GYNAECOLOGY

This is the study of diseases affecting the female

reproductive system.
As the genital tract is closely linked anatomically with the
urinary tract and the large bowel, certain disorders of the
urethra, bladder and rectum may lead the woman to a
gynaecologist.
General causes of gynaecological problems
 Congenital abnormalities.eg absence of the vagina,
ovaries, uterus or divided uterus.
 Environment
This can cause physical or mental illness.eg stress or
anxiety that can lead to absence of menstruation.
 Pathological agents
In relation with entry of pathogenic micro-organisms
which may lead to infection.eg vaginitis, vulvitis etc.
 Trauma
Genetic organs may be traumatized by instruments
leading to fistula.
 Clinical methods of assessing a gynaecological
patients.
1. History taking
The most important information is always provided
by the patient or relatives.
History taking tactics are required for it is concerned
with discussing intimate matters.
Therefore, privacy is essential inorder to get reliable
information from the patient.
a) Personal data
This includes name, age, address, next of kin,
occupation, religion, tribe etc.
b)Presenting complaints.eg
Pain onset
Where it is felt
Intensity
Defecation or micturition
Dyspareunia
c) History of presenting complaints.
d)Obstetric history
Number of pregnancies, abortion, type of delivery,
history of trauma, prolonged labour etc.
Menstrual cycle
 Menarche, regularity, duration and length of cycles,
volume of blood loss etc.
e)Social history
Look out for marital status, life style, smoking,
alcohol, occupation etc.
f) Past medical and surgical history
Has she ever suffered from a serious disease eg.
Tuberculosis, had an accident which involved the
spine, pelvis and lower limbs or any operation on her
pelvic organs.
g) Gynaecological history
Has she ever had any gynaecological condition like
fibroids, rectal vaginal fistula, vesicle vaginal fistula,
perennial tears, abortions etc., any operations on
the cervix or dilation and curettage.
2. Examination
a) General examination
The general examination is important in
gynaecology. This is done from head to toe.
Note.
General appearance of the patient
Behavior
Look out for signs of anaemia
Examine breasts
 Look for signs of pregnancy and any discharge.
Examine the breast to exclude malignancies.
Abdomen
It is inspected for size and shape and palpated
for tumours.
Pelvic examination
This is the last examination done to confirm the
diagnosis already suspected during history
taking.
The patient should consent for the examination,
if not married, parents can consent for her
because the hymen can be broken.
The patients bladder and bowels must be
empty.
Good light is also needed.
 Vaginal examination
Each part of the genital tract should be
examined in a logical sequence;
 Vulva
 Vagina
 Cervix (inspect for tears, prolapse etc.)
 Body of the uterus
 Pouch of Douglas
NB
 The cervix and uterus should be examined
for size, shape, position and tenderness.

Special procedures and investigations

These are useful to fill gaps which remain after history
taking during clinical assessment.
1. Evacuation
It refers to removal of the contents of a cavity.
It is done when pelvic examination has not been
possible.
Its disadvantage is that important signs of
tenderness are missed out. (examination is done
under anaesthesia)
2. Curettage
Refers to scrapping of the internal surface of an
organ or body cavity by means of a spoon shaped
instrument. (curette)
It is done to;
Remove retained products of conception
To obtain a specimen for diagnostic purposes
3. Biopsy
 This is the removal of a small piece of leaving tissue
from an organ or part of the body for microscopic
examination so as to exclude certain diseases.
It can be obtained from the cervix, endometrium etc.

4. Ultra sound scan

The use of ultrasound produces images of structures
in the human body using sound waves of high
frequency.
This is now used widely to detect diseases of the
pelvic organs and pregnancy.
5. Hysterosalpingography
Refers to x-ray imaging of the uterus and fallopian
tubes.
It is useful in diagnosing;
Tubal obstruction
Peritubal and intrapelvic adhesions
Malformations of the uterus
Small intracavity tumours
Detect the internal os of the cervix causing
abortion and premature labour.
6. Laparoscopy
Examination of abdominal structures by means of a
laparoscope (type of endoscope)
 This is passed through a small incision in the wall of
the abdomen
Used when;
Taking a biopsy
Aspirating cysts
Dividing adhensions
Collecting ova for vitro fertilization

GYNAECOLOGICAL OPERATIONS
1. Hysterectomy
This is surgical removal of the uterus.
Types of hysterectomy
a) Wertheim’s hysterectomy
It’s a radical operation performed for cervical cancer
involving removal of the entire uterus, the
connective tissue and lymph nodes close to it,
fallopian tubes, ovaries and the upper part of the
vagina.

b)Subtotal hysterectomy
Surgical removal of the body of the uterus leaving
the neck (cervix) in place.
c) Total hysterectomy
Surgical removal of the entire uterus.
Indications
Fibroids
cancers
raptured uterus
2. salpingectomy
Refers to surgical removal of the fallopian tubes.
Indications
raptured ectopic pregnancy
chronic salpingitis
3. vesico-vaginal fistula repair
This is an operation done to repair an abnormal
communication between the bladder and vagina.
4. Oophorectomy
This is the surgical removal of the ovary(s)
Indications
Tumours of the ovary
Chronic oophoritis
5. Myomectomy
Refers to surgical removal of one or more fibroids
from the uterus.
6. Rectal vaginal fistula
 An operation done to repair an abnormal
communication between the rectum and vagina.

7. Mastectomy
Surgical removal of the breast.
Types
a) Radical mastectomy
Surgical removal of the breast with the skin and all
lymphatic tissue of the armpit.
It is performed when breast cancer has spread to
involve the lymph nodes.
b)Simple mastectomy
Surgical removal of the breast retaining the skin and
if possible the nipple.
It is performed for extensive but not necessarily
invasive tumours.
8. Tubal ligation
An operation done by tying and cutting of fallopian
tubes which is used as a permanent family planning
method.
9. Vulvectomy
 Surgical removal of the vulva.
Types
a) Simple vulvectomy
Excision of the labia majora, minora and clitoris to
eradicate a non-malignant growth.

b)Radical vulvectomy
Excision of the labia majora, minora, clitoris and all
regional lymph nodes on both sides together with
the skin covering these areas.
It is carried out in malignant growths.
10. Dilatation and curettage
An operation in which the cervix(neck) neck of the
uterus is dilated using a dilator (heggars dilators) and
the endometrium is lightly scrapped off with a
manual curette or removed by suction using an
aspirator.
Indications
Removal of any retained products after abortion
Obtaining endometrial biopsy for histological
examination.
11. Perineoplasty
An operation done to enlarge the vaginal opening by
incising the hymen and part of the perineum.
 12. Perineorrhaphy
Surgical repair of a damaged perineum.
The damage is usually as a result of a tear sustained
during child birth.

MENSTRUAL DISORDERS
1. Dysmenorrhea
This refers to painful menses or cramping during
menstruation.
Types
a)Primary dysmenorrhea(spasmodic)
It is as result of uterine muscle contractions that
occur during ovulatory cycle and with no
identifiable pelvic pathology.
Causes
High levels of prostaglandins produced by the
endometrium during menses.
 This leads to increased myometrial contraction
(vasoconstriction) which causes ischemia (angina) of
the myometrium.
Psychosomatic factors
Eg tension and anxiety during adolescence.
Imbalance in the autonomic nervous control of the
uterine muscles. Ie there is overactivity of the
sympathetic nerves.
Increased vasopressin release during menstruation.
Vasopressin increases prostaglandin synthesis and
also increases myometrial activity directly.
vasopressin

hyperactivity of the uterus + dysrhythmic contractions

ischemia + hypoxia

pain

Endothelins
These cause myometrial smooth muscle contractions
specially in the endomyometrial junction. (JZ)
 Endothelins in the endometrium can induce
prostaglandins (PGF2α). Therefore, the endothelins
and PGF2α aggravate uterine hyperactivity.
Abnormal anatomical and functional aspect of the
myometrium.
The endomyometrial junction has irregular
thickening and hyperplasia of smooth muscles and
less vascularity.
This results in to dysperistalisis and hyperactivity of
the uterine junction zone.

Platelet activating factor

This is associated with the etiology of dysmenorrhea
as its concentration is high. It vasoconstricts and
stimulate myometrial contractions.

Clinical features
commonly in young girls of 13-25 years
pain is spasmodic and confined to the lower
abdomen
pain may radiate to the back or thighs
pain begins a few hours before or just with the onset
of menstruation
 It persists for 24 hours and rarely 48 hours.
Systemic discomforts eg.
 Nausea
 Vomiting
 Fatigue
 Diarrhea
 Headache
 Tachycardia
 Dizziness
Vasomotor changes
 Pallor
 Cold sweats
 Fainting
Treatment
Take full history and examination
Psychotherapy ie reassurance
Exercise
Apply warm compress to the lower abdomen

Drugs
 Mild analgesics to relieve pain eg ibuprofen
400mg tds.
 Prostaglandin synthetase inhibitors eg.
Mefenamic acid 250-500mg tds or
 Flufenamic acid 100-200mg tds
 Oral contraceptives eg
COCs. These decrease endometrial proliferation.
Progesterones. Eg dydrogesterone 10mg b.d
taken from day 5 of the cycle for 20 days.
Mechanism of action is presumably myometrial
relaxation.

b)Secondary dysmenorrhea(congestive)
This is painful menstruation resulting from a
pathologic process common in elderly women
above 35 years.
Causes
Cervical stenosis. (narrowing of the opening of
the cervix)
Chronic pelvic infection
Pelvic endometriosis
Pelvic adhesions eg intrauterine adhesions
Adenomyosis
Uterine fibroids
Endometrial polyps
Intrauterine devices
Clinical features
Pain comes late in life.
 Pain starts 3-5 days prior to onset of
menstruation and relieves with the start of
bleeding.
The pain is dull and situated in the back and
front (lower abdomen) without radiation.
There is no systemic discomfort unlike primary
dysmenorrhea.
Treatment
The treatment aims at the cause rather than the
symptom. The type of treatment depends on the
severity, age and parity of the patient.
Take proper history based on the cause.
Carryout investigations eg high vaginal swab for
culture and sentivity and treat.
Surgery eg myomectomy or hysterectomy may
be carried out in severe cases.
Drugs such as NSAIDS to relieve pain.

