Diagnostic Of Female Reproductive System

Examination of female reproductive system

Connetion way name: nancy Email: [email protected]

Examination of female reproductive system

1

General points

2

Medical history

3

Examination

4

Vaginal examination during labour

Examination of female reproductive system

5

Rectal Examination

6

Investigations

7

Imaging techniques

8

Test of fetal well-being

1

General points

Presenting problems and gynaecological history

1

Menstrual upset 2

Postcoital bleeding, Dyspareunia

3

Symptoms of bladder or pelvic floor disturbance and backache

Menstruation

 Definition: The cyclical loss of sanguineous fluid from the uterus in mature women  The days of menstrual loss and duration of the interval from the first day of one period to the onset of the next,e.g.5/28

The date of the first day of the last menstrual period (LMP)

History of current and previous pregnan cies

The previous menstrual pattern before conception

The expected date of delivery (EDD)

The time taken for the woman to return to a normal menstrual pattern The course and outcome of previous pregnancies

General points A live birth

A neonatal death

The outcome of Previous pregnancies

A stillbirth

General points

A woman’s gravidity is described by the notation para x+y

X is the number of babies delivered

Y is the number of pregnancies the woman has had

2

Medical history

Medical history

Medication or Treatment history

allergic reactions should be recorded

Medical history Changes in appetite



A Volume of urine passed

Frequency of urine passed

Change in bowel habit

G

B General and associated system assessment

F

E E Variations in sleep patterns

C

Change in weight

D Change in responses to normal exercise

Family and social history 1

2

3

Employment

Home condition

the length of relationships

The ethnic origins of the family

4

5

a detailed family history

3

Examination

Examination appearance

Secondary sexual development and hair distribution

The level of intelligence and education

gait

General

demeanour

responsiveness

Examination Hands Arms Following a predictable sequence

Eyes Head,neck Breasts, chest Abdomen Pelvic examination

Abdominal examination

Inspection

striae gravidarum  linea nigra  Scars  Fetal movement 

Palpation

Fundal height Fetal poles and fetal lie Presentationbreech,head ect Attitude Level of presenting part Fetal movements Liquor volume

Auscultation

Fetal heart rate

Four maneuvers of Leopold

(1)

(3)

(2)

(4)

The size of the uterus Fetal lie

Four maneuvers  of Leopold

Fetal presentation Fetal position engagement of the presentation

The size of the uterus is estimated from the fundal height

The fundal height is just above the symphysis pubis at 12 weeks’ gestation 22 weeks---at the umbilicus 30 weeks---equidistant from the symphysis pubis and the umbilicus 36 weeks---at the xiphisternum

36 weeks 30 weeks 22 weeks 12 weeks

Approximate fundal height with changing gestation

From 36 weeks the fundal height is also dependent on the level of the presenting part ,and will reduce as the presenting part descends into the pelvis

 Comparative assessments can be made by measuring either the symphsis-fundal height or the minimal girth measured at the level of the umbilicus

 Method of abdominal palpation to determine fetal lie and location of back

Fetal lie----the relationship of the long axis of the fetus to the long axis of the uterus

 Once the presenting part has a relationship to the pelvis,that relationship can be vertical or rotational

When the flexed head presents, the fetal occiput is termed the denominator

When the face presents the denominator is the chin

When the breech presents the denominator is the sacrum

 At At the the end end of of labour labour ,the ,the common common presenting presenting position position are are left left occipito-anterior occipito-anterior (LOA) (LOA) and and right right occipito-anterior occipito-anterior (ROA) (ROA)

(60%)

LOA

(30%) ROA

Engagement

(ischial spines)

 Engagement of the baby’head in the pelvis will usually have occurred by the time the leading edge reaches the level of the ischial spines(zero station)

 The vertical relationship of the presenting part to the pelvic

 Listening over the fetal back to the fetal heart

A record is made of the fetal heart rate(FHR), normally at the range from 115 to 160 beats/min

Pelvic Examination

vaginally

Pelvic examination

rectally

 The pelvic examination may be undertaken vaginally or rectally

For those who cannot use tampons or whose hymen is intact

Vaginally Examination

1

Before starting ,it is most important to explain every step to the patient

2

A good light is required and an assistant is necessary

3

Begin by inspecting the perineum in the dorsal or left lateral position

Vaginally Examination

Inspection of vulva Digital palpation Speculum examination

Inspection of vulva Mons pubis External urethral orifice

Hymen

Vaginal cavity The vulva

Any inflammation, swelling, soreness, ulceration or neoplasia of the vulva, perineum or anus is noted

