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PLACENTA AND FETAL MEMBRANES



PLACENTA
  • Development
  • Gross anatomy
  • Structures
  • Functions
  • Abnormalities

DEVELOPMENT

1.Chorionic frondosum- fetal part the major component
2.Decidua basalis- maternal part the minor component

Begins at 6th weeks of gestation
Ends at 12th weeks of gestation

Anatomy
  • Normally situated at or near fundus of uterus
  • Shape- discoid
  • Size- 15*20 cms, 2.5cm in thickness in centre
  • 500gms in weight
  • Two surfaces

1.Fetal- smooth, amniotic membrane, cord insertion and branching vessels.
2.Maternal- irregular,15-20 cotyledons,

Fetal surface

Maternal surface


Structure




Functions
  1. Nutrition
  2. Respiration
  3. Excretion
  4. Barrier
  5. Hormonal- CRH, GnRH, TRH, GHRH, ACTH, hCG, hPL, hCT
  6. Immunological- placental hormones, proteins(SP1), early pregnancy factor(EPF), steroids and hCG

Abnormal placenta

One or more smaller lobes of placenta placed at varying distances from placental margin.

Smaller chorionic plate than basal plate.


Cord Abnormalities

The cord is attached to the membranes.

The cord is attached to the margin of the placenta.



FETAL MEMBRANES
  • CONSISTS OF 2 LAYERS

CHORION

AMNION

FUNCTIONS OF MEMBRANES

1.PRODUCES AMNIOTIC FLUID

2.PREVENTS FETUS FROM INFECTIONS

3.HELPS IN CERVICAL DILATION IN LABOR

4.PRODUCES PGE2, PGF2alpha

PHYSIOLOGICAL CHANGES IN PREGNANCY


Various systems affected
  • Reproductive organ changes
  • Cardiovascular changes
  • Hematological changes
  • Respiratory changes
  • Changes in urinary system
  • Endocrine organ changes
Reproductive organs
  • Vagina
  • Cervix
  • Uterine corpus
  • Breast

Vagina

  • Increased vascularity and hyperaemia of mucosa
  • Increased thickness of mucosa, increased loosening of connective tissue, hypertrophy of muscles -increase in length and distensibility

  • Increased vaginal secretions, acidic medium with increased lactobacillus

Cervix

Pronounced softening and cyanosis –after a month of pregnancy (Goodell’s sign)
- increased vascularity & edema
- cervical glandular hypertrophy /hyperplasia
- rearangement of collagen with decrease in mechanical strength at term
Thick mucus – bloody show at labour

Uterus

Hypertophy and dilatation
normal 70gm ----------------10ml cavity
pregnant 1100gm -------------5litres
Increase in size is contributed by
muscle hypertrophy, hyperplasia, stretching
increased vasculature/lymphatics
Firm uterus –> soft in early pregnancy -> distensible muscular sac in late pregnancy

  • Change in size & shape
pear shaped –> almost spherical at around 3rd month-> oval in shape in later pregnancy
Size : hens egg at 6 weeks
cricket ball at 8 weeks
Asain pear at 10 weeks
out of pelvis after 12 weeks

  • Dextrorotation ? Due to rectosigmoid on the left side

Change in contractility
painless contractions from as early as first trimester
detectable by second trimester ( Braxton Hicks)
painful, regular, increasing in intensity and frequency – labour

  • Uteroplacental flow
uteroplacental flow is increased in pregnancy
450-750ml/min late in pregnancy. This is required to maintain an adequate placental perfusion.
  • Endometrium
Decidual reaction –3 layers differentiation
trophoblast formation

Isthmus

  • Hypertrophy ,elongation in first trimesterto three times its length
in second tri- gradually taken up and incorporated into the uterine corpus.
The circular muscles in region act as sphincter

Respiratory changes

ANATOMICAL

* diaphragm rises by 4 cm
* compensatory increase in thoracic transverse diameter by 2 cm
* Increase in circumference of the thorax

Pulmonary function
  • Respiratory rate – relatively no change
  • Vital capacity (3.2L) – almost unaltered
  • Pulmonary vascular resistance is decreased (Progesterone effect)
  • Residual volume – decreases by 20%
  • Tidal volume (485ml) _ increases by 40%
  • Airway conductance is increased, oxygen requirement is increased

Respiratory

Increased respiratory effort (dyspnoea)
arterial PCO2 is decreased and O2 is increased
facilitates O2 transfer to fetus

Respiratory diseases may worsen in pregnancy as O2 requirement in pregnancy increases