2. Amenorrhea
This refers to absence or stopping of the menstrual
periods during the reproductive years.
Types
a. Primary amenorrhea
 This is when a girl has never menstruated at all
by the age of 16.
Causes
Congenital abnormalities of the
reproductive system. Eg absence of ovaries
and the uterus.
Hormonal imbalance
Serious illness eg. Tuberculosis, AIDs etc
Maldevelopment of the pituitary gland and
ovaries.
Imperforated hymen where by the hymen
may be completely closed.
NB
a) Haematocolps
It is distension of the vagina by blood due to
imperforate hymen.
b)Haematometra
It refers to accumulation of blood in the uterus.
c) Haematosalpinx
Refers to accumulation of blood in the fallopian
tubes after long standing cases of imperforated
hymen creating a barrier for out flow of blood.
b. secondary amenorrhea
 It refers to absence of menstruation for 6 months or
more in a woman who has previously menstruated
normally.
Causes
 Pregnancy
There is absence of menstruation since the
endometrium has already been embedded by the
fertilized ovum.
 Lactation
Soon after delivery, prolactin is secreted in large
quanties by the anterior pituitary gland. This results
into partial suppression of the luteinizing hormone
production leading to amenorrhea.
 Surgical removal of the uterus.
 Disorders of the ovaries eg premature ovarian
follicles which leads to premature menopause.
 Pituitary disorders eg. Hyperprolactinaemia and
sheehan’s syndrome. (pituitary necrosis)
 Serious illness eg endometrial TB, AIDS etc
 Work problems eg frustration/stress
 Menopause
 Hypothyroidism
 Severe malnutrition
3. Menorrhagia (hypermenorrhea)
This is heavy prolonged vaginal bleeding.
Causes
Pelvic inflammatory diseases
Cancer of the endometrium
Endometriosis
Inherited bleeding disorders
Uterine fibroids
These increase the surface of the endometrium
thus increased shedding of blood.
Polyps eg cervical polyps
Intrauterine devices
Ovarian tumours
Hormonal imbalances

Treatment
Iron tablets are given to treat anaemia.
In severe cases, transfusion may be carried out.
Surgical operations to remove the cause may be
done eg myomectomy in case of uterine
fibroids.
Reassure the patients.
Rest during the bleeding phase.
Complication
 Anaemia

4. Polymenorrhea (epimenorrhea)
This refers to cyclic bleeding occurring at more
frequent interval eg between 14 – 21 days.
Causes
Hyperstimulation of the ovaries by the pituitary
hormones. Eg during adolescence, following
delivery etc
Endometrial cancer
Pelvic inflammatory diseases
Intrauterine devices
Signs and symptoms
Lower abdominal pain and back ache
Loss of appetite
Signs of anaemia may present due to frequent
blood loss.
5. Metrorrhagia
This is irregular vaginal bleeding.
Causes
IUDs
Break through bleeding in pill users.
Endometrial cancer
Uterine polyps
 PIDs
Foreign bodies in the vagina
Cervical cancer
Abortion
Treatment
Carryout proper history taking
Treat the infection according to the cause
Carryout investigations
Treat anaemia if present
6. Oligomenorrhea
This is diminished or scanty menstrual bleeding of a
normal cycle prolonged beyond 35 days.
Causes
Age related in adolescence and premenopausal
period.
Endocrine disorders eg polycystic ovarian
disorder, hyperprolactinaemia etc
Pills
Stress and exercise related
Endometrial tuberculosis
Weight related as it occurs in obesity.

7. Hypomenorrhea
 This is scanty menstruation that lasts for less than 2
days.
Causes
Endometrial tuberculosis
Hormonal use of oral contraceptives
Thyroid dysfunction
Premenopausal period
Malnutrition

8. Metropathia haemorrhagica
It refers to abnormal bleeding occurring in
premenopausal women due to disturbance of the
rhythmic secretion of gonadotrophins.
9. Epimenorrhagia
Frequent cycle associated with excessive and
prolonged bleeding.
10. Menometrorrhagia
So irregular and excessive bleeding that the menses
cannot be identified.

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

This refers to abnormal uterine bleeding without any
clinically detectable cause.
 DUB occurs more often in adolescents and
perimenopausal woman.
Causes
 Hormonal imbalance
These are probably related to alteration in the ratio
of endometrial prostaglandins.
 Pelvic inflammatory disease
 Endometriosis
 Neoplasms
Signs and symptoms
 Polymenorrhoea (frequent menses)
 Oligomenorrhoea (light or infrequent menses in
adolescence and preceding menopause)
 Menorrhagia
 Metrorrhagia
Investigations
 Blood tests
Hemoglobin
CBC
Platelets
Bleeding time
 Ultrasound scan
 Endometrial biopsy
 Laparoscopy
 High vaginal swab
Management
Correction of anaemia by diet, haematenics and
blood transfusion.
Oral contraceptives for menstrual cycle
regulation
Cyclic progesterone for anovulatory bleeding
Nonsteroidal anti-inflammatory drugs (NSAIDS)
to reduce the amount of menstrual bleeding.
Hysterectomy when abnormal uterine bleeding
cannot be corrected by conservative treatment
and the blood loss impairs the health of the
patient.

PREMENSTRUAL SYNDROME(PMS)
This is a cyclic cluster of behavior, emotional
and physical symptoms that occurs just prior to
menstruation ie the last 7 – 10 days of the
menstrual cycle.
Factors associated with PMS
 Alteration in the level of oestrogen and
progesterone starting from the mid luteal
phase.
 Neuroendocrine factors such as
decreased synthesis of serotonin.
 Psychological and psychosocial factors
ie these produce behavioral changes.

Clinical features
Irritability
Anxiety
Mood swings
Headache
Change in libido
Palpitations
Nausea
Diarrhea
Fatigue
Social isolation
Abdominal bloating
Breast tenderness
Swelling of extremities
Depression
Increased appetite
Treatment
Modify diet
Increase exercise
 Stress management
Avoidance of salt
Drugs.eg
 Antidepressants
 Diuretics to reduce fluid
retention
 Anxiolytics

Mittelschmerz’s syndrome (ovular pain)

It is mild menstrual pain that occurs around the time of
ovulation in a menstruating woman.
The pain
 Is usually located on one side and does not change
according to which ovary is ovulating.
 It usually lasts for 12 hours
 It may be associated with slight vaginal bleeding or
excessive mucoid vaginal discharge
Possible causes
 Increased tension of the graafian follicle prior rupture.
 Peritoneal irritation by follicular fluid following ovulation
 Contraction of the fallopian tubes and uterus
Treatment
 Analgesics
 Reassurance
 Contraceptive pills to make the cycle anovular in obstinate
cases
ECTOPIC PREGNANCY
This is when the fertilized ovum embeds outside the uterine
cavity.
Causes
 Congenital narrowing of the fallopian tube
 Congenitally long tubes which are liable to kink
 Pelvic inflammatory diseases.eg salpingitis
This cause destruction or erosion of Cilia, formation of
adhesions interfering with peristalsis in the tubes.
 Tumours pressing on adjacent sides of the tube causing
partial or complete blockage of the tube.
 Endometriosis ie development of the endometrium in
other places other than the uterus.
 Repeated induced abortions
 Tubal surgery ie surgical procedures on the fallopian tubes
may cause intraluminal or extraluminal adhesions.
 IUDs
 Previous ectopic pregnancy
 Hormonal imbalance ie this impairs tubal motility
Sites of ectopic pregnancy
 Fallopian tubes(commonest)
 Ovary
 Intraperitoneal abdominal cavity
 Cervix
Tubal pregnancy
This is when a fertilized ovum embeds it self in the fallopian
tubes.
Sites for tubal pregnancy
 Ampulla(commonest)
 Isthmus
 Fimbriated end(infundibulum)
 Interstitial part(rare)
Consequences of tubal pregnancy
Tubal mole
The zygote dies but it is retained in the fallopian tubes
surrounded by a blood clot.
Tubal abortion
The zygote separates from the fallopian tube lining and it is
expelled through the fimbriated end.
It may die out or continue to survive on abdominal organs
resulting into abdominal pregnancy which can go up to term.
Tubal rapture
The tube becomes too small for the growing zygote so it
raptures causing internal bleeding into the abdominal cavity.
Tubal erosion
The zygote erodes the fallopian tube lining causing bleeding in
to the abdominal cavity.
Signs and symptoms ectopic pregnancy (tubal rapture)
 On history taking
 History of amenorrhea
 Patient complains of a feeling of fainting, dizziness,
thirsty and vomiting.
 Patient complains of acute abdominal pain localized
in the iliac fossa which is colicky in nature.
 It can be referred to the shoulder especially on lying
down due to blood irritating the diaphragmic nerve
and peritoneum.
 On examination
 Signs of pregnancy are present.eg darkening of
areolar.
 Signs of shock ie cold, clammy skin, rapid and thread
pulse, low blood pressure and temperature.
 Patient is anxious and restless.
 Pallor of the mucous membrane.
 On palpation
 Abdominal tenderness especially on the affected side
 Abdominal muscles become rigid due to mother
guarding against pain.
 Abdominal distension due to presence of blood in the
abdominal cavity
 On vaginal examination
 Amount of bleeding doesn’t correspond to the
mother’s condition.
 Tenderness on movement of the cervix and a mass is
felt in the lateral fornix of the vagina.
 Painful mass in the pouch of Douglas
 Dark brown blood on the examining finger.
Investigations
 Ultrasound scan will confirm the diagnosis
 CBC
 Blood for Hb, grouping and cross match
Differential diagnosis
 Salpingitis if associated with irregular menses
  Appendicitis
 Abortion
 Twisted ovarian cyst
Management
In maternity center
Aims
 To prevent shock
 To relieve pain
 To reassure the patient

 Admission
The patient is admitted temporarily in a gynecological
ward in a well-made warm bed.
 Histories
these are taken including personal, social, surgical,
medical, obstetrical history, how the condition started etc
 Examination
This is carried out from head to toe to rule out anaemia,
dehydration, shock etc
 Observation
Temperature, pulse, respiration and blood pressure are
taken and recorded to assess functioning of vital organs.
 The foot of the bed should be raised to allow blood to
move to vital centers.
 Send for transport as soon as possible and inform the
patient and relatives about the decision made and why it is
necessary.
Treatment
  Put up intravenous infusion of normal saline to prevent or
treat shock. This is to elevate the low blood pressure.
 Administer morphine or pethidine to relieve pain as
prescribed.
Nursing care
 The vulva is swabbed and a clean pad is applied.
 Send the patient to hospital with a written note stating
when the patient reported to the center, condition on
admission and at time leaving and treatment given.

In the hospital
Aims
 To treat anaemia
 To prevent or treat shock
 To reassure the patient
 To prevent complications
NB
It is a gynecological emergency, so everything must be done
quickly as possible and all nurses must work as a team to see
that the patient is taken for operation as soon as possible.
 Admission
Admit the patient in a well-ventilated room and warm
admission bed. Establish a god nurse patient relationship.
 Histories
History is taken eg personal data, presenting complaint,
obstetrical, medical history etc.
 General examination
 This carried out from head to toe to rule out anemia,
shock, dehydration etc
 Observations
Vital observations like temperature, pulse, respiration and
blood pressure.
 Inform the doctor
The doctor is informed about the patient.
 Investigations
The following investigations are carried out as required by
the doctor.
 Hb, grouping and cross match
 Ultrasound scan
 Urinalysis
 Resuscitation
Intravenous fluids eg normal saline are put up and fluid
balance chart is maintained.
 Blood transfusion
This carried out depending on the haemoglobin results.
 Pain relief
Analgesics such as morphine is administered to relieve
pain as prescribed by the doctor.
The doctor will determine the operation.

