LECTURE HANDOUT

ON

GYNAECOLOGY
{HCM 506}

EVANS [Link]

FIRST SEMESTER
2026.

CODE:GYN 012/19L

1
 CONTENTS
UNIT ONE: GYNAECOLOGY-------------------------------------------------2-4

UNIT TWO: DISORDER OF MENSTRUATION---------------------5-16

UNIT THREE: ABORTIONS-------------------------------------------17-26

UNIT FOUR: ECTOPIC PREGNANCY-------------------------------27-34

UNIT FIVE: INFERTILITY----------------------------------------------35-48

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 UNIT ONE

GYNAECOLOGY

MEANING

This is the study of conditions or diseases that affect the female reproductive system in the life
time of a woman and their management. This however excludes pregnancy, labor and
pueperium

COMMON GYNAECOLOGICAL CONDITIONS

Bleeding before 28weeks of pregnancy; includes;

 Abortion

 Ectopic pregnancy

 Hydatidform mole

 Cervical polyps

 Cervical cancer

 Vaginal discharges

 Tumours

 Pelvic inflammatory disease

 Vesico vaginal fistula

 Rectovaginal fistula

GYNAECOLOGICAL CONDITIONS OF THE VULVA

o Genital warts

o Herpes simplex type 2

o Tumours including carcinomas

o Scaring due to female genital mutilation

o Trauma

o Batholinitis/Batholins abscess

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Imperforate hymen

GYNAECOLOGICAL CONDITIONS OF THE INTERNAL GENITALIA

Vagina

Abnormal vaginal discharge

Vesicovaginal fistula

Rectovaginal fistula

Uterus

Uterine malformations like biconuate uterus

Fibroids Menstrual disorders

Cervical polyps and cancer

Uterine tubes

Ectopic pregnancy

Infertility

Tubal abortion

Salpingitis

Ovaries Ovarian cysts and tumours

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 UNIT TWO

DISORDERS OF MENSTRUATION

IMPORTANT TERMINOLOGIES

PUBERTY

This is the period when the reproductive organs undergo accelerated growth to reach maturity.
The first signs include breast development and appearance of pubic hair. The body grows
considerably and takes on a female shape.

MENARCHE

This is the initial menstruation seen by a girl. The first few cycles may be an ovular (not
accompanied by ovulation) which is due to the unstable hormones. It occurs around 14 16 years
but rarely as early as 9 years or as late as 19 years.

MENOPAUSE

This is complete cessation of menstruation. The cycle first becomes irregular and then stops
completely. This period is also known as climacteric. It marks the end of child bearing age.
Menopause usually occurs around the age of 50 years but it should not be assumed that
climacteric is over until 2 years have elapsed since the last period.

DEFINITION OF MENSTRUAL DISORDER

These are abnormalities in menstruation during reproductive life. Common disorders

associated with menstruation are as follows;

Amenorrhoea

2. Dysmenorrhoea

3. Menorrhagia

4. Metrorrhagia

5. Polymenorrhoea (epimenorrhoea)

6. Dysfunctional uterine bleeding

7. Endometriosis

AMENORRHOEA

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This refers to absence of menstruation in a female during reproductive age.

Types of Amenorrhea

Primary Amenorrhea: This is the failure of menses to occur by 16 years of age. It could be due
to imperforated hymen when she has been menstruating but when blood does not come out.

Secondary Amenorrhea: This is the cessation of menses in a woman who has previously
menstruated. It is regarded as secondary when she takes a period of 6 months and above
without seeing her menses.

Causes

1. Physiological like pregnancy and lactation, during pregnancy the levels of oestrogen and
progesterone remains high thus ensuring the integrity of the endometrium resulting into
amenorrhoea.

2. During lactation- soon after delivery prolactin is secreted in large quantities by the anterior
pituitary. There is partial suppression of LH production so that the ovarian follicles may grow
but ovulation does not occur resulting into amenorrhoea.

3. Hypothalamic dysfunction-such kind of patients have lower levels of follicle stimulating

hormone (FSH) and luteinizing hormone (LH). Several congenital syndromes associated with
abnormal hypothalamic- gonadal function have been described and these conditions present
with primary amenorrhoea and absence of secondary sex characteristics. It is also due to failure
to the development of central structures of hypothalamus.

4. Pituitary disorder, this is associated with elevated levels of prolactin (hyperprolactinemia).

Congenital abnormalities, like imperforated hymen, vaginal septum, no uterus, no

endometrium but with uterus, absence of ovaries, cervical stenosis, and absence of
hypothalamus (kallmann’s syndrome). This is a congenital hypogonadotrophic hypogonadism
disorder characterized by absence of secondary sex characteristics.

5. Change of environment or occupation

6. Fear, anxiety or excitement

7. Pseudomenorrhoea: pseudo means false. Here a woman psychologically thinks that she is
pregnant yet she is not.

8. After hysterectomy or bilateral removal of ovaries

9. Full doses of radiation

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10. Drugs, like contraceptives especially hormonal methods

11. Debilitating diseases like, TB, HIV/AIDS, DM etc

[Link] of the pituitary gland, hypothalamus, ovaries and uterus

13. Early onset of menopause

14. Idiopathic

Diagnosis and investigation

A detailed history taking (history of change in weight, presence of stress, questions about
excessive weight, presence of excessive body or facial hair) and physical examination.