Urinary system

Kidney:
increase in size by 1 cm
dilatation of pelvis, calyces and ureter
GFR (50% increase) increases throughout pregnancy
renal perfusion increases by 25-50% in early pregnancy
So serum urea and creatinine values decrease in normal pregnancy.
Urine
  • Glycosuria- decrease in renal threshold,
persistent glycosuria – possibility of DM

  • Proteinuria - not evident in pregnancy
except in slight amounts after labour/puerperium

  • Hematuria – UTI, difficult labour, instrumental delivery

Ureter

Hydronephrosis and hydroureter due to effect of progesterone
RIGHT SIDE more than left
* cushioning by the sigmoid colon on the left
* right ovarian vein crosses the ureter obliquely
Elongation , angulation and lateral displacement of ureters by gravid uterus
Comes back to normal in 6 – 8 weeks post partum

Bladder

Few changes before the 4th month
Gravid uterus, pelvic congestion - causes
bladder trigone to be elevated, thickening of interureteric ridge and also rest of bladder,
increased tortuosity and size of vessels in mucosa
In late pregnancy, especially engaged head pushes base of bladder forward increasing the congestion , oedema and increase susceptibility to trauma and infection.
Post delivery esp vaginal – stress incontinence by urethral sphincter damage

CARDIOVASCULAR

ANATOMICAL

Heart is elevated and rotated towards left- causes apex to move more lateral and cardiac silhouette to appear larger

HEART SOUNDS

Splitting of first sound
Third sound heard loudly
Systolic murmur in 90% cases - disappear shortly after delivery
Continuous murmur (10%) – b/o increase in breast vasculature
ECG –left axis deviation

Cardiac output

Increase due to increase maternal weight, blood vol. increase, increased BMR
CO = SV X HR (minimal change)
Starts from early pregnancy (10weeks), increases cont upto 28weeks –
Max at 32 weeks – slight decrease towards term - increase in labour – decreases in postpartum
CO 4.5L - 6.2 L in pregnancy(30-40%)

CV changes

Blood pressure – remains same due to decrease in peripheral resistance
Mid pregnancy drop of 5-10 mmHg can occur due to pooling of blood in uteroplacental circulation.
More marked in hypertensives
Towards term –supine hypotension – gravid uterus compresses IVC – decreases venous return -hypotension

Venous system – pressure by gravid uterus and progesterone
- distensibility of veins
|
pedal oedema,varicose,haemorrhoids
thrombosis
Circulation – increased blood flow to uterus, kidneys, skin & lungs
In uterus 50ml /min in non pregnant to 750ml/min at term

Haematological changes

Blood volume : increases by 40%
* meet demand of increased uterus
* protect mother and fetus against deleterious effects of decreased VR
* safeguards the mother against effects of blood loss in delivery

Blood volume - increased plasma volume (40%)
- increased RBC volume (33%)


Haemodilution-
mean Hg falls from 13.3gm/dl in non preg to 10.9g/dl in pregnant .

<11gm/dl of Hg – anaemic
Hypercoagulable state
increase in plasma fibrinogen ,with increased rouleaux formation, decreased fibrinoltic activity


Haematological
  • WBC increased - 5 to 12000/cmm in pregnancy
14-16000/cmm in puerperium
even up to 20000/cmm

  • ESR increases (x4 times)

  • Blood protein : serum albumin level decreases by 30 % . Plasma protein conc decreases –decreased colloidal oncotic pressure

Iron metabolism

Iron content is decreased – increased erythropoiesis & increased transfer to fetus
Total iron needed
Increase in RBC (450ml) = 500mg
transfer to fetus = 300mg
insensible loss = 200mg
Total = 1000mg
Compensatory efforts are not sufficient

Metabolic changes
  • Weight gain : total about 12.5kg
  • 1 lb/week after 20 weeks

Water metabolism
  • Fundamental change in pregnancy is fluid retention.
  • Total about 6.5L of fluid is retained




Protein metabolism
  • Protein gain in pregnancy
500gm –fetus /placenta
500gm – contractile proteins, breast, Hb and plasma proteins
Protein supplementation in diet is needed, but along with carbohydrate & fat

Carbohydrate metabolism
  • Potentially diabetogenic
mild fasting hypoglycemia
post prandial hyperglycemia
hyperinsulinemia

All this to ensure a maintained supply of glucose to fetus
Insulin resistance could be due to ? Insulinase enzyme

Endocrine changes
  • Pituitary
increase in size
increase in GH – weight gain in preg
increased ADH and oxytocin
leading to oedema of pregnancy

Thyroid gland
  • Increase in size –hyperplasia of gland
  • TSH increase which causes hyperplasia, increase in BMR beginning from the third month
  • Increased Estrogen- increased TBG conc and binding capacity- increased serum protein bound iodine and Increase in circulatory T 4 and T 3

Adrenal gland

  • Slight increase in size-mainly cortex
  • Increase in level of serum cortisol, aldosterone
  • which could be responsible for the edema of pregnancy
Important Questions:


Q1.During CS, anaesthetist puts the patient in the left lat position. Why?