Preparation for theatre

 Explain the nature of operation to the patient and obtain
an informed consent.
 Reassure the patient to allay anxiety
 Theatre staffs are informed
 Pass an intravenous line for infusion
  Vulva swabbing is done to minimize infections
 Catheterization is done and a fluid balance chart is started.
 Pass a naso-gastric tube for aspiration gastric or stomach
contents or an anti-acid like magnesium trisilicate is given
to make the stomach contents alkaline. This prevents
aspiration of acidic contents into the lungs.
 Pre- medication is given like atropine to dry the secretions.
 Repeat vital observations and compare with the baseline
observations and record.
 Compile the clinical charts and notes, dress the patient in
gown and transport her carefully to theatre.
 In theatre give a full report to the theatre nurse about the
patient.
 Book about 1-2 units of blood.
NB
Laparotomy is done as well as salpingectomy. If the
rapture is acute and the blood is fresh, autotransfusion
may be done.
Fresh blood is collected from the abdominal cavity into a
sterile bottle containing anti- coagulant and replaced into
the patient by transfusion.

Post- operative care

 Post-operative bed should be made with all its accessories
such as a drip stand, oxygen machine, vital observation
tray, emergency tray, resuscitation tray etc ready to
receive the patient.
 When the operation is complete, the ward staff are
informed and two qualified nurses go to theatre to collect
the patient.
 In theatre, receive a full report from the anesthetic and
the theatre nurse in a recovery room should report the
condition of the patient.
 Confirm the report while patient is still in the recovery
room by;
 Checking airway, breathing and circulation.
 Taking vital observations
 Observing the site of operation for bleeding
 Observe the catheter to see if it is draining well and in
good position.
 After confirming, the patient is gently wheeled to ward in a
recumbent position with the head turned to one side
meanwhile observing the airway.
On ward
 The patient is lifted from the trolley with care to a well
made post-operative bed with all its accessories close to
the nurse’s station for close observations.
 The patient is put in a recumbent position with the head
turned to one side to allow drainage of secretions and also
to prevent falling back of the tongue.
Observations and records
 Vital observations of temperature, respiration, blood
pressure and pulse are taken1/4 ,1/2, 1, 2 hourly according
to surgeon’s instructions and duration is increased as the
patient stabilizes.
 These observations are continued until the patient is
discharged.
 Observe the site of operation for bleeding
 Observe the catheter if it is draining well, colour and the
quantity of urine passed.
 Maintain a fluid balance chart and balance it every 24
hours to rule out renal failure.
 On gaining consciousness, the patient is welcomed from
theatre, face is sponged, theatre gown changed, mouth
wash is done to remove anesthetic smell and a pillow is
offered.
Fluid/hydration
 Intravenous fluid.eg 0.9% are continued to replace lost
fluids.
 Observation of IV infusion are done such as observing the
cannular site for swelling, drip rate and incase of anything
it should be corrected.
 Keep monitoring fluid intake and out put to avoid over
hydration.
 IV fluids are stopped when bowel sounds are heard and
the patient is able to take by mouth.
 Cannula is also removed when necessary.eg if patient has
completed intravenous drugs.
Drug therapy
 Give administer prescribed strong analgesics for pain
relief such as pethidine for 48 hours then changed to
mild analgesics like diclofenac 50-100mg tds.
 Administer prescribed antibiotics to counteract
infections.eg x-pen 2mu qid for 72 hours then change
 to oral antibiotics of necessary such as amoxyl 250-
500mg tds for 5 days.
 Monitor the patient for side effects of the drugs
given.
 Supportive drugs such as ferrous and folic acid are
given to prevent anaemia.
Wound care
 Observe the wound for bleeding and if so add more
dressing if soiled change the dressing. Also check signs of
infections.
 Carry out daily wound dressing.
 Stitches are removed on the 7th and 8th day alternatingly.
Physiology
 Encourage the patient to do deep breathing exercise to
prevent chest complications like hypostatic pneumonia.
 Also encourage the patient to start with passive exercises
such as limb movement then active exercises like walking
around to prevent deep vein thrombosis.
Psychotherapy
 In addition to the psychological care given to the patient
pre-operatively, she is continuously reassured to allay
anxiety.
Diet
 First carryout digestion test and if positive the bowel
sounds are heard, start the patient on small sips of water.
Soft foods are introduced and given according to the
tolerance and should be rich in;
 Proteins to help in tissue repair
 Roughages to prevent constipation
  Carbohydrates for energy
NB
The nasal gastric tube is removed as long as the patient can
take orally without any complaint.
Hygiene
 Carryout bed bath on the first day of operation when the
patient is still weak and later assist her to the bathroom.
 Carryout mouthcare to prevent neglected mouth
complaints like stomatitis, halitosis etc
 Ensure that the patient’s clothing, bed linen and the
surrounding environment are clean.
Bowel and bladder care
 If urine is clear in 24-48 hours, the urethral catheter is
removed and patient is encouraged to pass urine.
 The patient is encouraged to pass stool, offered privacy
and also given foods rich in roughages to prevent
constipation.
 Incase of constipation and conservative measures have
failed, give purgatives such as bisacodyl 5-10mg o.d or
nocte.
Rest and sleep
 The patient is kept in a quiet well-ventilated room, visitors
restricted, bright light avoided so as to create a conducive
environment for the patient to sleep and rest.
Advice on discharge
When the patient is fit for discharge advise on the following;
 Should have enough rest at home
 Avoid heavy lifting so as to avoid straining the abdominal
muscles.
  To come back for review on appointed dates
 To attend ANC clinics when pregnant
 To bring the husband for treatment if the cause of ectopic
pregnancy was PIDs.
 To complete the prescribed medications

Complications of ectopic pregnancy

Immediate complications
 Shock
 Peritonitis
 Dehydration
Long term complications
 Sepsis
 Anaemia
 Fibrosis
 Adhesions following surgery
 Recurrence

UTERINE PROLAPSE
This is the downward displacement of the uterus into the
vagina.
Incidence
It is more common in women who have had children but it may
also occur in prime gravidas.
Causes
 Congenital weakness of ligaments
  Overstretching of muscles and fibrous tissue which occurs
with repeated child births, multiple pregnancies and
polyhydramnios.
 Increased intra-abdominal pressure such as in chronic
cough especially when the patient is overweight, has
fibroids etc
 Atrophy and weakness of ligaments after menopause due
to withdraw of hormones.

Degrees of prolapse
1st degree
The cervix descends down from its normal position into the
vagina at the level of the ischial spines.
2nd degree
The cervix appears at the vaginal orifice.
3rd degree
This is a complete prolapse. (procidentia) The whole uterus is
outside the vulva.
Signs and symptoms
 The patient complains of a bearing down feeling especially
when walking or standing.
 Backache or dragging pain in the pelvis which may be
relieved on lying down.
 Dyspareunia
 Difficult in passing urine. Ie patient may have to elevate
the anterior vaginal wall for emptying the bladder.
 Incomplete emptying of the bladder causing frequent
desire to pass urine.
 Urgency and frequency of micturition
  Stress incontinence usually due to associated urethrocele.
 Difficulty in passing stool. The patient may have to push
back the posterior vaginal wall to complete the evacuation
of feaces.
 On vaginal examination, the cervix may be visible if there
is 2nd and 3rd degree prolapse.

Management
In maternity center
Aims
 To alleviate suffering
 To restore good health
1. Welcome the patient and relatives to the maternity center
and offer seats.
2. Admit the mother temporarily on the ward
3. Take history like personal data, type of deliveries, number
of children, when she started feeling the signs and
symptoms etc.
4. Carryout a general examination from head to toe to rule
out malnutrition, dehydration, anaemia etc
5. Carryout vital observations to assess functioning of vital
organs.
6. Vulva inspection is done to rule out prolapse of the uterus.
7. Mother is reassured and counselled on personal hygiene.
8. Analgesics like paracetamol 1g tds may be administered to
relieve pain.
9. The mother is referred to the hospital with a written
document indicating details of the condition and the
treatment that has been given.
In the hospital
Aims
 To correct the condition
 To prevent infections and other complications
1. Routine admission on a well ventilated gynaecological
ward is done.
2. Histories are taken.
3. Vital observations of temperature, pulse, respiration and
blood pressure are carried out.
4. General examination is carried out from head to toe to
rule out dehydration, aneamia etc
5. The doctor is informed meanwhile, prepare a tray for
investigations.
When the doctor comes, he will examine the patient and
request for the following;
 Blood for hb, grouping and cross match
 X-ray
6. Treatment
The doctor will decide on either conservative or surgical
treatment depending on the degree of prolapse and
condition of the patient.
Conservative treatment
 Estrogen replacement therapy may improve minor
degree prolapse in post- menopausal women.
 In mild cases, exercises to strengthen the pelvic floor
muscles may help.
 Obese patients may be instructed to reduce weight in
order to reduce pressure on pelvic organs.
  A pessary may be placed inside the vagina to support
the pelvic organs for the patient who do not desire to
have surgery. (ring pessary)
This serves to relieve symptoms but does not correct
the condition.
 The patient is instructed to douche with saline daily
or carry out vulva toilet with antiseptic solution four
hourly.
 Reassure the patient to allay anxiety.
 Improvement on nutritional status
Surgical treatment
It depends on;
 Anatomical alteration of structures and the degree of
prolapse
 Patients age
 Patients reproductive and sexual functions
 Shortening and repairing of the transverse ligament is
done in theatre to rise the uterus to its normal
position. (Manchester operation or fothergill’s repair)
 Vaginal hysterectomy may be done if no further
children are needed.
 Nursing care depends on the treatment offered.

Prevention of uterine prolapse

During antenatal
 Health educate mothers on dangers of grand multiparity,
home deliveries which cause over stretching of muscles
and weakening of supporting ligaments.
 Emphasize on a balanced diet
  Proper screening of mothers at risk and send them to
hospital for doctors intervention.
 Discourage use of native medicine
 Encourage mothers to carryout light exercises in late
pregnancy to strengthen the pelvic floor muscles.
During labour
 Avoid prolonged and obstructed labour which may lead to
injury of supporting ligaments.
 Relief of pain by administering pain killers to prevent early
pushing.
 Proper management of second stage of labour.
 Avoiding too much fundal pushing to expel the placenta.
 Performing timely and adequate episiotomy.
During puerperium
 Encourage early ambulation and pelvic floor exercises
(Kegel exercises) to help muscles regain their tone.
 Advise on family planning to avoid too soon future
pregnancies.
 Advise the mother to avoid strenuous activities like heavy
lifting.
 Avoid constipation by taking plenty of fluids and
roughages.
 Proper treatment of chest infections eg chronic cough.