Rectocele Uterine prolapse

Digital vaginal examination

 With the patient in the supine position and with her knees drawn up and separated

Locate cervix bimanual palpation pelvic tenderness

Digital palpation

pelvic masses Ovaries and fallopian tubes

Assessment of uterus(position,mobility)

Bimanual examination

Two Two fingers(index fingers(index and and middle middle fingers) fingers) of right hand insert into of right hand insert into the the vigina,with vigina,with the the left left hand hand placed placed on on the abdomen above the symphysis the abdomen above the symphysis pubis pubis and and below below the the umbilicus umbilicus

The size,shape,position,consistency, and regularity of the relationship of the fundus of the uterus to the cevix is estimated Bimanual examination When attempts are made to move the cervix in the presence of pelvic inflammation,particularly in association with ectopic pregnancy,extreme pain results

Speculum Examination

 This is an essential part of gynaecological examination  The speculum should be warmed to body temperature and lubricated with water or a water-based jelly

Clinical instruments prepared for a Gynaecological examination

Cusco’s speculum used to expose the vaginal cavity and cervix

Smear from uterine cervix.

There are several abnormal squamous cells indicating situ carcinoma of the cervix. Large pink-stained normal superficial. Squamous cells and many inflammatory cells are also included

Technique for taking a cervical smear  In order to detect cervical pre-cancer,an Aylesbury or similar spatula ia used

 The tip of the spatula is placed firmly in the cervical os ,so as to allow the removal of surface cells from the whole of the squamo-columnar junction when the spatula is rotated through 360 degrees

Sims’s speculum used to display the anterior vaginal wall.

Using the left hang to elevate the right buttock. The blade then deflects the rectum, exposing the urethral meatus, anterior vaginal wall and bladder base

Uterine prolapse

FIST-DEGREE

SECOND-DEGREE

The cervix descends but lies short of the introitus

The cervix passes to the level of the introitus

THIRD-DEGREE

The whole of the uterus is prolapsed outside the vulva

VAGINAL EXAMINATION DURING LABOUR

Absence of pulsating umbilical cord, especially if the membranes are ruptured

The level of the presenting liquor

The examination is made to determine. .

The presence or absence of amniotic membranes

Data and effacement of the cervix

The size and shape of the maternal bony pelvis The degree of moulding of the fetal head, or the presence of the caput succedaneum

RECTAL EXAMINTION  When vaginal examination is not possible or not acceptable, rectal examination permits bimanual assessment of the pelvic viscera and is particularly valuable in assessing problems which are located in the pouch of Douglas, the uterosacral ligaments, or the rectovaginal septum

INVESTIGATIONS 1 2

PREGNANCY TESTING BACTERIOLOGICAL AND VIRUS TESTS

3

COLPOSCOPY

4

HYSTEROSCOPY

5

ENDOMETRIAL BIOPSY

6

CYSTOSCOPY AND CYSTOMETRY

PREGNANCY TESTING

URINE

Most pregnancy tests depend on the demonstration of HCG in the urine, The sensitivity of these tests varies. Very early diagnosis of pregnancy is now possible

BLOOD

Even earlier detection of pregnancy is possible by radioimmunoassay of the beta-subunit of HCG in blood

BACTERIOLOGICAL AND VIRUS TESTS

Bacteriological and virus tests used in gynaecology and obstetrics include the following: phase I

1

2

3

 Swabs from the throat, endocervix, vagina, urethra and rectum may be needed for sexually transmitted diseases

Bacteriological mid-stream urinalysis is important in both Obstetrics and Gynaecology

Tests for toxoplasma, rubella, cytomegalovirus and herpes simplex cover previous infections likely to be damaging to a pregnancy

COLPOSCOPY

Colposcopy permits visualization of the cervix, vaginal vault or vulva with a low-power binocular microscope to detect precancerous abnormalities of the epithelium

Colposcopy

HYSTEROSCOPY

This is a technique for viewing the cavity of the uterus using small diameter fibre-optic telescopes and cameras, such as endometrial ablation or resection of submuocus fibrods, which can be performed under general anaesthetic

Hysteroscopic view of an intrauterine device in situ

ENDOMETRIAL BIOPSY

One of the common investigations undertaken in Gynaecology is sampling of the endometrium. The biopsy is not always representative and may fail to make a diagnosis in up to one-third of cases An endometrial biopsy curette, a pipette cell sampler and fixing medium