Answer: Supine Hypotension

Q2.In a heart dis prgnant patient –most dangerous time is ?

Answer: Second stage of labor

Q3.USG done in a pregnant woman at 30 weeks shows hydronephrosis ? What will you do?

Diagnosis of pregnancy

How to diagnose pregnancy in first trimester.
  • symptoms
  • signs
  • investigations

First trimester

Symptoms :
  • amenorrhoea
  • morning sickness
  • increased frequency of micturition
  • breast discomfort : feeling of fullness

Signs of pregnancy in first trimester

Breast changes :

in 6—8 wks;
  • Enlargement & vascular engorgement;
  • Nipple & areola more pigmented;
  • Montegomery tubercles become more prominent
Per abdomen - Uterus not felt per abdomen till 12 wks

Pelvic changes

Jacquiemer or chadwick sign : it is the dusky hue of vestibule & anterior vaginal wall visible at about 8th wk

Vaginal sign: sofetning of vaginal walls, there is increased pulsation felt through lateral fornices at 8th wk called osiander sign

Cervix becomes soft with bluish hue as early as 6th wk called goodell sign.

Uterine signs:

  • On per vaginal exam
  • Size of Hens egg :6th wk
  • Cricket ball :8th wk
  • fetal head: 12th wk


Hegar sign :

between 6—8 wks
  • Upper body of uterus is enlarged by growing fetus and lower part is soft & elastic.
  • The cervix is firm
  • So on bimannual exam the abdominal and vaginal fingers oppose below the body of uterus ( two fingers in anterior fx and abdominal behind the body of uterus)


HCG
  • GLYCOPROTEIN
  • Half life is 24 hrs
  • Detected in plasma of pregnant women about 7 --9 days after the midcycle surge of LH that precedes ovulation.
  • Increase to about 100 iu\ml between 60th-80th days after the last menses
  • Beginning at about 10—12 wks the level of HCG in maternal plasma decline, a nadir being reached by about 20 wks.the level then is maintained at this low level for the remainder of pregnancy.

Agglutination inhibition test:
  • one drop of urine + one drop of solution that contains hcg antibody.
  • If hcg is not present in the urine the antibody remains free.
  • Now one drop of another soln that contains latex particles coated c hcg is added
  • So the pregnancy test is negative if there is agglutination
  • If hcg is present then it would bind the available antibody so there wont be agglutination when the latex coated particles c hcg are added. So no agglutination means pt is pregnant.

Immunological tests

  • Agglutination inhibition tests ( urine)
Sn: 0.5—1 iu\ ml
absence of agglutination
positive on 2 days after missed period
  • !Direct latex agglutination test urine)
Sn : 0.2 iu\ml
presence of agglutination
positive on 2—3 days after missed period

  • Membrane elisa \ card test (urine)
Sn : 30—50 miu\ml
on the first day of missed period
  • Elisa test
Sn : 1—2 miu\ml in serum
5 days before the missed period
  • ! Radioimmunoassay ( beta subunit) in serum
Sn : 0.002miu\ml
25th day of cycle

Ultrasonography

TVS
  • GS & yolk sac 5 menstrual wks

  • fetal pole & cardiac activity : 6 wks

  • CRL used between 7—12 wks








How to diagnose in second trimester ?

Second trimester

Symptoms :
  • amenorrhoea
  • quickening : perception of active fetal movements by the mother
  • progressive enlargement of lower abdomen

General examination:

Chloasma: pigmentation over forehead and cheek at 24 wk

Breast changes:
More enlarged and prominent veins under skin
Secondary areola usually appear at about 20 wks
Striae visible
Montegomery tubercles are prominent

Abdominal exam:
  • linea nigra
  • striae

Palpation:

  • fundal height
  • uterus soft & elastic
  • braxton hicks contractions
  • palpation of fetal parts by 20th wk
  • active fetal movements as early as 20th wk
FHR :
  • as early as 20th wk
  • uterine suffoule is heard

VE :
bluish discolouration of vulva, vagina & cervix- more evident





Investigations :

USG

How to diagnose in third trimester ?

