Common Gynecologic Procedures

1. Bimanual pelvic examination
Two fingers are placed in the vagina and the flat of the opposite hand is placed on the lower abdominal wall. Gentle palpation and manipulation should delineate the position, shape, mobility, tenderness, and size of the uterus and adnexal structures.

Indications: It is a part of routine pelvic exam and part of investigation for gynecologic pathology. Tenderness may be elicited on direct palpation or on movement/ stretching of pelvic structures (i.e. acute salpingitis or pelvic inflammatory disease [PID])

Drawbacks: Difficult to elicit any information on obese patients or uncooperative patients.

2. Cervical conization
It is a surgical procedure that involves excising a cone-shaped sample of tissue that includes the entire cervical transformation zone and a portion of the endocervical canal. The sample is then examined for any signs of malignancy.
Conization can be performed using a knife (cold knife cone), laser excision, and electrocautery (large loop excision of the transformation loop electrosurgical excision procedure.

Indications: It is used for either diagnostic or therapeutic reasons. The test is done when results of a cervical biopsy indicate precancerous cells in the area or cervical cancer. It may also be done if the cervical biopsy has not revealed the cause of an abnormal Pap smear.

Complications: An early complication is excessive bleeding. Infrequent complications include cervical stenosis or incompetence.

Important Definitions Used In Gynecological Practice.

Menarche – first menstrual period.

Menopause – date of final menstrual period. This can only be defined with certainty after a year has elapsed since the final menstrual period. It is also useful to ask about menopausal symptoms and hormone replacement therapy (HRT) use. The classic menopausal symptom is vasomotor flushes, but a myriad of other symptoms can also be experienced.

Perimenopause – the years of transition where irregular cycles occur. For most women, this lasts for 4 years before the final menstrual period occurs.

Menorrhagia – heavy periods. This is one of the commonest reasons that women are referred to gynecology.
You should ask for how long and how often bleeding occurs. The passage of clots and flooding through sanitary protection are signs that the menstrual flow is excessive. It can also be useful to ask about frequency of changing sanitary protection and whether ‘double’ protection is required, that is, having to wear a sanitary towel and tampon at the same time.

Abnormal Bleeding
Postcoital bleeding – bleeding occurring after intercourse.
Intermenstrual bleeding – bleeding between periods.
Postmenopausal bleeding – bleeding more than one year since LMP.

Irregular Bleeding
Primary amenorrhoea – failure to menstruate by age 16.
Secondary amenorrhoea – no menstruation for 6 months after periods are established.
Oligoamenorrhoea – infrequent, erratic periods.

Remember that anovulatory cycles occur at the extremes of menstrual life. It is therefore physiological to have erratic infrequent periods in the first few years after menarche and in the perimenopause.

Hyperemesis gravidarum - A Brief Discussion

Hyperemesis gravidarum: This is defined as persisting vomiting in pregnancy which causes weight loss (>5% of pre-pregnancy weight) and ketosis.

Incidence: It affects 1% of pregnant women.

Risk factors; Risk is increased in

• Very young, 
• primigravida, 
• working outside home, 
• preexisting diabetes, 
• hyperthyroidism, 
• psychiatric illness, 
• family history, 
• those with previous eating disorders and 
• multiple or molar pregnancy 

Clinical Presentation

• Inability to keep food or fluids down; 
• weight loss (2–5 kg)with or without nutritional deficiency, 
• dehydration, 
• hypovolaemia, 
• tachycardia, 
• postural hypotension,
• electrolyte disturbance with hypokalaemia and hyponatraemic shock,
• polyneuritis (B vitamins defeciency), 
• behaviour disorders, 
• liver and renal failure in severe cases.  
• There may be ptyalism (inability to swallow saliva) and spitting.

Workup

Bartholin gland Abscess

Introduction: Bartholin glands are locate on either side of the lower third of the vaginal introitus near the labia minora.
A cyst or abscess may result from an obstructed duct, often secondary to trauma or inflammation. Infection of the cyst is usually with mixed vaginal or fecal flora (Escherichia coli) but may also contain N gonorrhoeae and Chlamydia trachomatis.

Clinical Features: Cysts or abscesses may be asymptomatic or may lead to increasing pain, swelling,
an dyspareunia. A tender, fluctuant cystic mass with surrounding labial edema is easily appreciate on examination.

Differential diagnosis: Differentials should include

• epidermal inclusion cysts and sebaceous cysts of the labia majora, 
• hidradenitis suppurativa, 
• vulvar hematomas, 
• leiomyomas, 
• lipomas, and 
• fibromas.

Ultrasound Screening For Fetal Anomalies

Routine first trimester dating scanning has a number of benefits like
(1) it is more accurate at assessing gestational age than menstrual periods, and therefore reduces the
rates of induction of labour for post-term pregnancies
(2) detects multiple pregnancies early in pregnancy and
(3) can detect some major structural anomalies such as anencephaly.

Nuchal scan or Nuchal translucency (NT) scan: A  more detailed, although limited, anomaly scan is incorporated into a nuchal scan or nuchal translucency (NT) scan which helps in determining the basics such as

• the shape of the fetal skull, 
• presence of nose, hands and feet and 
• presence of stomach and bladder. 

Therefore, instigation of Down’s syndrome screening strategies such as the Combined or Integrated test which involve an NT scan are likely to not only increase the detection of aneuploidy but also major structural anomalies and particularly cardiac defects earlier in gestation.

Routine Second Trimester Ultrasound Screening For Fetal Anomalies 
In the UK and most of the other countries around the world. there is a policy of routine second trimester ultrasound screening for fetal anomalies .
However, detection of fetal anomalies varies considerably depending on the anomaly being screened for as well as the gestation at screening, the skill of the operator and the quality of the equipment used.

The detection of cardiac anomalies is of particular interest. Early prenatal detection of congenital heart disease (CHD) has increased due to advances in ultrasound resolution and the incorporation of at least a 4-chamber cardiac view in the routine anomaly scan.

Common Obstetric Procedures

1. Amniocentesis
Withdrawal of fluid from the amniotic sac to obtain fluid and cells for a variety of tests.Usually performed using ultrasonographic guidance to reduce the risk of fetal loss.

Indications: Determine the presence of genetic diseases (e.g., Down syndrome, Tay-Sachs), any fetal structural abnormalities (neural tube defects), fetal lung maturity, or intrauterine infection (i.e., chorioamnionitis)

Risks : 0.5% risk of fetal loss because of bleeding, infection, preterm labor or fetal injury.

2. Cerclage
It is the placement of a suture into and around the cervix to hold it closed. It is usually performed between 12 and 14 weeks and removed before labor begins.

Indications: Used to prevent cervical opening in an incompetent cervix and prevent preterm delivery or miscarriage.

Benefits: It is controversial whether a cerclage reduces the likelihood of a preterm delivery.

3. Cesarean delivery
It is the delivery of the fetus by making an incision through the abdomen and uterus. The incision can be made in two ways:

• (1) Classical midline longitudinal incision
• (2) Lower uterine segment section—transverse cut above the bladder; more commonly used and less bleeding