CYSTOSCOPY AND CYSTOMETRY

Viewing the interior of the bladder by cystoscopy gives information of its condition and allows biopsy of the mucosa or removal of foreign bodies

The pressure/volume relationships of bladder filling, detrusor and sphincter activity and urethral flow rate can be assessed with a cystometrogram

IMAGING TECHNIQUES

RADIOLOGICAL INVESTIGATIONS 1 HYSTEROSALPINGOGRAPHY

2 LATERAL X-RAY PELVIMETRY

HYSTEROSALPINGOGRAPHY

This is now used infrequently to image the uterine cavity and fallopian tubes after a radiopaque medium has been installed into the uterus .The fallopian tubal lumen and patency can also be seen. The technique is being replaced by hysterosonegraphy

An abnormal hysterosalpingogram: uteri didelphys

LATERAL X-RAY PELVIMETRY

　 An indication for this assessment is a planned breech birth, so that the succedent head can be certain to pass through the pelvis without bony obstruction

Now MIR pelvimetry is usually used, in order to limit radiation exposure

ULTRASOUND

Ultrasound generated form a piezoelectric crystal transducer is propagated through tissue at variable velocity depending on tissue density. The echo time and signal amplitude give an estimate of the size and consistency of the object scanned. Ultrasound scanning is used in medicine assessment of gestational age, blood flow and all important parameters of pregnant monitoring

 Two-dimensional imaging by "B" scanning is the primary modality, and additional information can be obtained by colour and pulsed Doppler which provides information on bloodflow.Transabdominal and transvaginal routes can be used.The former enables a wide field of view,greater depth of penetration and transducers movement; the latter,with higher frequency transducers,gives increased resolution and diagnostic power but over a more limited area

In early pregnancy (5-7weeks) ,the integrity, location and number of sacs can be viewed. At 11-13 weeks nuchal translucency mono dichorionicity and gross fetal abnormality can be detected. formal scanning at 18-20 weeks is performed to confirm structural normality and some functional activity. By 24 weeks uterine and placental blood flow can be assessed In Gynaecology, apart from the assessment of masses, ultrasound is useful to ascertain aspects of bladder function such as residual volumes and bladder neck activity. It is also helpful in the preoperative preparation of anal sphincter deficiency . .

CT SCNNING

CT scanning has proved less values in Gynaecology than that originally anticipated in other major and is used mainly for staging and follow up of malignancies

MRI MRI, however, offers an alternative to ultrasound and to X-ray imaging during pregnancy ;it uses no ionizing radiation and magnetic field strengths (0.2-2.0 tesla) in current application Good images are obtained with excellent differentiation of maternal and fetal tissues. Although ultrasound is much cheaper, no interactions from bone bowel gas occur

LAPAROSCOPY Visualization of the pelvic and abdominal MRI viscera is valuable if it can be done without a major injury to the abdominal wall (Fig.14.17).This is achieved by using a fibreoptic telescope illuminated by a light source remote from the patient. It is then possible to inflate the abdomen with carbon dioxide under general or local anaesthesia, so that the viscera, allowing inspection of the abdominal and pelvic contents

BIOLOGICAL TESTS Chorion biopsy This is a method of obtaining chorionic material at 911 weeks of pregnancy, usually through the abdomen so that genetic constitution or biochemical function of fetal cellular material can be determined. It is useful for the diagnosis of Down's syndrome, thalassaemia, and in a number of other hereditary conditions. Early and rapid diagnosis allows the therapeutic termination of an abnormal pregnancy, increasing the safety and acceptability of that procedure. There is still an increased risk of spontaneous abortion after the chorion biopsy and this technique is used only in specialized centres.

Maternal blood sampling for fetal cells

It is possible to isolate fetal cells from the maternal circulation which are suitable for chromosome analysis. Trials of this promising non-invasive test are currently underway

Chorion biopsy This is a method of obtaining chorionic material at 9-11 weeks of pregnancy, usually through the abdomen so that genetic constitution or biochemical function of fetal cellular material s can be determined. It is useful for the diagnosis of Dowm's syndrome, thalassaemia,and in a number of other hereditary, conditary conditions. Early and rapid diagnosis allows the therapeutic termination of an abnormal pregnancy, increasing the safety and acceptability of that procedure. There is still a increased risk of spontaneous abortion after the chorion biopsy and this technique is used only in specialized centres