Urine for HCG to rule out pregnancy

Ultra sound scans of the pelvis to visualize the contents or organs of the pelvic cavity.

Blood for hormone analysis to rule out hormonal imbalance.

Computerized tomography (CT) scans to visualize the organs.

MANAGEMENT

This will depend on the cause. It may be medical, surgical, or psychological.

Hyperprolactinaemia is treated by administration of bromocriptine. This is an ergot alkaloid
which directly opposes prolactin secretion. Radiotherapy is reserved for those patients who fail
to respond to medical therapy.

Imperforated hymen is treated by incision and drainage. Very large amount of blood may be
released, and if the septum is particularly thick, some form of plastic operation may be required

DYSMENORRHOEA

These are painful menstrual periods. Nearly 50% of all women have some degree of pain
associated with their periods. About 10% are unable to perform their normal activities because
of this pain.

Dysmenorrhoea can occur at any age, though uncommon in the first 6 months after the onset
of menses and relatively uncommon in the years prior to menopause. The most common ages
for this problem to occur are in the late teens and early twenties.

Cause

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This is due to release of a chemical substance called prostaglandins from the lining cells of the
uterus at the time of menstrual period. The prostaglandin causes contractions of the muscle
wall of the uterus, which are called menstrual cramps.

TYPES OF DYSMENORRHOEA

Primary dysmenorrhoea: This refers to painful menstruation that starts few years after puberty
and usually no exact cause can be identified.

Pre-disposing factors

 Narrow cervical (stenosis), which results into tension during contraction of muscles.

 Reduced blood supply to the endometrium (ischaemia)

 Hormonal imbalance

 Retroverted uterus, that is, when the uterus leans backwards resulting into tension.

 Psycological or social stress, fear or anxiety

Signs and symptoms

Dysmenorrhea is cyclic with pain most often occurring just before or during the first few days of
each period.

 Lower abdominal pain (LAP) that varies in severity among individuals, ranging from mild to
colicky or crampy, extending to the back, thighs and legs.

 Nausea and vomiting

 Constipation or diarrhea

 Fainting, headache, malaise

 Irritability, nervousness, depression

Diagnosis

- It is through history taking; ask about the nature of pain, duration and when it occurs. This is
often confirmatory.

- It is also through physical examination to rule out pelvic tumours, endometriosis which is
often absent.

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Treatment

 Non steroidal anti inflammatory drugs (NSAIDS) like Iboprufen, mefenamic acid, diclofenac
and others. These prevent the formation of prostaglandins in the uterine lining cells. They are
more effective if taken before the onset of cramps.

 Antispasmodics like Buscopan

 Anti-emetics like Phenergan for nausea and vomiting

NOTE

 Begin treatment 2 days before menstruation periods begin and continue until 2 days after
the period has stopped.

 Avoid additive drugs since this treatment is for long period.

 Contraceptive drugs like COCs may be given to suppress ovulation and relieve pain. Usually
given for 4-6 months and many get permanent relief after this treatment has been stopped.

 Dilatation and Curettage (D&C) may be of help to remove necrotic tissue of endometrium,
but usually not encouraged since it increases the risk of infections.

 Cervical stenosis can be treated by surgical widening of the canal.

 Effective counseling is important since pain is usually psychological to avoid drug dependence
and abuse.

 Delivery or with age will finally treat pain since there will be relaxation of uterine muscles
and reduce ischemia

 Encourage enough rest and sleep as well as exercises, hygiene and good diet.

 Other management options may include hypnotherapy and acupuncture.

Secondary dysmenorrhea

This refers to painful periods which start many years following normal and well established
menstrual periods. It is more of pathological occurrence and on investigations the cause is
easily established.

Causes

 Pelvic inflammatory diseases (PID)

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 Uterine fibroids. This results into the partial contraction of the uterus resulting into pain.

 Endometriosis. This is the growth of the endometrial tissue in other area rather than the
uterus.

 Endometritis. This is the inflammation of the endometrium.

Signs and symptoms

 In addition to signs and symptoms found in primary dysmenorrhoea, there is;

 Lower abdominal pain (LAP) usually happens 3-4 days or even a week before menstruation
and either pain becomes better or worsens with menstruation.

 There may be backache

 Signs and symptoms of menorrhagia

 Painful coitus

 Infertility; this is the inability to conceive.

Management

 Investigate and treat the cause.

NURSING MANAGEMENT

Nursing concerns

 Acute pain

 Stress

 Nausea and vomiting

Nursing diagnosis

Acute pain related to increased uterine contractility evidenced by verbalization of the girl or
woman. Nursing interventions

 Warm the abdomen, this causes vasodilation and reduces the spasmodic contractions of the
uterus.

 Massage the abdominal area that feels pain, this reduces pain due to the stimulus of
therapeutic touch.

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 Perform light exercises, to blood flow to the uterus and improves muscle tone.

 Perform relaxation techniques to reduce pressure to get relaxed.

 Administer analgesics as prescribed

Ineffective individual coping related to emotional stress evidenced by patient’s verbalization.