Complications
Before surgery
 Urine retention
 Infection
After surgery
  Sepsis
 Hemorrhage
 Dyspareunia
 Recurrence of prolapse
 Infertility

CYSTOCELE
This is downward bulging or pouching of the bladder into the
anterior vaginal wall.
Causes
 Weakness of the vaginal walls due to repeated child birth
or due to withdraw of hormones.
 Overstretching of pelvic floor muscles
 Aging tissues due to old age
 Increased intra -abdominal pressure due to obesity,
fibroids and cough.

Signs and symptoms

 Vaginal lump is felt on vaginal examination.
 Frequency of micturition and urgency
 Urine incontinence (stress incontinence)
 Back pain and pelvic pain may occur as well.

Treatment
In maternity center
Any person who comes with the above condition should be
referred to hospital for proper management.

In hospital
  The patient is put under close observation and seen at
regular interval to assess the condition.
 Management will depend on degree of prolapse.
 Kegel exercises which involve contracting or tightening of
vaginal muscles are encouraged to help strengthen the
weakened muscles.
These are more effective in early stages of cystocele.
 In mild cases watch and wait if symptomless, review
annually.
 In severe cases surgical repair of the anterior vaginal wall
is done (colporrhaphy)

Prevention
 Good antenatal care
 Health education on family planning
 Proper screening of mothers during antenatal care
 Early and timely referral of those who are likely to develop
complaints to the hospital.

Complications
 Psychological torture
 Ascending infections to the uterus, bladder etc
 Breakage of marriage

RECTOCELE
This a condition in which the rectum bulges into the posterior
wall of the vagina.
Perennial lacerations may affect the muscles and tissues of the
pelvic floor and this may occur during delivery.
Causes
Same as cystocele
Signs and symptoms
 Feeling of incomplete defecation
 Pain on defecation
 There is deep dyspareunia
 Can be visualized on coughing as bulging or incontinence
Treatment
 In mild cases the patient is put under close observation
and seen at regular intervals.
 Watch and wait. If symptomless see the patient at a yearly
interval for good follow up.
 In severe cases, posterior colporrhaphy is performed.

Prevention and complications

Same as for cystocele
NB
Repair of perineal lacerations is called perineorrhaphy.

ENTEROCELE
It is the protrusion of the intestinal wall into the vagina. It is
also called vaut prolapse or hernia of the pouch of Douglass.

FISTULA
This is an abnormal communication between two internal
hollow organs or between an internal hollow organ and the
exterior of the body.
Types
 Vesicovaginal fistula (VVF)
 Rectovaginal fistula (RVF)
 Urethral vagina fistula (UVF)
Vesicovaginal fistula (VVF)
This is an abnormal communication between the vagina and
bladder and urine escapes into the vagina causing true
incontinence.
This is the commonest type of genitourinary fistula.
Incidence
It occurs in 65-90% of the women.
Causes
 Radiotherapy
If the patient has cancer of the cervix and is undergoing
radiotherapy for long standing time, the rays penetrate
the bladder hence destroying it.
 Malignancy
Advanced carcinoma of the cervix, vagina and bladder may
produce fistula by direct spread.
 Trauma
Fistula can be due injuries following a fall on pointed
objects, use of sticks in criminal abortion or following
fracture of the pelvic bone.
 Operative injury in gynaecological procedures
During operations such as hysterectomy and cesarean
section the bladder may be injured accidently.
Also, during dilatation and curettage.
 Prolonged obstructed labour due to cephalopelvic
disproportion.
 The baby’s head while descending through the pelvis
compresses the anterior vaginal wall against the back of
the symphysis pubis. This results into prolonged pressure
on the tissues which under go ischemia, necrosis,
sloughing and fistula in 3-5 days following delivery.
Signs and symptoms
 History of cesarean section, obstructed labour, criminal
abortion etc
 Urine incontinence
 Offensive ammonia like smell
 Patient looks miserable and psychologically unfit due to
wet pants and bed.
 On examination, there is vulvitis and vaginitis due to
alkaline media which attracts micro -organisms.
 Itching of the vulva

How to come to a diagnosis

 History taking
 Vaginal examination to visualize the fistula using a
speculum.
 Cystography
 Dye test
A speculum is introduced and the anterior vaginal wall is
swabbed dry.
When methylene blue solution is introduced into the
bladder by a catheter, the dye will be seen coming out
through the opening.
 Three swab test.
 Three cotton swabs are placed in the vagina; one at the
vault, one in the middle and one just above the introitus.
Methylene blue dye is instilled in the bladder through the
catheter.
Patient is asked to walk about for 5 minutes and she is
then inspected.
 Catheter test(rare)
A mental catheter is passed through the exeternal urethral
meatus, when it passes out through the fistula VVF is
confirmed.

Management
Aims
 To prevent or treat infections
 To promote quick healing
 Health education
 To reassure the patient
1. The patient is admitted on a gynaecological ward that is
clean and well ventilated. Normal admission procedures
are carried out.
Establish good patient nurse relationship.
2. Inform the doctor. The doctor will carry out digital
examination.eg
 Cystography
 Ultrasound scan
 Hb, grouping and cross match
 Cervical biopsy
 Urinalysis
 3. Self-retaining catheter is passed and patient is kept on
continuous bladder drainage for 6-8 weeks.
This may cause spontaneous closure of the fistula if it it is
small with minimal tissue damage.
4. Patient is put on appropriate antibiotics to treat or
counteract infections.
5. Give a balanced diet to the patient to promote quick
wound healing.
6. Continuous psychological care through reassurance to
allay anxiety.
7. If there is foul vaginal discharge due to disloughing of
necrotic tissue, it is treated with antiseptic vaginal
douches.
8. At the end of puerperium, the patient is assessed by
means of a speculum.
Enough time has to be given to allow the tissue heal and
strengthen up sufficiently.
There fore the patient will have to be sent back home and
asked to re attend surgery after 3 months.
Treatment
Local repair of fistula is the treatment of choice.

Day before operation

 Obtain an informed consent from the patient
 Psychological care is done to allay anxiety
 Check for the required investigations results and book
units of blood for transfusion to restore general health.
 Ensure rest and sleep
 Starve the patient 6 hours to operation.
Morning of operation
 Shaving is done
 The patient is encouraged to have a bathe and a clean
gown is provided.
 Theatre staffs are informed about the patient
 The patient together with clinical charts is taken to
theatre.

Post- operative care

 Position the patient in prone to prevent pressure on the
sutures.
 Provide plenty of oral fluids to flush the bladder.
 Maintain a strict fluid balance chart
 Observe the drainages and the odour of urine.
 Remove the pad on the 2nd day of operation.
 Do vulva swabbing 8 hourly
 Take vital observations TPRBP
 Daily observation of the bed
 Observe the catheter and drainages so that the patient
does not lean on it as it will prevent the urine from
draining causing bladder distension.
 Give light diet with plenty of roughages to prevent
constipation.
 Keep patient on complete bladder drainage for 14 days.
 Bladder training
This is started on the 14th and 15th day post-operatively
and if the dye test is negative.
1st day - ½ hourly
 2nd day - 1hourly
3rd day -2 hourly
4th day - 3 hourly
 At night the urinary bag is placed back. This is done in
order to avoid disturbing the patient’s sleep.
 While training, observe for bed wetting and if dry remove
the catheter.
 Reassure and counsel both partners
 Advice on discharge
 Abstain from sex for 3 months
 Advise to pass urine 2 hourly following removal of
catheter.
 Do light exercises to avoid putting strain on the
healing wound.
 Practice family planning methods so as to prevent
early pregnancies.
 If contraception occurs report to the physician and
must have antenatal checkup and hospital delivery.
 Always come back for review on appointed dates.
Complications
 Urinary tract infections secondary to blockage of catheter.
 Depression or psychological torture
 Stigma
 Divorce
 Social out cast
Prevention
 Encourage hospital delivery. This is done through health
education during antenatal.
  Encourage regular attending of antenatal clinics to rule out
risk factors.
 Proper monitoring of labour using a partograph.
 Careful use of instruments during assisted deliveries.
 Health educate on criminal abortion by giving counselling
services to teenagers.
 Minimal use of radiotherapy treatment in case of cancer.
 Encourage immunization against poliomyelitis during
childhood. This is because polio affects pelvic bones
leading to a contracted pelvis thus obstructed labour.
 Health educate on prevention of early marriages which
predispose young girls to difficult deliveries.
 Early detection and treatment of malignant diseases.

INFERTILITY
This refers to failure to conceive inspite of regular un
protected sex during the child bearing age that is 15-49
years without any contraception for atleast one year.

Types of infertility
Primary infertility
It is inability to conceive in a couple that has had no
previous pregnancies.
OR
This is where one has never conceived at all.
Secondary infertility
It is where one has ever conceived but then stops to
produce when she is not on any method of family
planning.
Causes of infertility
In males
Depression
Release of immature sperms or abnormal or little or
slow in movement.
Poor or failure to ejaculate
Extreme heat
An increase in temperature of the testes from a
prolonged fever or exposure to excessive heat can
greatly reduce sperm count, vigor of sperm
movement and it increases the number of abnormal
sperms in semen.
Hydrocele ie excessive collection of the fluids in the
scrotum. This prevents adequate production of
sperms.
Varicocele ie varicose veins of the scrotum.
This abnormality may prevent proper supply and
drainage of blood from the testes thus rising the
 temperatures and reducing the rate of sperm
production.
It also affects ejaculation.
Drugs of amoebiasis called amoebicides, anti-
hypertensives like aldomet and diabetic drugs cause
failure in erection.
Diseases like mumps cause a condition called
orchiditis (inflammation of the testes)
Hormonal imbalance.eg inadequate production of
testosterone hormone may result into immature
sperms.
Degenerative changes in sperms. This can be caused
by nitrofurantoin.
Excessive smoking and alcohol consumption.
Obesity
Retrograde ejaculation
This is ejaculation into the bladder. It is assessed by
urinalysis after ejaculation
Exposure to toxic chemicals or radiations affects the
spermatogenesis.