Amniocentesis Samples of amniotic fluid can be used for:

Chromosome analysis This is undertaken at 13-18 weeks of pregnancy and is currently much safer than chorion biopsy. The amount of desquamated fetal cells obtained is much smaller in quantity than chorion biopsy. The amount of desquamated fetal cells obtained is much smaller in quantity than that from chorion biopsy and cell culture is necessary (which takes about 3weeks)before a chromosomal diagnosis is made. However, rapid preliminary results can be obtained using the fluorescent immunostaining method when other chromosome abnormalities are suspected

Bilirubin concentration

Sometimes it is measured in amniotic fluid pool in the latter stage of pregnancy in order to assess the health of a baby affected by maternal rhesus isoimmunization

DNA analysis Fetal cells obtained by amniocentesis, chorionic villus sampling or cordocentesis, (see below) can be used for DNA analysis of nuclear chromatin in order to directly test for a number of genetically-determined diseases, for example Tay-Sach's disease and Duchenne muscular dystrophy, in families known to be at risk. DNA testing and chromosomal studies should both only be carried out with fully informed parental consent, and with the help of a genetic counselling service

Cordocentesis In this procedure a needle is needed to insert through the abdominal wall and into the amniotic sac to obtain fetal blood from the placental insertion of the cord. It is used when chromosomal abnormality, haemophilia , haemoglobinopathies, inborn errors of metabolism, fetal viral infections or fetal anaemia are suspected. Althought the procedure carries more risk than amniocentesis, it is less traumatic than fetoscopy while providing rapid diagnosis

BIOCHEMICAL TESTS Early pregngncy Alpha fetoprotein This is a normal fetal protein which passes from the fetus into the amniotic fluid and maternal serum. Its’ maternal concentration varies in a predictable way with gestation. At 16 weeks 'gestation, the increased levels suggest fetal spina bifida or anencephaly However, similar levels can be caused by several other conditions, including threatened abortion, multiple pregnancy and exomphalos. Decreased levels are associated with the presence of an infant with Down's syndrome. A computed risk of Down's syndrome can be produced from maternal weight, gestation, parity and race ,measured against alpha fetoprotein, HCG and unconjugated oestriol ,and the results matched against ultrasound findings

Labour Fetal health in labour can be assessed by checking the liquor for tje presence of meconium, by checking the responsiveness of the fetal heart rate, and by monitoring feral movements. In addition to these simple clinical tests, fetal PH measured on a scalp blood sample can be used to detect acidosis. This is particularly useful if labour is prolonged ,complicated or known to be high-risk, e.g. in diabetic mothers. The fetal scalp is displayed using an amnioscope and a small sample of capillary vessel is obtained. If an urgent PH of the sample is below 7.2 then delivery is an urgent priority. Continuous oximetry by near infrared reflectance although useful is not in general use

BIOPHYSICAL TESTS Fetal movements In some cases with placental blood supply insufficiency, fetal movements decreases or stop 12-48 hours before the fetal heart ceases beat .In healthy pregnancy fetal movements increase from the 32nd week of pregnancy to term, but the 12 hour daily fetal movement count falls below 10 in only 2.5% of normal pregnancies. Thus a variety of counting systems which are used by mothers to count fetal movement and fetal welfare have been devised. These can alert the mother that a more sophisticated and detailed surveillance is required

Ultrasound Visualization by real time Sequential ultrasonic scanning to detect the presence of symmetrical or asymmetrical growth retardation or changes in fetal activity, breathing, movements, etc, can be used to assess placental function. If it becomes clear that fetal growth has halted or the child's survival in utero is in doubt, then urgent delivery should be planned with paediatric support

Cardiotocography(CTG ) Assessment of the fetal heart rate and its variation with fetal and uterine activity can be recorded antenatally with ultrasound using the Doppler principle(Fig.14.18).A pressure transducer is attached to the abdominal wall so that variations in uterine activity can be matched with the ultrasound recordings. The production of an accurate recording requires patience and considerable interpretive skills. If with membrane rupture during labour, a more accurate of the fetal heart rate can be produced by an electrode attached to the fetal scalp (Figs14.19and14.20).The recording is triggered by the fetal ECG

Doppler blood flow and Placental volume

 Studies of the circulatory changes

in the uterine circulation may predict fetal urgence in the umbilical, aortic and cerebral, especially in already compromised circumstances.  Ultrsound measurements of placental volume may also help in the prediction of fetal growth retardation