Nursing interventions

 Assess patient’s understanding of the condition. This is because patient’s anxiety of the pain
is greatly influenced by knowledge.

 Provide an opportunity to discuss how the pain is. Help the patient identify coping
mechanisms.  Provide the patient with periods of sleep or rest. Ensures relaxation of the body
and mind.

3. Risk for imbalanced nutrition less than body requirements related to nausea and vomiting.

Nursing interventions

 Provide the patient with periods of sleep or rest; this is to ensure relaxation of the body.

 Encourage small frequent feeds. These are easily tolerated by the patient.

 Administer anti-emetic drugs like promenzathine. This blocks the emetic centres.

Nursing interventions

 Provide the patient with periods of sleep or rest; this is to ensure relaxation of the body.

 Encourage small frequent feeds. These are easily tolerated by the patient.

 Administer anti-emetic drugs like promenzathine. This blocks the emetic centres.

MENORRHAGIA

This refers to heavy or prolonged menstrual bleeding or both.

Causes

Uterine fibroids

PID (pelvic inflammatory disease)

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Clotting disorders

Retroverted uterus

Functional tumours of ovaries resulting into hormonal imbalance

Cancers like cancer of the cervix and endometrial cancer

Signs and symptoms

 Heavy bleeding which may be painful or not, with a prolonged duration

 Signs and symptoms of anaemia and shock

Investigations

Bleeding time to test for coagulopathy

Prothrombin time to test for coagulopathy.

Clotting time to test for availability of platelets.

In the above three tests, results will be abnormal.

Full haemoglobin levels and hormone analysis to rule out hormonal imbalance.

Ultra sound scan to rule out new growth in the uterus

MANAGEMENT

The best management is to investigate and treat the cause

NURSING MANAGEMENT

Nursing concerns

 Heavy bleeding

 Anxiety

 Self care disturbance

Nursing diagnosis

Ineffective tissue perfusion related to excessive bleeding evidenced by pallor.

Nursing interventions

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 Assess patient’s vital signs. To obtain baseline data.

 Lift the foot of the bed. To allow blood flow to vital centres of the body like brain, kidneys,
lungs, heart and liver.

 Administer intravenous fluids. To maintain the circulatory volume of fluids.

 Administer vitamin k as prescribed to reduce bleeding. Vitamin k activates coagulation

factors.

 Administer whole blood as prescribed. To maintain circulatory volume of blood.

METRORRHAGIA

This is irregular and heavy uterine bleeding not associated with menstruation. The bleeding
occurs in between periods. This is sometimes called spotting or break through bleeding per
each period. This is a symptom of some underlying pathology which may be organic or
functional.

Causes

Fibroid uterus

Adenomyosis (A disorder of the glands that secrete cervical mucus and fluids)

Pelvic endometriosis(The presence of endometrium elsewhere than in the lining of the uterus
causing premenstrual pain and dysmenorrhea)

Chronic tubo-ovarian mass

Retroverted uterus-due to congestion

Uterine polyp. This is due to vast blood supply to the polyp which makes it bleed easily.

Cervical erosions. This is due to the presence of a wound and an increase in blood supply
resulting into bleeding.

Cancer of the cervix or endometrial cancer.

Chronic threatened abortion or incomplete abortion

Retained pieces of placenta. This interferes with contraction of the uterus to seal off blood
vessels after birth.

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Mole pregnancy. This is due to an abnormal uterine mass which grows after fertilization and is
supplied with a lot of blood capillaries resulting into bleeding.

Ovulation bleeding

Short cycles like polymenorrhoea

Investigations

Through history taking

Digital and speculum examination; to visualize the cervix for any abnormality.

Biopsy for histology to rule out cancer.

Pelvic scan; to visualize pelvic organs and rule out any abnormality.

MANAGEMENT

The best management to investigate and treat the cause

POLYMENORRHOEA/ EPIMENORRHPEA

This refers to menstruation periods that occur at shorter intervals than usual (14-21 days), but
they are frequent and regular.

Causes

 Ovarian dysfunction

 After abortion or normal delivery Diagnosis

 History taking

 Physical examination

 Hormone analysis to rule out hormonal imbalance.

MANAGEMENT

 Investigate and treat the cause.

 If following abortion or delivery, reassure the mother.

 Administer hormonal therapy to stabilize the cycle.

 Carry out dilatation and curettage (D&C) to remove retained products.

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DYSFUNCTIONAL UTERINE BLEEDING

This refers to abnormal bleeding resulting from hormonal changes rather than from trauma,
inflammation, pregnancy or a tumour.

Incidence

The prevalence varies widely but an incidence 10% among patients attending the outpatient
seems logical. The bleeding may be abnormal in frequency, amount or duration or combination
of both.

Causes

It is due to sustained levels of oestrogen leading to thickening of the endometrium which shed
incompletely and irregularly.

Pathophysiology

In most cases, abnormal bleeding is caused by local causes in the endometrium. However,
there is some disturbance of the endometrial blood vessels and capillaries and coagulation of
blood in and around these vessels. These are caused by alteration in the ratio of endometrial
prostaglandins which are delicately balanced in hemostasis of menstruation and may be related
to incoordination in the hypothalamo-pituitary –ovarian axis.