Third trimester

Symptoms :
  • amenorrhoea
  • enlargement of abdomen
  • lightening at about 38 wks
  • frequency of micturition reappears
  • fetal movements
Signs :
  • Cutaeneous changes more prominent
  • Increased pigmentation & striae
  • Uterine shape is changed from cylindrical to spherical
  • Fundal height
  • Braxton hicks contraction more evident
  • Fetal movements easily felt
  • Fetal parts easily palpable
  • FHR


Differential diagnosis of pregnancy

  1. Distended urinary bladder
  2. Uterine fibroid
  3. Cystic ovarian tumour
  4. Haematometra (???)
  5. Encysted tubercular peritonitis

Anatomy of Female Reproductive System

Case: A 27 year old lady comes to your clinic with complaints of pain abdomen for 2 days and nausea and vomiting for 5days which is more in the morning. She also complains of increased frequency of micturition for a week. Her last menstrual period was 6 weeks back. On examination you find no abnormality except for slight breast tenderness. Per speculum and per vaginal examinations are normal. What investigation would you like to order the first?

Introduction

External genitalia
Internal genitalia
Vessel and nerve and lymph
Adjacent organs
Pelvis
Pelvic floor

External genitalia

Labia majora
  • The venous drainage is extensive and forms a plexus with numerous anastomoses. Vulva hematoma
Vaginal vestibule
  • Bordered by the labia minora laterally, by the urethra and clitoris anteriorly, by the hymenal ring inferiorly.

Internal genitalia





Vagina

1.Strong canal of muscle (7.5cm)
extend from the uterus to the vestibule of the external genitalia. its long axis is almost parallel with that of the lower part of the sacrum. the anterior wall of the vagina is 1.5-2cm shorter than the posterior wall.

2.vaginal fornix
the circular cul-de-sac formed around the cervix
4 regions: the anterior fornix, the posterior fornix and 2 lateral fornices.

Wall structure
  • mucosal layer (stratified squamous epithelium)
  • submucous area ( with a dense plexus of veins and lymphatics)
  • muscular layer (3 layers)





  • Uterus
Pear-shaped,thick-walled, muscular organ





Body and cervix:
Babyhood 1:2, manhood 2:1

Isthmus uteri
connect the body to cervix, 1cm (non-pregnancy)

Layers of uterine wall

The serous layer (perimetrium)
  • Thin and firmly adherent over the fundous and most of the body
  • Uterovesical pouch of the peritoneum
  • Rectouterine pouch of the peritoneum (pouch of Douglas)
The muscular layer
  • Outer layer (longitudinal fibers)
  • Inner layer (interlaced and various directions)

The mucous layer (endometrium)

  • Compact layer: response to hormones periodically, a single layer of ciliated columnar epithelium

  • Spongy layer: response to hormones periodically. contains many tubular glands

  • Basal layer: single layer of cells, no response to hormones periodically


Cervix
  • lower 1/3 of uterus. connects uterus to vagina via endocervical canal
  • External os: opening of endocervical canal to ectocervix
  • Internal os: indistinct upper limit of endocervical canal


Ligaments
  • Broad ligament
  • Round ligament
  • Cardinal ligament
  • Utero-sacral ligament

Oviduct
Anatomy
Interstitial portion:
Isthmic portion: narrow
Ampulla: wide and tortuous
Fimbria: funnel-shaped mouth

Layers of wall
  • Serous
  • Muscular: outer longitudinal and inner circular
  • Mucous: ciliated columnar epithelium, coarse longitudinal folds

Ovary
Anatomy
Paired organ, elliptic
The suspensory ligament of the ovary
The ovarian ligament

Structure of ovary

  • Covered by cuboid or low columnar epithelium
  • Consist of a cortex and a medulla
  • Cortex: oocytes in various stages of maturity.
  • Medulla: fibers, smooth muscle cells, blood vessel, nerves.


Vessel and lymph

Blood vessel

1.The ovarian artery
  • Orginated as branches of the abdominal aorta, (vein left: left renal vein).
  • Turn over the common iliac artery and ureter,descend into the pelvis. Enter into ovary through the mesovarium

2.The uterine artery
  • a terminal branch of the hypogastric artery
  • Cross the ureter near the cervix (2cm)
  • Ascend along the lateral border of the uterus
  • uterine body branch and cervix-vagina branch

Vaginal artery
Internal Pudendal artery

Lymph
  • External genitalia
  • superfical inguinal gland
  • deep inguinal gland
Pelvic lymph

1.iliac lymph
internal iliac and external iliac, common iliac
2.Anterior Sacral lymph
3.Lumbar lymph: abdominal aorta


Adjacent organs
  • Urethra
  • Urinary bladder (uterovesical pouch)
  • Ureter (Water under the bridge)
  • Rectum (rectouterine pouch or pouch of Doughlas)
  • Vermiform appendix
Pelvis

  • Bony pelvis (True and False pelvis)


  • Joints


Ligaments

1.Sacrospinous ligament
Extend from the lateral border of the sacrum and coccyx to the spine of the ischium
2.Sacrotuberous ligament
Extend from the posterior aspect of the lower 3 sacral vertebrae to the ischial tuberosity



Pelvic divisions (iliopectineal line )

1.False pelvis (pelvis major)
2.True pelvis (pelvis minor)

True pelvis is located below the iliopectineal line, bounded anteriorly by the pubic bones, posteriorly by the sacrum and coccyx, laterally by the ischium and a small segment of the ilium.