Management
General history taking
 This includes the patient’s particulars and
history.eg name, sex, age, number of years in
 marriage, sexual relationship, when do they
meet, diseases.eg mumps, gonorrhea etc,
 Occupation. If the man is a dobby, temperature
is always high so the testes are over heated and
affected.
 Find out whether the man works under tension
or he is ever anxious.
 Ask about habits like smoking and alcoholism
 Find out any history of scrotal injury or trauma
to the genital organs.
Physical examination
Look for abnormalities of the genitalia eg descend of
testes, disease and general condition of the patient.
Investigations
 Carryout semen analysis
Normal volume ≥ 2ml or 2.5ml
Concentration ≥ 20 million/ml
Motility ≥ 50% with forward motility
Morphology ≥ 30% normal shape
 Blood tests
This is to measure the level of testosterone
hormone responsible for testicular function.
Nb. To make a conclusion on the above test, two
samples should be tested.
The man should be healthy for atleast 72 days
before the sample is taken.
 Treatment
This is done depending on the cause;
 Surgery incase of anything on the
reproductive organ.eg scrotum and testes.
 Hormonal supplements of testosterone
40mg capsules for 2-4 weeks
 Counselling of the couple incase of meeting
at wrong time.
 Advise on change of job incase of a dobby
or working under tension.
 Advise on nutrition

Causes/factors in females
General health and nutrition.eg TB, AIDs and
malnutrition.
Psychological factors like stress and depression
Ovulatory factors or disorders of the ovulatory cycle
Anything affecting the hypothalamus and the
pituitary glands.
Uterine factors.eg the fibroids, polyps and congenital
malformation.
Tubal factors.eg tubal blockage due to adhesions
resulting from STIs.eg gonorrhea
Intrauterine adhesions after myomectomy
Hostility of cervical mucus. The acidity of cervical
mucus leads to death of sperms.
Wrong timing of sexual intercourse during infertile
periods.
Obesity

Management
History taking
This includes name, age, sex, any contraception
used, number of years in marriage etc
 Occupation
 Absence from home and for how long
tension at the place of work, exhaustion and
anxiety.
 Social habits.eg alcohol and smoking
 General health
Has she been sick and for how long?
His of any disease like PIDs
Physical examination
This to rule out malnutrition, anaemia, obesity etc
Investigations
 Hysterosalpingography to rule out uterine
or tubal abnormalities.
 Post coital mucus test
 Ultrasonography of the uterus and ovaries
 Hormonal tests for measurement of LH and
FSH and estrogen peak.
 PAP smear for cancer of the cervix
Treatment
Treat according to the cause.
Prevention
Stop smoking
Reduction of alcohol consumption
Proper diet
Meeting at the right time
Reduction in stress and tension
Counselling
Artificial insemination
Complications
Depression
Divorce
Sexual immorality
Polygamy

NB
Azoospermia
Lack of sperms in semen
Oligospermia
Little or few sperms less than 20 million/ml
Asthenospermia
Decreased motility of the sperms
Teratospermia
Excessive abnormality of the sperms in semen.

PELVIC INFLAMMATORY DISEASES

These are inflammatory conditions of the pelvic cavity
that may involve the uterus (endometritis), fallopian
tubes (salpingitis), ovaries (oophoritis), pelvic
peritoneum or pelvic vascular system.
Aetiology
It is usually caused by bacteria but it may also be
attributed to virus, fungus or parasites.
Gonococcal and chlamydial organisms are most likely
cause.
Mode of spread
Direct spread ie from the neighboring organs.
Blood spread ie haematogenous.eg Tb
Causative organisms
Streptococcus
Staphylococcus
E. coli
Mycobacteria
Predisposing factors
Multi sexual partner
Poor hygiene during menstruation
Intrauterine device
Previous history of PIDs
Use of unsterile instruments

Signs and symptoms

Increased vaginal discharge
Lower abdominal pain
Abdominal tenderness
Pain usually increase during micturition and
defecating
 Fever
General malaise
Anorexia
Nausea and vomiting
Headache
Irregular and excessive vaginal bleeding due to
endometritis

Management
In mild infections, the patient may be treated as an
outpatient but hospitalization may be necessary at
times.
The patient must have enough bed rest.
Monitor patients’ vital observations of temperature,
pulse, respiration and blood pressure.
Administer intravenous fluids as prescribed.
Treat with broad spectrum antibiotic therapy
Treat both sexual partners
Hydrosalpinx and any abscess formation must be
relieved by laparotomy and drainage.
Complications
Infertility
Ectopic pregnancy
Chronic pelvic pain
Pelvic abscess
Pelvic peritonitis
Salpingitis
Inflammation of the fallopian tubes.
In most cases both tubes are occluded.

Acute salpingitis
Signs and symptoms
It has an acute onset
Lower abdominal pain which worsens on movement
Pyrexia accompanied with vomiting and sweating
Dehydration due to vomiting
Tachycardia
Pus discharge if gonococcal
On abdominal palpation, mass may be felt in iliac
region.
Tenderness of the abdomen with rigidity and
guarding.

Management
Admit the patient on a gynaecological ward and on
complete bed rest.
Take history
Carryout a general examination to rule out
dehydration, anaemia etc.
Carryout vital observation of temperature, pulse,
respiration and blood pressure to assess functioning
of vital organs.
Resuscitate with intravenous fluids.
Carry out investigations as requested by the doctor;
o Urinalysis
o Blood for culture and sensitivity
o High vaginal swab for gram staining
o Ultrasound scan
Apply warm towel to relieve pain.
Drugs
o Administer strong analgesics eg pethidine to
relieve pain.
o Administer antibiotics according to culture and
sensitivity results.
Eg. In gonococcal infection, doxycline 100mg bd
Surgical treatment
This is done incase of pelvic abscess (incision and
drainage)
In repeated attack of salpingitis or deterioration,
exploratory laparotomy is done.
Nursing care
Tepid sponging to lower body temperature
Give a balanced diet to the patient
Exercise
Psychological care
 Elimination
Advice on discharge
o Maintenance of hygiene
o Should complete prescribed drugs
o Abstain from sex until completion of treatment
o Bring sexual partner for treatment
o Encourage them to come back for review

Chronic salpingitis
Signs and symptoms
Has a gradual onset
History of amenorrhea
Excessive vaginal discharge
Painful coitus
History of infertility
Management
Administer antibiotics for 3-4 months
Apply heat packs or warm towels to relieve pain
Encourage exercises
Incase of Tb salpingitis, give tuberculosis treatment
Encourage a balanced diet
If the condition persists, hysterectomy is done.

Complications
Infertility
Ectopic pregnancy
 Pelvic peritonitis
Chronic salpingitis if it was acute.
ENDMETRITIS
This is inflammation of the lining of the uterus.
(endometrium)
Causes
Retained placenta after delivery or abortion. This is
the most cause of postpartum infection.
Infected amniotic fluid from stool excreted by the
fetus.
STDs like gonorrhea, chlamydia etc
Tuberculosis
Normal vaginal bacteria can be a reason for
endometritis.
Risk factors
Cesarean section significantly increases the chances
of postpartum infection.
Premature rapture of fetal membranes.
Presence of IUD
Instruments used in some procedures such as
dilatation and curettage if unsterile.
Signs and symptoms
Postpartum endometritis develops 48-72 hours
Abdominal distension
Abnormal vaginal bleeding
Abnormal vaginal discharge with foul odour
 lower abdominal pain
Fever
Malaise or general body weakness
Tests and investigations
Abdominal palpations to discover tenderness
Pelvic examination
Blood tests.eg RBC, CBC, and ESR
Culture from cervix for organisms
PAP smear to detect the presence of abnormal cells
Endometrial biopsy
Management
Admit patients with serious symptoms or
postpartum infection in an isolated room of a
gynaecological ward.
Administer broad spectrum antibiotics for 5-7 days
Administer intravenous fluids to prevent
dehydration.
Aspiration to drain the uterus is done.
Evacuation of retained products of conception ie
placental tissues
Encourage adequate rest
Administer anlgesics.eg paracetamol for pain and
fever relief.
Hysterectomy may be done to remove the infected
uterus and damaged uterus.
Complications
 Infertility
Pelvic peritonitis
Uterine abscess formation
Septicemia
Septic shock
Hysterectomy

CERVICITIS
This is inflammation of the cervix.
The inflammation may be acute or chronic.
It usually occurs following;
Child birth
Any operation from the cervix
Abortion
Causative organisms
Streptococcus
Staphylococcus
E.coli
Gonococci
Clinical features
Spotting after sexual intercourse
Yellowish white discharge
Red edematous cervix
Cervical tenderness on movement of the cervix
Treatment
Antibiotic therapy
 In chronic cervicitis, the diseased tissue may be
destroyed by diathermy/cauterization
Any associated cervical tear if present may be
required.

ABORTION
This is expulsion of products of conception before 28
weeks of gestation.
It can be complete or incomplete. It is extreme that 10-
15% of the pregnancies end up in abortion and it is
common in 8-13 weeks of gestation.
Causes of abortion
These are classified as follows;
Fetal causes
Malformation of the zygote in chromosomal
disorders.
Abnormal implantation in the uterus.ie attachment
of the placenta near the internal os. (placenta
previa)
Maternal causes
Acute illness with high temperatures.eg malaria,
typhoid, rubella etc
Chronic illnesses.eg anaemia, chronic nephritis, DM,
syphilis etc
Cervical incompetence
Severe malnutrition
Oxytocic drugs
Hormonal insufficiency
 Insufficient production of progesterone by the
corpus luteum before the placenta is fully
formed will lead to inadequate development of
the decidua and abortion may take place.
 Thyroid deficiency and hyperthyroidism may be
a contributing factor of abortion
Uterine abnormalities
 Retroverted uterus
 Divided uterus (bicornuate)
 Fibroids (submucosa fibroids)
Trauma
 Severe trauma on the uterus may cause
detachment of the embryo.eg a heavy blow on
the abdomen or a fall.
 Insertion of instruments or foreign bodies in the
uterus through the cervix
 Operations like myomectomy. These should not
be done during pregnancy.
Operations such as removal of ovarian tumours in
early pregnancy increase the risk of abortion
because the corpus luteum is removed too.
Immunological of the fetus
Some recurrent abortions may be caused by
antibodies produced in the maternal blood crossing
 the placenta to destroy the fetal erythrocytes.
(rhesus incompatibility)
Acute emotional disturbances
Eg severe fright or sudden bereavement may induce
contractions hence abortions.
Clinical varieties of abortion
Abortions are usually categorized as spontaneous and
induced.
Types of spontaneous abortion
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Septic abortion
Missed abortion
Recurrent or habitual abortion.
Types of induced abortion
Legal or therapeutic abortion
Illegal or criminal abortion

THEREATENED ABORTION
This is when products of conception tend (threaten) to
come out before 28 weeks of gestation but the
disturbance is so slight that the fetus will grow up to
term.
Clinical features
 Absence of menstrual periods for 1-2 months
Slight vaginal bleeding
A brown discharge may follow after a week
Patient may complain of backache and abdominal
discomfort
The cervix is closed
No recognizable uterine contractions
Nb. No vaginal examinations must be done unless the
bleeding is severe with clots.