Signs and symptoms

Irregular, prolonged and sometimes heavy bleeding.

NOTE: A diagnosis of dysfunctional uterine bleeding is made only when all other possibilities of
causes of bleeding have been excluded.

Investigations

Ultra sound scan to rule out new growth

Blood analysis for hormonal imbalance

Biopsy for histology

MANAGEMENT

Treatment depends on various factors like age, condition of the uterine lining and the woman’s
plans regarding pregnancy.

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Total hysterectomy is indicated if the woman is over 35 years, uterine lining thickened and
contains abnormal cells and she does not want to become pregnant.

When the uterine lining is thickened but contains normal cells, heavy bleeding may be treated
with high dose of oral contraceptive oestrogen and progestin(COC) or oestrogen alone usually
intravenously, then followed by a progestin given by mouth. Bleeding generally stops within 12-
24 hours and then low doses of oral contraceptives may be given in usual manner for at least 3
months.

Women who have lighter bleeding may be given low doses from the start.

If a woman has contraindications to oestrogen containing drug, progestin only pills may be
given by mouth for 10-14 days each month.

D&C may be used if response or hormonal therapy proves ineffective.

If a woman wants to become pregnant, clomiphene drug may be given orally to induce
ovulation.

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 UNIT THREE

ABORTIONS

DEFINITION

This can be defined as the expulsion of the fetus before it reaches viability. This is the expulsion
of products of conception before viability period i.e. before 28 weeks of gestation. Most
abortions occur between 8-10 weeks. This could be induced or spontaneous.

Incidence The frequency of spontaneous abortion is 12-18 percent. The frequency of habitual
abortion is 0.4% - 0.8%.

WHAT ARE SOME OF THE CAUSES OF ABORTIONS?

1. Age: The risk increases 2-3% after the age of 30.

2. Past history: Risks after abortion is 36-90% after 3 abortions 60% after 4 abortions

3. Psychological factors: Too much stress can cause abortions.

4. Parity: It’s possible that mothers who have delivered many children can have abortions.

5. Chromosomal cause (genetic): Abortions can be due to errors during gametogenesis.

6. Infections: Are the second causes of abortions. Severe germs can infect the egg and
endometrium causing repeated spontaneous abortion e.g. UTI, viral infections like rubella,
herpes, syphilis, nonspecific infections like Ecoli, bacilli, local infections like endometriosis,
malaria etc.

NB Common viruses like mumps, influenza virus, varicella, herpes zoster (have no proved risks).

[Link] causes

[Link] to the ovum

9. Multiple pregnancies

[Link] over distension

[Link] rapture

12. Uterine septicemia

[Link] incompetence

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[Link] and curettage deliveries

15. Metabolic and vascular causes e. g

- Diabetes if poorly controlled

- HT increases the risks

- Tobacco consumption

- Chronic renal abscess

Immunological causes

- Rejection of paternal antigens

- Auto-immune abnormalities circulatory anticoagulants

Endocrine causes

- Poorly controlled diabetics

THE TYPES OF ABORTION

THREATENED ABORTION

It’s a common type in developing countries ending up with complete or incomplete abortion or
may carry the pregnancy to term. The pregnant woman develops bleeding with or without
painful contractions and so other causes of bleeding should be excluded.

On taking a real – time pelvic ultra sound examination, it shows

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- TRHA normally sized amniotic sac and a feotus whose heart is beating

- An empty amniotic sac

- A missed or incomplete miscarriage So if the first is found, a threatened abortion is confirmed.

Signs and symptoms

- History of amenorrhoea

- Painless vaginal bleeding

- No abdominal pain

On examination

- General condition is good, on VE the OS is closed

- Slight bleeding per vagina

- Signs of pregnancy

- The size of the uterus corresponds with the weeks of amenorrhoea

Management

- Admit the patient to a gynaecological ward

- Treat the cause accordingly

- Give a bed rest until days after blood loss ceases

- Intercourse is forbidden until bleeding stops and all pads used must be kept for examination.

- Avoid wasting if products of conception are seen.

Drugs:

- Salbutamol is given parentally to inhibit prostaglandins

- Sedatives are given if a patient is restless and anxious

- Folic acid is given for mitosis especially to avoid congenital abnormalities.

- Bleeding should stop within 24- 48 hours with bed rest in case it persists the patient is

re evaluated.

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Investigations

- USS to see if initial bleeding has stopped

- It reveals if the pregnancy is or is not viable

- Demonstration of an empty gestation sac after 8 weeks is relative evidence of absence or

death of embryo.

Reassurance

The patient must be reassured after the threatened abortion setting. That bleeding hasn’t
harmed the developing embryo although the obstetrician should bear in mind the possibility of
insufficiency in late pregnancy.

In the maternity centre

- Admit the patient and keep her in bed at complete bed rest.

- Ask the patient to allow you look at the vulva to estimate how much blood she is losing.

- The patient is examined generally not forgetting abdominally.

- Secure your hands and do a septic vulval swabbing and give a clean pad. (all pads used must
be examined)

- Give phenobarbitone tablets 30mg 80.