Bony birth canal
the Pelvic inlet, the pelvic out let and the pelvic cavity


Types of pelvis

1.The gynecoid type
round, slightly ovoid or elliptical inlet, adequate sacrosciatic notch, wide interspinous diameters(≥10cm). 52%-58.9%

2.The platypelloid type
distinct oval inlet. very wide subpubic arch. 5%

3.The anthropoid type
long, narrow, oval inlet, extended and narrow anterior and posterior segments, wide sacrosciatic notch, long , narrow sacrum. Straight side walls. 25%

4.The android type
elliptical inlet, equal anterior and posterior segments with slightly narrow anterior segment. 20%


Pelvic floor

  • The tissues closing down the pelvic outlet (muscles and fasciae)
suspend and support the pelvic organs, such as uterus and bladder and rectum
  • anterior part (urogenital triangle)
urethra and vagina pass through
  • posterior part (anal triangle)
rectum pass through

Tissues

Outer layer

Bulbocavernosus muscle
Ischiocavernosus muscle
Superficial transverse perineal muscle
External anal sphincter

mid layer

urogenital diaphragm

Inner layer (pelvic diaphragm )

  • the main support of the pelvic floor
  • formed by the levator ani and coccygeus muscles and covering fasciae.
  • Levator ani: pubococcygeus , iliococcygeus, pubovaginalis


Perineum

the tissues between vagina and anus.

Vaginal Discharge

    General Consideration

    Discharge per Vg
    Color - White, Creamy, Yellow, Greenish

    Physiological Discharge

    slight discharge
    • Due to Ovarian function ( mid cycle )
    • Normally seen in the vulva and vagina
    • Secretion from bartholins, sebaceous, sweat & apocrine glands
    • Vaginal mucosa
    • Cx secretion
    • Fallopian tube sec

    Amount
    • Comfortably moist
    • No enough to stain the under clothing
    • Premenstrually increase amount.
    • During preg.
    • Sexual excitement – bartholin’s gland sec

    Leucorrhoea

    (Running of white substance)
    More than normal amt.
    • Mainly Cx component
    • Fresh color— creamy
    • Dries color – brownish
    • Micros- mucus, epith debris, organisms, leucocytes

    • Stain clothes

    • Vulva soreness

    • Never cause – pruritus, and offensive odour

    • fear of cancer and STD

    Causes of leucorrhoea

    non pathological

    When the normal vg secretion increases

    Physiologically ↑in puberty, preg, at ovulation, premenstrually

    • Active or passive congestion of the pelvic organs esp. Cx.
    • Prolong ill health
    • Anxiety states
    • Neurosis
    • Sedentary occupation ( prolong sitting )
    • Standing for long period in hot atmosp.

  • ↑ Glandular elements in the Cx
  • OCP ( oral contraceptive pills)
  • Due to develop. of ectopy on the Cx
  • Regular douching (misconception of genital hygene)

  • Discourage Regular Douching
    • Regular douching does not improve genital Hygene

    • Washing away naturally protective lactobacilli

    • Altering the Vg pH, invite infection

    Inflammatory Discharge

    Infection
    • Mucopurulent or frankly purulent
    • Cream to yellow color
    • Offensive esp. coliform bacilli
    • Microscopically – pus cells
    • Lesions – vulvovaginitis, cervicitis,
    • endometritis

    VD
    Reproductive Tract Inf. (RTI)

    STI infection.
    Chlamydia, Gonococcus, Trichomonas


    Non STD
    Bacterial Vaginosis,
    Candida ( Vg yeast inf. Candidiasis or Moniliasis) fungus

    Vuvovaginitis

    Gonococcus

    Trichomonous vaginalis

    Candida albican

    Bacterial vaginosis

    Cervicitis

    Goococcal

    Chlamydial

    Anaerobic

    Secondary infection in puerperium

    Bacteria Vaginosis ( BV )
    • Alteration of normal Vg Bacteria flora
    Loss of acid producing lactobacilli
    Overgrowth of predominantly anaerobic
    bacteria