Management
Admit the mother in the gynaecological ward for
complete bed rest.
Take histories such as personal, obstetrical
histories.eg last normal menstrual period.
Take and monitor vital observations.eg temperature,
pulse, respiration and blood pressure.
Carry out a general examination to rule out anaemia,
dehydration and jaundice.
Investigations
 blood for hb, grouping and cross match
 blood smear for malaria parasites
 urine for urinalysis
Reassure the mother and calm her down
Only carry out vaginal inspection, clean the vulva
with normal saline and apply a clean pad.
 Encourage mother to pass urine frequently thus
avoiding urine retention.
Provide roughages to avoid constipation which may
lead to strain while passing stool.
Diet
Provide a highly nutritious diet to the patient.
If the patient is restless and anxious, give mild
sedatives.eg Valium to allay anxiety
Treat the cause of abortion if identified.eg malaria
etc
Ensure and maintain airway, breathing, circulation if
necessary.
Hygiene
 Change soiled linen
 Carry out bed bath
 Ensure oral hygiene
 Provide clean clothings to the patient
Advice on discharge
 Continue with bed rest at home
 Avoid sexual intercourse for 3-6 weeks
 Avoid heavy work such as lifting heavy things
 If bleeding reoccurs, she should report
immediately for medical assistance.
 Attend antenatal clinics
 Take only prescribed drugs
Note
If threatened abortion is not attended to properly, it may
lead to inevitable abortion.

INEVITABLE ABORTION
This is when no measures can be taken to stop the
abortion. Therefore, pregnancy cannot continue.
Clinical features
Absence of menstrual periods for 1-2 months
Lower abdominal pain and backache.
Heavy vaginal bleeding with clots
The cervix is dilated
Painful uterine contractions
Membranes may rapture and liquor may be seen
especially after 16 weeks.
On speculum examination, membranes and other
products of conception may be seen protruding
through the cervix or the vagina.
The mother may have signs and symptoms of shock
The uterus if palpable may be smaller than expected.
Nb. Inevitable abortion may either be complete or
incomplete.
Management
Admit the mother to a gynaecological ward in a well-
made admission bed.
Take complete history particularly when the
bleeding started, amount of blood lost and any
history of infection or disease.
Reassure the patient and relatives to allay anxiety
Do a brief general examination to assess the
condition of the mother and to rule out anaemia,
dehydration and shock.
Estimate the weeks of gestation by palpating the
mother’s abdomen.
Take baseline vital observations such as
temperature, pulse, respiration and blood pressure
assess functioning of vital organs.
Clean the vulva and prepare for vaginal examination
for the doctor.
Apply a sterile pad on the vulva.
Sometimes you may see parts of the placenta or
fetus through the cervical os or vagina, try to remove
them.
Inform the doctor.
Carry out investigations as requested by the doctor
such as;
 blood for hb, grouping and cross match and
book some units of blood.
 Blood smear
 Urine for urinalysis
 VDRL for syphilis
 Blood loss may be controlled by administering
oxytocin/ergometrine injection.
Blood transfusion may be necessary according to the
laboratory results.
Administer intravenous fluids to elevate the blood
pressure so as to prevent shock.
Drugs
 Analgesics should be prescribed to reduce pain
by blocking pain receptors.
 Haematinics may be prescribed.eg ferrous
Ensure good hygiene of the patient.
Give a nutritious diet to the patient
Prevention
Attend antenatal clinics so that risk factors of
abortion are identified and treated early.
Report early bleeding to maternity centers
Seek medical advice and treatment whenever sick.
Complications
Shock
Anaemia
Dehydration
INCOMPLETE ABORTION
This is when some products of conception usually the
placental tissues (chorionic membranes) are retained
within the uterus.
Clinical features
 Heavy and profuse vaginal bleeding
Abdominal pain and backache
The cervix is partially open and soft
The uterus is bulky
Management
Admit the mother on a gynaecological ward.
Take patients’ history
Reassure the patient and relatives to allay anxiety
Notify the doctor who will request for investigations
such as hb, grouping and cross match.
Resuscitate the patient with intravenous fluids.
If in shock, keep the patient warm.
Monitor vital observations
Obtain an informed consent from the patient.
Administer oxytocin or misoprostol to help contract
the uterus and expel the retained products of
conception as well as control bleeding.
If products are seen in the vagina, scrub up, put on
sterile gloves and remove the products by manual
evacuation.
Monitor airway, breathing and circulation.
Transfuse according to laboratory hb results.
Shave and dress the patient in a clean theatre gown
and inform theatre staffs.
The uterus is evacuated under general anaesthesia
in theatre when the mother is in a stable condition.
 Give prophylactic antibiotics to counteract
infections.
Give ferrous/ folic acid.
Ensure a good nutritious diet.
Advice on discharge
 Have enough rest at home
 Have a nutritious diet
 Report back for review on appointed dates.
 Take medications as prescribed
 Attend antenatal care clinics at any time
Complications
Shock
Anaemia
Sepsis

Complete abortion
This is when all the products of conception have been
expelled out spontaneously.
Clinical features
Ceasation of pain
Scanty blood loss
The uterus on palpation is well contracted
Signs of pregnancy will regress
Note
If no more active bleeding and ultrasound scan shows an
empty uterine cavity, no further treatment is required
and the patient does not require hospital admission.

SEPTIC ABORTION
This is an abortion characterized by micro-organisms
invading the retained products of conception in the
uterus.
This condition is most commonly a complication of
induced or incomplete abortion.
Causative organisms
Escherichia coli
Non haemophilic streptococci
Staphylococcus aureus
Streptococcus pyogens
Streptococcus pneumonae
Clinical features
The patient may present with pyrexia
Rapid pulse
The patient can tell whether the pregnancy was
interfered with or not.
Headache
Tenderness of pelvic region
General malaise
Severe lower abdominal pain
 Profusive offensive brownish discharge from the
vagina
Mental confusion and endotoxic shock
Management
Admit the mother to a gynaecological ward in
isolation.
Take history from the patient
The patient should be nursed in a sit up position to
help drain liquor or pus from the uterus.
Do general examination from head to toe to rule out
anaemia, shock etc.
Carry out vital observations
Inform the doctor
Carryout investigations as required by the doctor.eg
 Blood for hb, grouping and cross match
 High vaginal swab for culture and sensitivity
Administer intravenous fluids for rehydration and
electrolyte replacement.
Blood transfusion should be done if the patient is
anaemic.
 Give a highly nutritious diet
Administer wide spectrum antibiotics should be
given in accordance to the laboratory results.
Avoid urine retention and oliguria which may
indicate tubular necrosis.
 Evacuation is carried out after the course of
antibiotics.
Medical treatment
 Injection penicillin 4 hourly
 Gentamycin 80-160mg tds
 Injection hydrocortisone 500mg on high dose to
convert shock given 4 hourly
Complications
Septicaemia
Renal failure
Perforation of the uterus
Pelvic thrombophlebitis
Anaemia

MISSED ABORTION
This occurs when the embryo dies or fails to develop and
the products of conception are retained in the uterus for
weeks or months.
Clinical features
Symptoms of threatened abortion occur and cease.
Absence of usual signs of progress of pregnancy
The products of conception are completely
separated from uterine walls but for unknown
reasons the uterus does not contract to expel them
out.
 The uterus ceases to enlarge and the cervix is tightly
closed.
After several weeks of occurrence, a brown
discharge occurs followed by bleeding, lower
abdominal pain and a reddish-brown mass is
expelled.
Management
Admit the patient on a gynaecological ward. This is
because after a few weeks of a spontaneous
complete abortion may occur.
If spontaneous abortion does not occur, on
intravenous infusion of prostaglandins or oxytocin
may be given and for this the concentration of
oxytocin is increased gradually.
If the mole is not expelled after the above infusion
the uterus is emptied surgically with a suction
curette after dilating the cervix.
Analgesics are given to relieve pain.
Carryout vital observations of temperature, pulse,
respiration and blood pressure.

HABITUAL ABORTION (recurrent abortion)

It is an occurrence of spontaneous abortion in three or
more consecutive pregnancies.
This problem affects 1% of all woman and the risk of
further abortion increases with each pregnancy lost.
The incidence of recurrent abortions suggests that there
are underlying causes.

Factors associated with habitual abortion

Genetic causes
Abnormal parental karyotype of which the most
common is translocation.
Immunological factors
Women with history of pregnancy loss have been
found to lack immunological G (1gG) locking agent.
In normal pregnancy, the 1gG coats the fetal
antigens and protects the fetus from infections.
Endocrine factors.eg hypersecretion of LH
This may act on the oocyte causing it to age or on
the endometrium resulting into errors in
implantation.
Mother with polycystic ovaries have reduced fertility
and an increased risk of early pregnancy loss.
Infections
Structural abnormalities
 Uterine abnormalities such as bicornuate
uterus.
 Cervical incompetence
Management
Mothers should be referred to specialized clinics
where screening services are available thus enabling
a probable cause to be identified.
Specific treatment is given for any cause
identified.eg
Cervical cerclage at 14 weeks of gestation by
Shirodkar’s or McDonalds method.
Anon absorbable suture is inserted at the level of the
cervical os. This remains in site until 38 weeks or the
onset of labour when it is removed.

MENOPUASE
It refers to permanent cessation of menstruation at
the end of reproductive life due to loss of ovarian
follicular activity (45-55 years)
Terms used
Pre-menopause
It refers to a period before menopause.
Post menopause
It refers to the period after menopause.
Climacteric
It is a phase of aging process during which a woman
passes from the reproductive to the non-
reproductive stage of life.
This phase covers 5-10 years on either side of
menopause.
Changes during menopause
Organ changes
a) Ovaries
They shrink in size, become wrinkled and
whitish in colour.
There is thinning of the ovarian cortex.

b)Fallopian tubes
The muscle coat becomes thin
Celia disappears
c) The uterus
It becomes smaller in size
Endometrium becomes thin and atrophic
The cervical secretions become scanty
Ligaments and fascia which support the
uterus atrophy and prolapse may become
evident if there has been previous damage
during child birth.
d)The vagina
It becomes narrower due to loss of elasticity.
The rugae becomes less prominent or
progressively flattened.
There are no lactobacilli
No glycogen
The vaginal PH becomes alkaline.
e)The vulva
 It shows features of atrophy
The labia become flattened
Pubic hair becomes scanty
f) Breasts
Breast fat becomes reabsorbed and glands
atrophy
Nipples decrease in size
Nb. Therefore, breasts become pendulous and
flat.
g) Bladder and urethra
The epithelium becomes thin
Loss of pelvic muscle tone due to low levels of
estrogen.
This leads to pelvic laxation which then leads
to genital prolapse.
h)Bones
Osteoporosis has been attributed to estrogen
deficiency.
i) Cardiovascular system
Deficiency of estrogen increases the risk of
cardiovascular disease such as coronary heart
disease.
Menstrual pattern
Menstrual pattern in the pre-menstrual period.
 A sudden cessation of menses.
  Gradual hypomenorrhea (scanty menses) or
infrequent cycles (oligomenorrhoea)
 Irregular with or without excessive bleeding
Menopausal symptoms
 Cessation of menstruation
 Hot flashes.ie it is a sudden onset of feeling of
warmth
 Dyspareunia
 Stress incontinence
 Frequent urinary tract infection
 Vaginal infections and pruritis
 Night sweats
 Osteoporosis
It may lead to;
Back pain
Kyphosis
Fractures of bones
Psychological symptoms
 Increased anxiety
 Un explained headache
 Insomnia
 Irritability
 Depression
 Dementia
 Mood swings
 Inability to concentrate
Diagnosis of menopause
Cessation of menses for 12 consecutive months
during the menopausal period.
Appearance of menopausal symptoms
Features of low osteogeny on vaginal epithelium
(vaginal cytology)
Laboratory demonstration of low estrogen and
increased FSH and LH.