- Food that causes constipation or diarrhea shouldn’t be given

- No enema should be done

- Give plenty of fluids about 3-5 litres a day and maintain fluid balance chart

- Vulval swabbing

- Oral hygiene

- Pay special attention to the bladder

- Do vital observation as directed by the doctor

- Give antimalarials if it’s the cause of abortion

- The patient is then kept in the centre for 7 days.

- If the bleeding increases, refer the patient to hospital without delay. Advice on discharge

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- The patient should have rest (enough)

- She should not do heavy work and exercises

- No sexual intercourse until the mother is stable - She should return for review after 2 weeks if
there is no bleeding and come back immediately in case of bleeding.

- Advise her to have foods containing iron, proteins and vitamins.

COMPLETE ABORTION

It’s a type of abortion where all the products of conception have been expelled.

Signs and symptoms

- History of amenorrhoea

- History of vaginal bleeding which has either stopped, reduced or become slight.

- Signs and symptoms of abortion e.g. fever, abdominal pain more so lower abdominal pain.

- The uterus is smaller than the period of amenorrhoea

The following are possible causes of abortion

- Febrile illness ie malaria

- Infections especially UTI

- Congenital abnormalities

- Trauma

- Medical conditions eg diabetes mellitus, renal diseases, hypertension and anaemia.

- Drug eg cytotoxic drugs used in chemotherapy, egometrine

Management

If the patient’s general condition is poor, admit to a gynecological ward

Reassure and counsel the patient

Take off blood for HB, blood grouping and cross matching

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Urinalysis should also be done.

Blood for culture and sensitivity

Drugs;

Give antibiotics to combat infection

Haematemics like ferrous, folic acid

Advice on discharge

- Once pain ceases and bleeding is minimal, no further treatment is needed but the patient
should be warned to return immediately bleeding or pain occurs.

- If she develops a temperature, this can be suggestive that some products must have remained
and infected.

NOTE: A patient who has complete abortion is treated like one who has had a normal delivery.

INCOMPLETE ABORTION

This is a type where part of the products of conception usually the placenta has been retained.
It causes the uterus to contract continuously in order to expel the retained products hence the
patient continues experiencing paid.

Signs and symptoms

- Bleeding, the amount of blood varies however this may be accompanied by dangerous shock.

- It’s possible that a lady bleeds severely and the Hb lowers to as low as 5g/dl /5g/100ml -
History of amenorrhoea

- The uterus is small than expected because some products of conception have been expelled.

- Abdominal pain

- Signs and symptoms of underlying cause like UTI, malaria

- Signs and symptoms of shock.

- On examination, anaemia whose degree will depend on amount of blood test.

- Sweating with low BP and tarchycardia

- On abdominal palpation the uterus is palpable

22
- On VE, the cervix is open, products of conception in the uterus are felt.

DEFINITIVE TREATMENT

Evacuation by manual vacuum aspiration is done by use of equipment consisting of a piston

valve and Karmar cannular. Occasionally if bleeding persists because of large pieces of placenta
held in the cervical canal, the removal of this is done under direct vision using a sterile
speculum and sponge holding forceps which allow uterine retraction to reduce bleeding.

NB

The above procedure is done under anesthesia

Ergometrine 5mg is given as soon as the uterus is emptied

Anti D globin unless the patient is known to be rhesus positive

Antibiotics to combat infections.

IF THE PATIENT COLLAPSES DUE TO BLOOD LOSS

 Receive the mother in a warm bed

 Give ergometrine 0.5mg

 Do urgent cross matching

 Administer IV fluids i.e NIS or RIL to circulatory failure

 Give oxytocin 10 units

 Monitor vitals including temperature, BP and pulse every 15-30 minutes

 Evacuation is done under anesthesia

 Gauze piece may be inserted into the uterus

 Give parenteral antibiotics

 The mother may be discharged on the 4th and 5th day after evacuation.

 Do a high vaginal swab for culture and sensitivity and give rights antibiotics.

 Rule out pelvic inflammatory diseases

Treatment

23
- Treat shock

- Give antibiotics

- Give analgesics

NB: Counseling is very vital in every management

INEVITABLE ABORTION

This is the abortion that will come out by all means despite all effects done to try saving it.
Inevitable abortion comes when the bleeding increases greatly and uterine contractions
become rhythmic and strong.

The cervix is dilated and the products of conception may sometimes be seen through the
internal OS.

NB: It’s common for the entire contents of the uterus to be expelled and that is a complete
abortion.

After the 12th week, the membranes often rapture and the foetus is passed leaving the
placenta behind and then complication of incomplete abortion may site.

Causes:

- Syphilis especially in the mid trimester

- Congenital abnormalities

- History of induced abortion

- Incompetent cervix Signs and symptoms

- Abdominal pain

- Fever

- Backache

On examination if an infection has set in the patient is sick looking and may be anaemic
depending on blood loss. Depending on the weeks of amenorrhoea, the uterus is palpable.

On VE, the cervix is open and products may be felt in the cervical canal.

Investigations

24
USS reveals products of conception in the uterus.

Management

- Admit the mother in the gynaecological ward

- Do routine management like for other abortions

- Give oxytocin 20 iu intravenous or

- Ergometrin 0.5mg or 1m to control bleeding

- Resuscitate the mother with IV fluids

- Treat the cause and give analgesia

- Assess if abortion is complete or incomplete and manage accordingly.