    Dx of BV

    1. Fishy Vg odour noticed following intercourse with Vg discharge
    2. Grey colour, coated the Vg wall
    3. pH 4.5 to 5.7
    4. Microscopically ↑ No. of clue cells
    5. Vg secretion + KOH →fishy ,amine like odour (Whiff test)


    Treatment of BV

    for anaerobic ( not for lactobacilli)

    Metronidazol
    • 400 mg PO tds X 7 days or
    • Single oral dose 2 gm stat

    Cure rate 75- 84 %

    2% clindamycin cream HS X 7 days
    (vaginally )
    OR
    Orally clindamycin 300mg BD x 7 days


    Trichomonial Vaginalis
    • STD
    • Flagellated parasite anaerobic
    • Often accompany BV




    Clinical features
    • Profuse purulent discharge
    • Green color
    • Vulva pruritus
    • Vg erythema
    • Strawberry Cx
    • Saline drop + discharge drop – motile org
    • Mertonidazol – tinidazol -95% effective
    • Partner should be treated

    Vulvovaginal candidiasis (moniliasis)- yeast inf.
    • Candida albican
    • Curdy white
    • adherent discharge
    • Erythematous Vg

    Common in---
    • Pregnancy
    • Diabetes
    • AB users



    Treatment

    Topical cream clotrimazol or nystatin

    Oral antifungal- fluconazol 150 mg single dose

    Investigation

    History,
    Clinical examination

    Any Vg discharge that is frankly purulent and contain pus cells should be considered to be due to specific Vg infection

    Chlamydia Trachomatis
    • Most common of all bacterial STIs
    • Abnormal Vg Ds
    • Silently destroys Fallopian tube
    • If untreated, PID, Infertility, ectopic

    Rx:
    Doxycyclin 500mg po bd for 7 days
    OR
    Azithromycin 1gm po stat

    UTERINE PROLAPSE


    “I had just given birth to my first child and was working in the fields near my village. Suddenly I felt as if my insides were dropping out of me,” the 66-year-old recalled Baffled by what had happened, she told no-one - not even her husband – hoping the problem would go away. But over the years, her prolapsed uterus got worse, to the point that it protruded from her vagina completely, making it difficult for her to walk or even sit upright. She required surgery; a fact prompting this uneducated mother-of-five to finally seek help.

    UTERINE PROLAPSE

    Definition
    • Protrusion of uterus into and out of the vagina from its normal position
    • The pelvic structures are divided into 3 compartments : anterior, middle and posterior
    • Anterior : urethra /bladder
    • Middle : uterus/vault
    • Posterior : rectum/anus

    Prolapse
    • According to the structure underlying it the prolapse is termed as urethrocele
    cystocele
    uterine prolapse
    enterocele
    rectocele
    vault prolpase

    Degree of prolapse
    • First degree: slight descent of uterus from its normal position but still within the vagina
    • Second degree: descent of uterus upto the introitus
    • Third degree: protrusion of part of the uterus out of the introitus.
    • Procidentia : when the whole of the uterus prolapses out of the introitus.The whole vagina or at least the whole of its anterior wall is inverted




    Normal supports
    • Axis of the uterus and vagina: anteverted and anteflexed
    • Uterus projects into the ant wall of the vagina at an angle so uterus is not in axis with the vagina.
    • upper and lower vagina also meet at an angle of 130degree such that the upper half rests on the levator plate


    Normal axis of uterus/vagina and the levator plate

    Normal anatomy
    • Supports of the uterus /vagina
    Bony cage
    ligaments : Mackenrodts ligament,uterosacral ligament, pubocervical ligament,broad ligament, round ligament
    Fascia: endopelvic fascia, Fascia of Denonvillier
    Muscles : levator ani and sacrococcygeus (pelvic diaphragm)
    urogenital diaphragm

    Supports

    The muscles of the pelvic floor form the MAIN support of the uterus and vagina .The normal resting tone and voluntary intermittent contraction ,along with contraction of the bulbocavernous muscle constrict the vaginal lumen and elevate the ant. vaginal wall. This is the basis for the Kegel’s exercise.