Management of menopause
a) Counselling
Adequate explanation to every woman with
symptoms may help them to understand and
accept the changes.
b)Non-hormonal treatment
Nutritious diet. It should be balanced with
proteins and calcium.
Supplementary calcium and vitamin D
Exercises.eg jogging, walking etc
Cessation of smoking and alcohol
c) Hormonal replacement therapy (HRT)
Replacement of estrogen is prescribed for
women with surgical or radiation menopause.
Abnormal menopause
 Premature menopause
It occurs at ≤ 40 years of age.
 Treatment by substitution therapy is usually
followed.
 Delayed menopause
It occurs at 55 years.
Causes
Uterine fibroids
An estrogen producing tumour of the ovary.

Treatment
Therefore, detailed investigations for any pelvic
pathology and appropriate treatment is indicated.
 Artificial menopause
This is a permanent cessation of ovarian function as
a result of surgical removal of ovaries or by
radiation.

GESTATIONAL TROPHOBLASTIC DISEASES

This is a group of disorders characterized by abnormal
placental development.
The cells that would normally develop into the placenta
during pregnancy divide abnormally forming tumors.
Most gestational trophoblastic diseases are benign (non-
cancerous) but some are cancerous.
Types of gestation trophoblastic diseases
 Hydatidiform mole (most common form)
 Invasive mole
 Choriocarcinoma
Hydatidiform mole
It is also known as molar pregnancy/vesicular mole.
Molar pregnancy is a gestational trophoblastic disease
which grows into a mass that has swollen villi with fluid
in the uterus.
These villi grow in clusters that resemble grapes.
Types of hydatidiform mole
i. Complete hydatidiform mole
This is a type of mole that contains no evidence of
the embryo, cord or membranes.
Most often develops when either one or two sperm
cells fertilize an empty egg cell.
Therefore, all the genetic material comes from the
father’s sperm cell thus no embryo is formed.
Sperm + empty egg
23X 23X

ii. Partial hydatidiform mole

This is a type of mole in which evidence of the
embryo or amniotic sac may be found as death
occurs at the 8th or 9th week.
 Chromosome analysis usually show this as triploid
with 69 chromosomes.ie;
Three sets of chromosomes;
1 maternal set of chromosomes
2 paternal set of chromosomes
Eg.
Paternal maternal
23x/23y + 23x 69xxx
23x/23y 69xxx

Nb.
These tumours contain some fetal tissue but this often
mixed in with trophoblastic tissue.
Signs and symptoms of hydatidiform mole
History of amenorrhea of 8-12 weeks
Abnormal enlargement of the uterus ie. The size of
the uterus is too big for the expected dates.
Persistent nausea and vomiting
Vaginal bleeding
Expulsion of grape like vesicles per vagina
Lower abdominal pain. This is due to over distension
of the uterus.
Signs of anaemia are present.eg pallor
Features of pre-eclampsia are present.eg
 High blood pressure
  Proteinuria
 Edema especially of the ankles
Fetal parts cannot be palpated
Fetal movements are absent
Absence of fetal heart sounds
Abdominal guarding and rebound tenderness may
be present if hemoperitoneum has occurred.
Investigations
Abdominal ultrasound scan
Serum levels of HCG is high
Urinary pregnancy test
Hb, grouping and cross match
Treatment
Suction curettage is the procedure of choice
A hysterectomy may be an option for older women
who do not wish to become pregnant in future.
Note
It is important to avoid pregnancy and use a reliable
contraceptive for about 12 months after treatment of
molar pregnancy.
Women who get pregnant too soon after a molar
pregnancy have a greater risk of having another one.

Invasive mole
This is a condition in which the molar tissue burrows
through the decidua and into the myometrium and
associated blood vessels.
It may result from complete or partial hydatidiform
mole.
Perforation of the uterus may occur
Sometimes parts of the villi may form emboli and
can reach the lungs.
The moles are not completely removed by dilation
and curettage since they grow in uterine muscle
layers.
Bleeding occurs into the pelvic/ abdominal cavity.

Choriocarcinoma
This is a malignant form of GTD.
It is more likely than other types of GTD to grow quickly
and spread to organs away from the uterus.
Choriocarcinoma most often develop from;
Hydatidiform mole
A normal pregnancy
A pregnancy that ends in an abortion.

Complications of GTD
Anaemia
Shock
Pulmonary embolism
 Re-occurrence in subsequent pregnancies
Rapture of the uterus
Perforation of the uterus

CERVICAL ECTROPION (cervical erosion)

This is a condition in which there is a raw looking area on
the cervix.
It occurs when a thin inner lining of the cervix comes out
onto the part of the cervix that can usually be visualized
during a speculum examination.
Causes
Trauma following multiple child birth
Chemicals
Tampon use
IUDs if used for a prolonged period.
 Oral contraceptive pills
Infections (common cause)
Carcinoma
Risk factors
Low socio-economic status
Poor general hygiene
Early marriage
High parity
Signs and symptoms
Increased vaginal discharge/ leucorrhoea
Pain
Post coital bleeding
Investigations
High vaginal swab for culture and sentivity
PAP smear
Treatment
Mostly cervical erosion is present in women who do not
have any symptoms and thus no specific treatment is
advised.
Usually a spontaneous regression takes place after
squamous metaplasia but treatment can speed up this
process.
Cryo cauterization
Electrocoagulation
Cautery with laser

CERVICAL POLYP
It is an out growth of the cervix usually benign protruding
from the mucous membrane.
It can be diagnosed in early pregnancy because of per
vaginal bleeding.
Signs and symptoms
Symptoms
Per vaginal discomfort
Per vaginal bleeding especially on contact
Urinary symptoms.eg increased frequency of
micturition
Per vaginal discharge
signs
 On vaginal examination, you can feel the mass which
is soft mobile attached to the cervix and roundish in
shape.
Contact bleeding during this examination
On speculum examination, you can see a mass
arising from the cervix.
Treatment
Surgical removal of the polyp. (polypectomy)

Cervical trauma
Causes
Following child birth
Tampone usuage
Criminal abortion ie use of sticks and others
Gynaecological procedures.eg D&C

GENITAL MALGNANCIES
CANCER OF THE CERVIX
The cervix is a cylinder-shaped part of the uterus that
connects to the vagina.
It is covered by two kinds of cells;
Squamous cells found in the ectocervix
Columnar cells found in the endocervix. (these
secrete cervical mucus)
Definition
Cervical cancer is a malignant tumour found in the
tissues of the cervix.
It occurs when abnormal cells in the cervix turn into
cancer cells.
Cervical cancer is the most common gynaecological
cancer in Africa and it is commonly among women of
over 35 years of age.
Types of cervical cancer
Squamous cell carcinoma (80-90%)
Adeno carcinoma (10-20%)

Predisposing factors of cervical cancer

1. Human papilloma virus
HPV type 16 and 18 causes about 7/10 cancers of the
cervix.eg squamous cell cancer and adeno carcinoma.
 Women with persistent HPV infection are at greater risks
of developing cervical cell abnormalities and cancer.
2. Multiple sexual partners
Women who are sexually active are at a risk of getting in
contact with atleast one type of HPV during their life time
unless protection is used.
3. Immune suppression
The immune system helps the body to fight against
infections and also destroy abnormal cells before they
become cancerous.
Therefore, diseases and some medications that reduce the
immune system can increase the risk of cervical cancer.
4. Smoking
Women who smoke are at a risk of getting cervical cancer
as well as other cancers.
Both tobacco smoking and exposure to second hand
smoke have been associated with the development of
cervical cancer. This is because cigarette smoke contains a
cancer causing chemical benzyrene.

5. Oral contraceptives
Women on pills are more likely to be sexually active and
may not necessarily use barrier contraception.eg condoms
which could increase their risk to picking HPV.
6. Herpes simplex infection
 Research has found out that having both herpes and HPV
infection increase the risk of cervical cancer.
7. Un circumcised male partners
These have a secretion called smegma which keeps
clogging around their prepuce thus becoming carcinogenic
later in time in men with selfcare deficit of the penis.
8. Low social economic status
Women with lower incomes are at higher risks of
developing cervical cancer because they are less likely to
receive regular PAP test screening.
9. Diethylstilbestrol (DES)
This is a drug that was used to stop miscarriages. The drug
was found out to increase the risks of developing
precancerous cells and cervical cancer.
Others
10. Early onset of sexual intercourse
11. High parity
12. Repeated induced abortions
13. Ineffective treatment of STDs
14. Constant exposure to radiations
15. Poor maintenance of local hygiene

How does cancer spread

 Direct spread (ie to neighbouring organs)
 Lymphatic spread
 Blood spread
Cervical cancer staging
Staging according to FIGO
Stage 0 Carcinoma insitu (pre-invasive carcinoma)
Some cells of the cervix have cancerous changes but
the abnormal cells are all confined within the surface
layer of the cervix.
Stage 1: Carcinoma confined in the cervix
1A:
The growth is so small and it can only be seen with a
microscope.
1A1:
Cancer has grown less than 3mm in the tissues of the
cervix and less than 7mm wide.
1A2:
Cancer has grown between 3-5mm into the cervical tissues
and less than 7mm wide.