MISSED ABORTION

This is when the foetus dies in the uterus but the gestation sac is retained in the uterus for
several weeks or months. There is slow progressive haemorrhage that takes place into the
decidual space. The effused blood eventually surrounds the embryo and separates it from its
attachment. The most resistant amnion usually is found intact in the midst of the clot. The
amniotic cavity is surrounded by terminated blood clots which have a fleshy appearance hence
the description corneous mole.

NB: Corneous mole may not have infections in it because of the presence of calcium ions in it.
The mother must be counseled.

Presentation

- The signs of threatened abortion arise and then subside.

- The presence of a mole in the uterus appears to inhabit menses and the patients may think
that her pregnancy is continuing.

- The uterine parts grow and soften, it may retain the dead foetus for a long period
approximately 14 months.

- Breaths become active, soft and other signs of pregnancy may disappear.

- Brownish vaginal discharge is seen but no pain.

25
- The mother notices a little stained discharge for a day or 2 between 8th and 12th weeks of
pregnancy.

- Vaginal bleeding is seen.

- On abdominal examination;

 The size of the uterus is less than the weeks of amenorrhoea

 The USS confirms missed abortion (No foetal movements are seen).

 After commencement of vaginal bleeding, the breasts cease to be enlarged but the patient
often doesn’t notice until she realizes that the uterus is not increasing.

Investigations

- Abdominal / pelvic scanning

- Immunological tests for pregnancy usually become negative about 10 days after the death of
the embryo.

Management

At maternity centre

- Prepare transport to hospital while doing the following:-

 Get complete history from the patient

 Examine the patient then record down

 Give supportive management

 Do coagulation profile to find out the fibrinogen level i.e. it usually reduces (normal range
150g/d) if it’s less blood transfusion

 Check blood for clotting time

 Induce labour using misoprostol or oxytocin.

26
 UNIT FOUR

ECTOPIC PREGNANCY

DEFINITION

This is when the fertilized ovum is embedded outside of the uterine cavity.

CAUSES

 Congenitally long uterine tube which may cause kinking or prolongs the journey of the
fertilized ovum

 Narrowing of the uterine tube which may be congenital or due to infections

 Pelvic infections which may cause destruction of the cilia in the tube thus prevent proper
movement

 Blockage of tubes due to presence of adhesions inside the tube, presence of pus ( pyo
salphinx) or presence of fluids 9 hydro salphinx)

 Pressure from tumours outside the uterine tube causing narrowing or complete blockage

 Presence of endometriosis where endometrial tissue is found outside the uterine cavity

 Intra uterine device which may interfere with implantation of the fertilized ovum into the
IUuterine cavity.

SITES OF ECTOPIC PREGNANCY

The commonest is the uterine tube but can also occur in the broad ligament, ovary and
abdominal cavity.

TUBAL PREGNANCY

This is when the fertilized ovum embeds in the uterine tube

SITES

Ampulla is the commonest site, Isthmus is the most dangerous because it has tendency to
rupture very early sometimes even before the mother realizes she is pregnant. This is so
because it is the narrowest part. Fimbriated end is a rare site.

INCIDENCE

Ectopic pregnancy is very common among women of middle age

27
POSSIBLE OUTCOMES OF TUBAL PREGNANCY

 Tubal mole: The fertilized ovum dies but is retained within the uterine tube enclosed by a
blood clot. This may result into a slow leaking ectopic pregnancy

 Tubal erosion: The villi erode through the wall of the uterine tube causing bleeding into the
peritoneal cavity.

 Tubal abortion: the fertilized ovum separates from the inner lining of the uterine tube and is
pushed through the infundibulum. If dead it may be absorbed into the peritoneal cavity. If alive
it may embed on any organ in the peritoneal cavity e.g. intestines, omentum and result into an
abdominal pregnancy.

 Tubal rupture: This is due to the increasing size of the fertilized ovum which becomes too big
for the uterine tube causing it to burst. It is one of the obstetric emergencies since it causes a
lot of internal bleeding and thus shock.

SIGNS AND SYMPTOMS RUPTURED ECTOPIC PREGNANCY

History taking

 History of amenorrhea 6 – 10 weeks

 Complains of acute abdominal in the iliac fossa

 Patient complains of dizziness, vomiting, thirst

General examination

 Signs of pregnancy are present

 Mucous membranes are pale Patient is restless and anxious

 Cold clammy skin and extremities

Observations

 Signs of shock are present e.g. low blood pressure, rapid pulse, subnormal temperature,
rapid respirations

Abdominal examination

 Abdomen distended due to presence of fluid in the peritoneum

 Tenderness and guarding especially on the affected side

28
 Abdominal muscles are rigid and may not move well with chest respirations

Vaginal examination

 Bleeding may be minimal and not corresponding with patients condition

 There may be brownish discharge

 Excitable cervix where tenderness is increased if cervix is moved to opposite side of affected
tube

 A mass may be felt in the lateral fornices or pouch of Douglas

Investigations

 Ultra sound scan will reveal the rupture and collection of blood on the affected side.