    Levator plate is the median raphe between the anus and the coccyx: the shelf on which the pelvic organs rest. Laxity of this plate leads to prolapse

    Muscles of the pelvic floor



    Consequences



    Aetiology

    Congenital : Ehler Danlos Syndrome associated with connective tissue defects; congenital elongation of the cervix

    Obstetric : excessive stretching, tearing ,nerve damage that can occur in pregnancy/labour

    Menopausal

    Iatrogenic : post major surgeries like vaginal and TAH, abdominoperineal resection of rectum etc

    Aggravating factors

    Chronic constipation, heavy exercise, obesity, chronic cough, weightlifting and pelvic tumours all aggravate the already weak supports

    Presentation
    • Degree of prolapse bears little relationship to the presenting complaint
    • 80% present with complaint of something coming down per vagina
    • dragging or bearing down sensation
    • backache > on standing, progresses towards the day, relieved on lying down
    • difficulty in coitus
    • Discharge PV
    • tenesmus and constipation sometimes relieved by digital reduction of prolapse – rectocele
    • frequency ,incomplete voiding, dysuria, stress incontinence- cystocele

    Examination
    • vulva examination : laxity of introitus, prolapse type and degree, atrophy changes, ulcer and discharge, rectocele, urethrocele and cystocele
    ask patient to cough or strain : stress incontinence
    check whether 3rd degree or procidentia,pinch tissue at introitus

    PV examination: size of uterus, degree of decent, levator tone, any associated pathology. Diagnose enterocele

    Investigation


    • No specific investigation for diagnosis


    • Most of investigation aaimed at ruling out aggravating factors or complications
    eg Urine RE and culture, IVU
    chest Xray
    swab from discharge
    biopsy of non healing ulcer
    pap smear
    endometrial biopsy in case of bleeding PV



    Management

    EXPECTANT
    PESSARIES
    SURGERY

    Expectant
    • Cases with mild prolapse ,those diagnosed during gynecological examination with minimal or no symptoms
    • inform patient of condition

    • pelvic exercise

    • aggravating factors treatment

    • HRT in menopausal women

    Pessaries
    • Used as early as 2000BC by Egyptians
    • Various types have been used over the century
    • Main purpose is to stretch the vault and hold the uterus up. Some amount of inherent tone is needed for the ring to remain in place
    • Ring Pessary commonly used : rubber
    • changed every 3 monthly
    • temporary method of treatment

    Types of pessaries


    pessary
    • If patient refuses surgery
    • Patient medically unfit for surgery
    • Temporary measure while patient waits for surgery
    • Ulcer : helps in healing of the ulcer
    • in pregnancy : early pregnancy
    • in puerperium
    Its use is not without problems

    Surgery
    • Type of surgery depends on the reproductive goal, age of patient , surgical fitness, type of prolapse and severity, need for preservation of coital function, assocaited other pelvic disease
    • symptomatic cases especially those with mod to severe degree of prolpase

    uterus preserving

    anterior colporrhapy
    post colpoperineorraphy
    Manchester Operation
    Colpocleisis
    Le Forts Operation
    Sling operations

    Fothergill or Manchester operation


    • Dilation and curretage
    • anterior plication of the cardinal ligaments
    • amputation of cervix and reconstruction
    • ant colporraphy
    • PFR
    ideal in women with congenitaly elongated cervix


    Lefort operation:

    rectangular folds of vaginal wall from ant and post wall are removed and the raw surfaces are sutured together
    can even be done under LA ,suitable in old medicaly unfit lady with prolapse

    Colpocleisis : concentric sutures placed in vagina which is used to close the vagina and so hold up the prolapse

    Sling operations

    • for young women with severe prolapse who want to conserve the uterus
    • objective of operation is to buttress the weakened supports of the uterus with substitutes like fascial or synthetic material.
    eg : sacrohysteropexy: post junction of uterus and cervix is attached by mesh to the ant longitudinal ligament of sacral vertebrae
    abdominocervicopexy: musculofascial strips from ant abd wall inserted onto isthmus of uterus

    Operations

    • Uterus is removed

    • Vaginal Hysterectomy with Ant Colporraphy with pelvic floor repair

    PELVIC INFLAMMATORY DISEASE


    DEFINITION

    INFLAMTION OF UPPER GENITAL TRACT ENVOLVING with ascending infection from lower
    genital tract including
    endocervix

    • Endometris
    • Salpingitis
    • Oophritis
    • Parametritis
    • Pelvic peritonitis

    Introduction

    Delays of only a few days in receiving appropriate treatment markedly increase the risk of sequelae, which include:
    1. Infertility,
    2. Ectopic pregnancy and
    3. Chronic pelvic pain.


    AETIOLOGY

    While sexually transmitted infections such as :

    1. Chlamydia trachomatis and
    2. Neisseria gonorrhoeae have been identified as causative agents,
    3. Mycoplasma genitalium,
    4. Anaerobes and other organisms may also be implicated.

