Endometrial tuberculosis 3 Pan wal uterine bleeding (AUB) 5 aioe eaten . Pathologic amenorrhoea Postmenopausal bleeding 1. DUB 2. Endometrial polyp 3. Removal of UD 4. Incomplete abortion ‘Combined 1. DUB 2. Endometrial polyp {[Ref: Dutta : 8th : 492] to know Contraindication of D&C 1. Pregnancy 2. Pelvic infection [Ref: Prof. Nurjahan : 7th :492] down the steps of D & C operation. [DU-02Ja, RU-04s] + Write down the procedure of D & C. [CU-06Ja, RU-06s] Ans: Steps of D & C operation 1 z 13, 14, 15, 16, V7 18 The patient is to empty the bladder prior to operation The operation is done under general anaesthesia or under diazepam sedation with or without paracervical block / She is be placed in lithotomy position The vulva and vagina should be swabbed clean by sponge holding forceps with antiseptic savion or providone iodine solution The vulva should be sufrounded with sterile sheets Thorough pelvic examination is mandatory (o determine the position, size and mobility ofthe uterus) The cervix should be exposed by introducing Sim’s vaginal speculum into vagina The anterior lip of the cervix is grasped with the volsellum foreeps and drawn down ‘An uterine sound is introduced to confirm the position and to note the length of the uterine cavity ted gradually with a series of metal dilators upto desirable level (Hegar's dilator Cervical canal is then d is most commonly used) ‘After the desired dilataion, ‘The whole of the endomet cavity the cavity in a clockwise direction - systematically shouldbe collected ona gauze put in Between he. vx and the Sim's speculum ‘The cuttings ted for their gross appearance and then carefully picked up from the gauze is then inspect 4 ae eer “rgsecting forceps and placed immediately ina sterile vil containing, 10% formo the tip saline settum is removed, the cori is looked for any injury and bleeding. After that, Sims speculum The volsellum ? should be removed ‘The vagina is swabbe The patient is then put ba The tissue should be sent for the uterine cavity is curetted by an terine curette cavity is scraped away starting at 12 0” clock position and working round ‘the anterior, left lat ral, posterior and right lateral walls 4 clean of blood and a sterile pad is placed over the vulva in the supine position, both of het legs should be brought down together histopathology with proper labeling. [Ret: Duta: 8th: 493, Prof, Nurjahan : nh: 492-493]463, r aca vaginal hysterectomy. [DU-18Ja] eaenc at Of vaginal hysterectomy. [CU — 12 Jal Write down the post-operative ordi after vaginal hysterectomy & pelvic floor repair? [DU-155U] Write down 5 important Post-operative * patient of vaginal hysterectomy. [CU-09J0, SU — 20May, 18/115U} jos Postonerative manarmcotofuathdinucte ee om: See the answer of “Post- " Post-operative management of abdominal hysterectomy” What are the post-operative manage hat are the compli 1 Soa es ae God [DU — 20NOV, 16Ja, 08JU, CU 12/10 Ja, 09 JU, RU- j 18Ja, 11 JU, 10 Ja, SU -20May/Ja, 18/17Ja, 17/14/105U, 14/13Ja] + Write down the preoperative and post operative complications of vaginal hysterectomy. [SU-194UI ‘ans. Complications of vaginal hysterectomy ‘© Per-operative complications 1. Haemorthage 4, Injury to the ureter, intestine and the omentum 2. Haematoma formation 5. Anaesthetic hazards 3. Injury to the bladder ~ ‘© Post-operative complications © Immediate 1. Reactionary haemorrhage 2. Abdominal distention 3. Cystitis 4. Urinary retention 5. Secondary haemorrhage 6. Deep venous thrombosis and pulmonary embolism 7. Vault haematoma and vault abscess 1. Dyspareunia 2. Vault granuloma causing discharge 3. Stress incontinence 4. Vault prolapse Wertheim’s Hysterectomy Syn: Radical Hysterectomy [Ref : Prof. Nurjahan : 7th : $42-543] 1. What are the indications of wertheim’s hysterectomy? Ans. Indications of Wertwetm’s byster ; ‘Carcinoma of the cervix upto stage 118 Carcinoma corporis et cervicis ‘i inoma : Stage IIB . Enamel cited unpre oan) a Mae ience of cervical cancer afer radiotherapy (growth limited to cervix and upper vagina) ecu e IRéf: Prof, Nurjahan : 7th : $25, Dutta : 8th : 508) yaeeee 2 what are the components of Werthelm’s hysterectomy? [CU-16Ja] ‘ oe ‘Ans. Components of Werth Tray with bilateral salpingo-oophorectomy lL. Total abdominal hyste! vi tissues 2. Removal of the parame, ‘int x a of wee pelvic Iymph nodes such as intemal ae, obturator, extemal iliac and sometimes femoval 0 common iliac. [Ref : Prof. Nurjahan : 7th : 525]Wow S Stn is Gamnctry Steps of D & C in short 1. Patientt is explained the procedure 2. Anaesthesia : Local / epidural / General 3. Position: Lithotomy 4, Empty bladder 5. Clean the vulva, vagina and perineum 6. Drapping with sterile towels 7. 