 Haemoglobin level will be low

 Pregnancy test is positive

 In an emergency if scan is not available a puncture into the Pouch of Douglas fresh blood will
be found on aspiration.

DIFFERENTIAL DIAGNOSIS

 Salpingitis especially if related to irregular periods.

 Appendicitis

 Abortion

 Twisted ovarian cyst

 Urinary tract infection

29
MANAGEMENT

HEALTH CENTRE

This is an emergency and everything must be done as quickly as possible to save life of the
mother. Admission Mother is admitted temporarily. Histories are taken, general examination,
observations, abdominal and vaginal examination done. A diagnosis is then made.

Resuscitation

A drip of normal saline is put up and morphine 15 mg given intramuscularly.

Transfer

The decision is explained to the patient and relatives, a well written note made stating time of
admission, treatment given condition on arrival and leaving. Transport is arranged then the
mother is transferred to hospital. The midwife escorts the mother and hands her over to the
hospital staff.

HOSPITAL MANAGEMENT

Aims

 Prevent shock

 Treat anaemia

 Preserve life This is an emergency and everything must be done as quickly as possible to save
mother’s life. All nurses work as a team to ensure that the patient is in theatre within the
shortest time possible.

Admission

Patient is admitted in gynaecological ward in a comfortable bed and is reassured

History taking

Histories are taken from the patient if able or from the relatives if patient is unable (collateral
history).These will include social, medical, surgical, obstetrical, gynaecological histories. More
emphasis is put on history of the presenting complaint i.e. when the condition started, amount
of bleeding, site of pain, any vomiting or if any treatment has been given. Weeks of
amenorrhoea are estimated. The doctor is then informed

30
Observations: These are done including vital; observations (T, P, R and BP) general and specific
observations are also done.

General examination: Done from head to toe to rule out anaemia, jaundice, dehydration or
oedema.

Abdominal examination:

Done to identify site of pain and determine size of abdomen to rule out distention or if fundus
is palpable which may show a different condition. Resuscitation Intravenous Normal saline is
started to prevent or treat shock. Morphine 15 mg I.M. will be given as ordered by doctor. If
mother is in shock it is also managed.

Investigations These are ordered by doctor a\and may include

 Haemoglobin estimation to rule out malaria

 Blood group and cross matching because blood transfusion may be necessary

 Pregnancy test to confirm that the mother was pregnant and the pain is not due to other
conditions

 Ultra sound scan to confirm the diagnosis

 Urinalysis to rule out urinary tract infection Pre-operative care

Pre-operative care

The decision for operation is communicated to the patient and procedure explained by doctor.
The nurse obtains an informed consent from the p\patient

Theatre is informed

Catheterization is done and any premedication order is given e.g.

 Atropine to reduce secretions which would lead to inhalation

 Anti-acids to neutralize the stomach contents in case patient vomits to prevent inhalation.
This is done if patient had a meal within the last 4 hours where the stomach may still be full.

 Antibiotics may be given as prophylaxis to prevent infections later.

 Sedatives like valium to prevent anxiety

31
Nursing care

A bed bath is given, theatre gown offered, observations done and recorded, all charts collected
then the patient is wheeled to theatre. The patient is handed over to the theatre staff and if
possible the ward nurse stays with the patient until she is anesthetized. The nurse goes back to
the ward and makes a post-operative bed with all its requirements.

In theatre Laparatomy and salpingectomy is done to remove the ruptured portion and repair
the area to control bleeding. The other tube is examined for patency and unblocked if possible.
If the rupture was acute and the blood is fresh it may be collected, sieved into an anticoagulant
(sodium citrate) and retransfused into the patient. This is known as auto transfusion. If this is
not possible cross matched blood is transfused.

Post-operative care

Reception

A message is sent to the ward then ward staff goes to collect the patient. Observations are
done and reports received d from the surgeon, anaesthetist and recovery room nurse. The
patient is then wheeled to the ward.

On the ward

Patient is received in a warm post operative bed .She is positioned flat head turned to one side
so as to continue observing the operation site. Warmth is provided by covering the patient.
Observations

These are done and recorded. Half hourly for the first hour, hourly until stable then 12 hourly
until discharge. Observe the site for bleeding and note any vaginal bleeding. Observe level of
consciousness, pain or anxiety.

On gaining full consciousness

Welcome the patient back from theatre, explain what was done, give a mouth wash and change
the gown. A pillow is offered if needed. Observations are then repeated.

Medical care Drugs are given as ordered by doctor

Antibiotics

 Ampicillin 500 mg 6 hourly for 5 days

 Ceftriaxone 2 gm o.d. for 5 days

32
 Metronidazole 500 mg 8 hourly for 5 days

 Gentamycin 160 mg o.d. for 5 days

Analgesics

 Pethidine 100mg 8 hourly for 3 doses

 Diclofenac 75 mg 8 hourly for 12 hours

 Panadol 1 gm 8 hourly to complete 5 days as soon as patient can take orally.

Supportive drugs

 Haematenics to prevent or treat anaemia

 Sedatives to ensure rest and sleep

Care of wound

The wound is left untouched unless bleeding where dressing is added. Stitches are removed on
the 7 day. Dressing may be changed if soiled.