1B:
The cancerous area is larger but the cancer is still only in
the tissues of the cervix.
1B1: Cancer is not larger than 4cm
1B2: Cancer is larger than 4cm
Stage 2:
 Cancer extends beyond the cervix but does not
reach the pelvic side walls or lower third of the
vagina.
2A:
It involves the upper third of the vagina without
parametrial involvement.
2B:
It spreads up to the tissues around the cervix without
reaching the pelvic side walls.
Stage 3:
Carcinoma extends to the true pelvic side walls
(muscles and ligaments) or the lower third of the
vagina.
3A:
Cancer has spread to the lower third of the vagina but not
pelvic walls.
3B:
Cancer extends to the pelvic side walls or blocking one or
both of the ureters.
Stage 4: Advanced cancer
Carcinoma extends beyond the true pelvis or involves
the urinary bladder or rectal mucosa.
4A: Involves the urinary bladder or rectal mucosa
4B: Spreads to distant organs.eg lungs
Signs and symptoms
In early stages of cervical cancer, the woman may or may not
experience symptoms.
Early symptoms
 Abnormal vaginal bleeding or spotting between periods.
 Watery or blood-stained foul- smelling discharge from the
vagina.
 Pain during sexual intercourse
 Post coital bleeding
 Post-menopausal bleeding
Late symptoms (advanced cancer)
 Cachexia (severe weight loss)
 Anaemia
 Dehydration
 Back/pelvic pain
 Urine incontinence
 Haematuria
 Loss of appetite
 Fatigue
 Rectal bleeding
 Bone and joint pain (due to bone metastasis)
 Bone fractures
 Tenesmus (desire to defecate)
 Enlarged organs.eg liver and kidneys
 Fistulas
Screening tests
  PAP (Papanicolaous) smear
It is a useful method in detecting cancer of the cervix in its
early stages as well as following up patients who have
been treated for early cancer of the cervix.
 Acetic acid test
This is visual inspection using acetic acid.
3% acetic acid is painted on the cervix. Colour changes on
the cervix are noted and reported.
The abnormal area stains white.
 Biopsy for histology
 Colposcopy
A procedure in which a colposcope (a lighted magnifying
instrument) is used to examine the cervix for
abnormalities and tissue sample is taken.
The cervix lesion may be inform of;
 An ulcer
 Looks ugly
 Tends to bleed easily when touched
Other investigations
 Full blood count
 Liver function test
 Ultrasound scan
 Chest x-ray
 Rectal examination
Treatment
The treatment options depend on the following;
  The stage of cancer
 The size of tumours
 The patients desire to have children
 The patients age
Stage 1 - Surgery is the treatment of choice
- Also, radiotherapy may be used
Stage 2: 2A – Surgery or chemoradiation
2B –Chemoradiation
Stage 3: Chemoradiation
Stage 4: -Chemoradiation
-Palliative care
Examples of chemotherapy include
 Methotrexate
 Bleomycin
 Cisplatin
Side effects of radiotherapy
This depends mainly on how much radiation is given and the
part of the body involved.
 Vomiting
 Nausea
 Diarrhea
 Urinary problems
 Alopecia
  Dryness, itching or burning in the vagina.
NB
Chances of living for atleast more than 5 years after being
diagnosed with cancer of the cervix.
Stage 1 80-99%
Stage 2 60-90%
Stage 3 30-50%
Stage 4 20%
Prevention of cervical cancer
 HPV vaccination
 Screening
 Male circumcision
 Being faithful to a single sexual partner
 Stop smoking
 Use of condoms
 Effective treatment of STDs
 Maintenance of local hygiene

BREAST CANCER
Breast cancer is one of the common (30%) cancers in women. It
is second to cervical cancer affecting women.
Over 40,000 new cases are identified annually. A woman has a
12% life time risk of developing breast cancer and 3.3% chances
of dying of cancer.
Cause
Un known
Risk factors
 Genetic ie family history of breast cancer.
 Age ie. ≥ 60 years
 Hormonal replacement therapy (estrogen)
 Early menarche
 Late menopause (> 55 years)
 Late parity (> 30 years)
 Prolonged use of oral contraceptives (estrogen containing
contraceptives)
 Personal history of breast cancer
 Benign proliferative lesions
 Obesity and life style
 Alcohol use
 Women who never breast fed
 Nulliparity
 High dose of breast or chest irradiation
 High dietary fat intake
Clinical features
  Painless breast lump
 Nipple retraction
 Dimpling of the breast skin appearing like an orange (peau
d’orange)
 Nipple discharge that may be bloody
 Ulceration of the skin
 Un uniform breast enlargement
 Pain in advanced stages
 Enlargement of axillary lymphatic glands
Investigations
 Mammography
This soft tissue x-ray of the breast.
NB
Mammography should not be done in women below 30
years because;
 Their breasts are young, dense and have a lot of
breast tissue.
 They are likely to feel pain during mammography as
the breast is squeezed.
 Ultrasound scan
 Excision biopsy
 Fine needle aspiration cytology biopsy (FNAC)
 Breast magnetic resonance imaging (MRI)
 Full blood count
 Liver function test
 Chest x-ray
THE TNM CLASSIFICATION
T – Breast tumour
Tx- primary tumour cannot be assessed
To- No evidence of primary tumour
Tis- Carcinoma in situ
 Ductal carcinoma in situ (DCIS)
 Lobulated carcinoma in situ (LCIS)
 Paget’s disease of the nipple with associated tumour.
NB
Paget’s disease is a malignant condition in which the
nipple is gradually eroded by the infiltration of malignant
cells.
T1 Tumour is 2cm or less in greatest dimension
T1a 0.5cm or less
T1b More than 0.5 – 1cm
T1c More than 1- 2cm
T2 Tumour more than 2cm up to 5cm in dimension
T3 Tumour is > 5cm in dimension
T4 Tumour of any size with direct extension to the chest
wall or skin.
T4a Extension to chest wall
T4b oedema, peau d’orange, ulceration of the breast skin etc.
T4c Both 4a and 4b
T4d Inflammatory carcinoma

N – Regional lymph nodes

Nx - Regional lymph nodes cannot be assessed
No – No regional lymph node metastasis
N1- Metastases to movable ipsilateral axillary nodes
N2 – Metastases to fixed axillary nodes
N3 – Metastases to ipsilateral internal mammary nodes
M – Distant metastases
M0 – No distant metastases
M1 – Distant metastases present

TNM staging of breast cancer

Cancer insitu (stage 0)
 DCIS
 LCIS
 Paget’s disease
Early breast cancer
T1N0M0 Stage 1
T1N1M0 Stage 2A
T2N0M0
T2N1M0 stage 2B
Late/ advanced breast cancer
T3N0M0
T3N1M0 Stage 3A
T3N2M0
T4 any NM0 Stage 3B/C
Any TN3M0
Any T any NM1 Stage 4

Management
Treatment options vary according to the stage of disease.
 Carcinoma insitu (stage 0)
Ductal/lobular carcinoma in situ
 Surgery (local excision to remove the lump ie
lumpectomy)
This is followed by;
 Radiotherapy to reduce the risk of local recurrence
 Hormonal therapy to prevent tumour cells from
receiving stimulation from oestrogen.
  Early breast cancer
Stage 1 and 2
 Surgery
Tumours < 3cm (breast conserving surgery)
Tumours > 3cm, cancers are multifocal or central
(simple mastectomy)
 Adjuvant radiotherapy
 Hormonal therapy
 Chemotherapy
 Locally advanced breast cancer
Stage 3
 Surgery ie radical mastectomy
 Radiotherapy
 Chemotherapy
 Hormonal therapy
 Advanced metastatic cancer of the breast
Stage 4
The aims of management;
Prolongation of survival
Maintain highest possible quality life (ie reducing
disease related symptoms as well as treatment
related toxicity)
 Palliative care (treatment of choice)
 Hormonal therapy
 Chemotherapy
 Radiotherapy
Examples of cytotoxic chemotherapy regimen
  Cyclophosphamide
 Methotrexate
 5-fluorouracil
 Adriamycin
Examples of hormone therapy regimen
 Tamoxifen 20mg o.d for 5 years
 Anastrozole 1mg o.d for 5 years
It is for post-menopausal women who have failed with
tamoxifen.
 Medroxyprogesterone acetate 0.4-1.5g o.d

Assignment
1. Describe the pre-operative care of a patient to be done
mastectomy.
2. Describe the post-operative management following
mastectomy.
3. Mention atleast 6 complications of breast cancers.
UTERINE CANCER (ENDOMETRIAL CANCER)
Endometrial cancer is a malignant growth that originate from
the inner lining of the uterus.
It is the 5th most common cancer in women and it accounts for
almost 5% of all female cancers.
Cause
Un known
Risk factors
  Hormonal replacement therapy in post-menopausal
women.
 Functioning ovarian tumours
 Tamoxifen used for treatment of breast cancer is noted as
contributing to endometrial cancer
 Personal or family history of cancer
 Age ie. Older age between 50-60 years
 Low parity ie. It is common more in un married and
nulliparous women.
 Late menopause
The chance of carcinoma increases if menopause fails to
occur beyond 52 years.
 Obesity
 Fibroids is associated to 30% of the cases.
 Early menarche
 Pelvic radiation therapy
 Diabetes, hypertension etc
 High intake of animal fat
Mode of spread
 Direct spread
Cancer may infiltrate the myometrium and spread to the
parametrium or into the peritoneal cavity.
 Lymphatic spread
In advanced cases the pelvic, para-aortic, inguinal and
femoral lymph nodes are involved.
 Blood
Clinical features
 Post- menopausal bleeding
 Abnormal uterine bleeding and menstrual periods
 Signs and symptoms of anaemia.eg pallor
 Lower abdominal pain
 Abdominal mass
 Pain during sexual intercourse
 Watery and offensive discharge
Investigations
 PAP smear may be either normal or show abnormal
cellular changes.
 Endometrial biopsy
 Ultrasound ie. Transvaginal ultrasonography
 Hysteroscopy and direct visualization of the uterine cavity
to take biopsy.
 Fractional curettage to detect the extent of growth.
Diagnosis
 History and clinical examination
 investigations
staging of endometrial cancer (FIGO 2010)
Stage 1: Tumour is confined in the endometrium
1a: Invasion of less than half the endometrium
1b: Invasion is more than half the endometrium
Stag 2a: Endocervical glandular involvement only
2b: Cervical stroma invasion
Stage 3: Local or regional spread of the tumour
3a: Tumour invades the serosa
3b: Vaginal or parametrial involvement
3c: Metastasis to pelvic and para-aortic lymph nodes
c1: Pelvic node involvement
c2: para-aortic lymph node involvement with or without
pelvic node involvement.
Stage4a: Tumour invasion to the bladder or bowel mucosa
4b: Distant metastasis including the abdominal
metastasis or inguinal lymph nodes.

Management
Stage 1
Primary treatment is surgery. Ie total abdominal hysterectomy
and bilateral salpingo-oophorectomy with sampling of the
peritoneal fluid for cytology.
NB
Patients with stage 1 disease who are unfit for surgery can be
treated effectively with radiation (radiotherapy)
Stage 2
 Surgery
 Adjuvant radiotherapy
Stage 3 and 4
 Systemic therapy
 Chemotherapy or
 Hormonal therapy
 Radiotherapy
Complications of treatment
 Uterine perforation may occur during D&C or an
endometrial biopsy.
 Intrauterine adhesion may occur as result of D&C
 Infertility