8. 9 ‘Sims speculum is introduced with anterior vaginal wall retractor Volsellum for holding anterior lip of cervix ; Pass uterine sound to determine size and direction of uterine cavity 10. Pass dilators steadily and gently : 11, Cervix should be dilated enough to admit the curette easily 12, After dilatation, sharp curette is passed in axis of cervico-uter fundus 13. With steady pressure scrape down in all direct st 14, A grating sensation is felt by curette when endometrium is satis 15. Collect the endometrium in saline or citrate soultion 16. Gently massage uterus between two hands to remove all blood. [Ref : Jeffeoate : 9th : 849-850] canal till it touches the jon in a systematic way factorily removed Nice to know ‘Signs of completion of D&C ‘No product is coming out Air bubble will come ‘A grating sensation is felt by curette Gripping of the cannula No P/V bleeding ‘Nice to know Instruments for D&C Operations : Kidney dish 8. Uterine curette Sponge holding forceps 9. Uterine sound Sterile drapes 10. Anterior vaginal wall retractor ‘Antiseptic solution 11. Volsellum Sterile pads 12. Biopsy curette ‘Sims speculum 13. Urinary catheter Hegar’s dilator [Ref Jeffeoate : 9th : 850) ‘Ata glance Time of discharge following D & C ‘* Depends on the patient’s condition «Usually the patient is discharged within 24 hours ; [Ref Prof. Nurjahan : 7th : 496] 4, What are the ad given during discharge following D & C operation? Ans : Advice during discharge following D&C © General advices 1. Antibiotics such as cap. ampicillin 250 mg 6 hourly for 7 days 2. Abstinence from coitus for 2 weeks 3, Not to lift heavy weight for 2 weeks. After 2 weeks she can start her usual activity ‘© Special advice Depends on the indication. Such as prescription of clomiphene citrate in infertile women who hed anovulatory menstrual cycles. [Ref : Prof, Nurjahan : 7th: 496] ‘Senay Amit's Gynaecology - 2308)acs” Sunny Amit’s Gynaecology Nice to know Dilatation of the cervix onl mon There are some situations that need dilaation of the intemal o8 of the cervix without subsequent endometrial curettage Indication ‘Spasmodic dysmenorthoea i Fetherglls operation (o facilitate the introduction ofthe needle through cervix) To allow drainage of pus from the uterine cavity in pyometra . Insertion of radium or caesium Cervical stenosis For hysteroscopy Insertion of the laminaria tent and IUCD occasionally Insufflation of the fallopian tubes Insertion of manipulator during laparoscopy. [Ref Prof. Nurjaban : 7th: 501} 8. Write a short note on fractional curettage. Ans : Fractional curettage In fractional curettage the cervical canal is curetted before dilatation of the intemal os and the tissue is preserved. The internal os is dilated next. Thereafter the endometrial curettage is done and the curettings are preserved separately. * Indications 1. Postmenopausal bleeding 3. Endometrial carcinoma 2. Endocervical malignacy ‘+ Importance 1. Chance of missing of malignant or abnormal tissue in any where 2, Management differ if cervix is involved in endometrial carcinoma. [Ref: Prof. Nurjahan : 7th : 494-495] Scenario 1 During D&C of an old incomplete abortion, 4mm dilator passed through internal os with loss of resistance [SU-09 JU) ‘a, What is your diagnoisis? b. How can you manage this case? a, Perforation of uterus following D & C 'b. Management : See in the page no 467 Laparotomy 1. What is laparotomy? [CU-16/08JU, 15Ja] © Define laparotomy. [CU-19Ja] Ans. Laparotomy Laparotomy means the orrring of the abdomen for the purpose of diagnosis, provided there is sufficient reason. [Ref : Prof. Nurjahan : 7th : 507] 2. Write down the name of four incision for laparotomy for gynaecological conditions. { CU-18Ja] Write down the name of different incision for laparotomy. (CU-16JU] ‘Ans. Types of Incisions in lapartomy/abdominal o| 1. Vertical (infraumbilical) incision a. Midline incision b. Paramedian incisions either right or left Pfannenstiel incision Joel cohen incision Maylard’s incision [Ref : Prof, Nurjahan : 7th : 507] Ans Bey