    RISK FACTORS

    1. Early age of sexual activity
    2. Multiple sex partners
    3. Sex workers
    4. Use of immune suppressant drugs
    5. Infection with HIV
    6. Drug abuse
    7. Alcoholics
    8. Gynecological procedures like D/Cs

    CLINICAL FEATURES

    Symptoms

    Pain lower abdomen bilateral
    Fever (38.4)
    Vaginal discharge
    Dyspareunia
    Menorrhagia

    SIGNS

    Increase temperature
    Tachycardia
    Abdominal tenderness/rebound tenderness
    Abnormal discharge per vaginum
    Fornicial tenderness
    Cervical motion tenderness

    INVESTIGATIONS
    • Blood :- Hb,TCDC,ESR,Sugar,Urea, grRh,CRP
    • Urine
    • Endocervical Swab for Gm stain and culture, WBC count.
    • Endometrial biopsy
    • USG- Abdominal and vaginal
    • Laparoscopy, peritoneal fluid culture (Gold standard)
    • Laparotomy

    CDC CRITERIA

    Minimum
    1. Cervical motion tenderness
    2. Adnexal tenderness and uterine tenderness
    3. WBCs on wet mount of discharge

    Additional

    1. Fever (> 38°4C)
    2. Abnormal discharge
    3. Raised ESR
    4. C reactive protein
    5. Culture positive swab

    Definitive criteria

    • Histopathologic evidence of endometritis on endometrial biopsy

    • Transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex

    • Laparoscopic abnormalities consistent with PID

    Classification

    • Acute

    • Chronic

    Clinical diagnosis

    Laparoscopy :

    Enables specimens to be taken from the fallopian tubes and the pouch of Douglas and

    Can provide information on the severity of the condition.

    Although Laparoscopy has been considered the gold standard in many studies of treatment regimens, 15–30% of suspected cases may have no laparoscopic evidence of acute infection.

    When there is diagnostic doubt, however, laparoscopy may be useful to exclude alternative pathologies.

    Transvaginal ultrasound scanning may be helpful where there is diagnostic difficulty.

    When supported by power Doppler it can identify inflamed and dilated tubes and tubo -ovarian masses, but there is insufficient evidence to support its routine use.

    Laparoscopic view of normal pelvis






    Oral treatment

    Recommended Regimen A

    Levofloxacin 500 mg orally once daily for 14 days* OR Ofloxacin 400 mg orally twice daily for 14 days* WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

    Regimen B

    Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

    Oral Regimen B

    Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently in a single dose PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

    Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) PLUS Doxycycline 100 mg orally twice a day for 14 days WITH OR WITHOUT Metronidazole 500 mg orally twice a day for 14 days

    Inpatient treatment

    Recommended Parenteral Regimen A

    Cefotetan 2 g IV every 12 hours OR Cefoxitin 2 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours

    Alternative parental Inpatient regimens

    Levofloxacin 500 mg IV once daily* WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours
    OR Ofloxacin 400 mg IV every 12 hours* WITH OR WITHOUT Metronidazole 500 mg IV every 8 hours
    OR Ampicillin/Sulbactam 3 g IV every 6 hours PLUS Doxycycline 100 mg orally or IV every 12 hours

    Inpatient treatment

    Admission to hospital would be appropriate in the following circumstances:
    1. Surgical emergency cannot be excluded
    2. Clinically severe disease
    3. Tuboovarian abscess
    4. PID in pregnancy
    5. Lack of response to oral therapy
    6. Intolerance to oral therapy.



    In more severe cases inpatient antibiotic treatment should be based on intravenous therapy, which should be continued until 24 hours after clinical improvement and followed by oral therapy.

    Treatment in pregnancy

    A pregnancy test should be performed in all women suspected of having PID to help exclude an ectopic pregnancy.

    Treatment in a woman with an intrauterine contraceptive device

    An intrauterine contraceptive device (IUCD) may be left in situ in women with clinically mild PID but should be removed in cases of severe disease.

    Other modes of treatment

    Surgical treatment should be considered in :
    1. Severe cases or
    2. Where there is clear evidence of a pelvic abscess.
    3. Failure of medical treatment

    Laparotomy/laparoscopy may help early resolution of the disease by division of adhesions and drainage of pelvic abscesses.
    Culdotomy
    Ultrasound-guided aspiration of pelvic fluid collections is less invasive and may be equally effective.

    Management of sexual partners of women with PID, which may be sexually acquired

    • If adequate screening for gonorrhoea and chlamydia in the sexual partner(s) is not possible, empirical therapy for both gonorrhoea and chlamydia should be given.

    • Referral of the index patient and her partner to a genitourinary medicine clinic is recommended, to facilitate contact tracing and infection screening.

    Women who are infected with HIV

    Women with PID who are also infected with HIV should be treated with the same antibiotic regimens as women who are HIV negative.