Nursing care

Diet: patient is on IV fluids until bowel sounds are back. She starts sips of water if well tolerated
light diet is started then gradually back to normal diet. Maintain a fluid balance chart.

Bowel and bladder: Catheter is removed as soon as IV fluids are discontinued. Encourage
mother to empty bowel and bladder regularly. If by 3rd day bowel is not opened an apperient
e.g. Dulcolax can be ordered by doctor.

Rest and sleep: Control noise, visitors and light. Reassure patient, Give analgesics in time and
occupy the patient.

Exercise: Encourage patient to turn in bed as soon as possible, to move out of bed on second
day move around bed then free ambulation on 3rd day.

Hygiene: Bed bath is given, mouth care treatment of pressure areas, bed making until the
patient is able to go to the bath room by herself.

Advice on discharge

 Explain the operation done and how it will affect her reproductive health.

33
 `Prevention of sexually transmitted diseases which may lead to blockage of the other tube

 Take drugs as ordered

 Come back for review within 2 weeks

 Have enough rest and sleep at home

Complications

 Hemorrhage from the ruptured tube

 Anaemia due to internal haemorrhage

 Shock

 Sterility when the tube is removed and the other may be blocked as well

 Peritonitis due to infection to the peritoneum

 Reoccurrence ectopic may occur in the other tube

 Generalized sepsis

34
 UNIT FIVE

INFERTILITY

PREAMBLE

Most normal couples achieve a pregnancy within a few months of trying. Failure to conceive
after 2 years may be arbitrarily defined as infertility provided the normal intercourse is taking
place less than 4 times a week.

Definition

Infertility is the inability of a couple to conceive or to get a child after two years of regular
coitus without having used any form of contraception.

TYPES OF INFERTILITY

[Link] Infertility

2. Secondary Infertility

Primary Infertility

Is the term used for a couple who have never achieved a pregnancy at any time after 1 year of
unprotected sex.

Secondary Infertility

Refers to a couple who have previously succeeded in achieving at least one pregnancy even if
this ended in spontaneous abortion being unable to conceive again.

Statistics show that at least 10% of all couples have an infertility problem. 30% may be the male
partners’ contribution, 40% the woman’s contribution and 30% the responsibility of both
partners.

35
AETIOLOGICAL FACTORS AFFECTING FERTILITY OR CAUSES OF INFERTILITY CAUSES OF
INFERTILITY IN FEMALE

Are best discussed under the following headings

 Defective Implantation

 Endocrine Disorders

 Ovarian Disorders

 Defective Transport

 Physical/Psychological Disorders

 Systemic Disorders

DEFECTIVE IMPLANTATION

- Major cause is tubal blockage due to PID (in Uganda especially) This contributes to 60 – 70%.

Salpingitis caused by infection after abortion or delivery by gonorrhoea, clamydia or

tuberculosis or by yykpelvic peritonitis from acute appendicitis may damage the tubal
epithelium and in severe cases bring about tubal blockage.

This. mostly occurs at the outer end of the tube where the fimbriae adhere together but is also
seen in the very narrow, interstitial part of the tube.

When the tubes are not completely blocked, fertilization of the ovum may still take place but
because of the damage to the ciliated epithelium the fertilized ovum may not be carried down
the tube to the uterus and an ectopic pregnancy results.

-Abnormalities of the uterus. Some people are born with no uterus or with a bicornuate uterus
or Didelphys uterus with 2 horns).

-Uterine fibroids (gross) causing an irregular implantation surface.

-Endometritis, Severe inflammation of the endometrium also called synache

-Over curreting of the uterus or surgery of the uterus i.e. Hysterectomy.

-Stenosed Cervix due to trauma or injury due to dilatation and curretage May be acquired or
congenital Gynaeatresia i.e. a very small hole with a blind end of the vagina.

36
- Endometriosis- A condition where patches of the endometrial like tissue develop outside the
uterine cavity in abnormal locations such as ovaries, fallopian tubes and abdominal cavity. Can
grow with hormonal stimulation causing pain, inflammation and scar tissue hence infertility.

- Trichomonas vaginalis (evidence of cause in Zambia).

-Use of barrier contraceptives e.g. condoms, IUDS and Spermicides

-Septate vagina and rigid hymen

-Congenital absence of fallopian tubes

ENDOCRINE DISORDERS

- Hormones, Pituitary and Ovarian Inefficiency There may be alteration of hypothalamic

function resulting from stress (resulting in altered dopamine or noradrenaline transmission)

Or Alteration of hypothalamic function due to some drugs e.g. rawolfia, phenothiazines or

metaclopramide

Or Weight loss or excessive weight gain causes unstable cerebrum and

Hypothalmus

- May be a pituitary tumour which leads to production of excessive prolactin hormone hence
causing Anovulation.

These tumours are usually micro and macroadenomas which cause hyperprolactinaemia.

Elevated levels of prolactin levels are normal during lactation and anovulation ensues as a
result but if not lactating causes infertility.

- Changes in thyroid function (hyper or hypothyroidism) or in adrenal function (cushings

syndrome or congenital adrenal hyperplasia) result in anovulation.

Age – menopause. Fertility declines with age. Postponement of childbearing because of career
can be a problem.

OVARIAN CAUSES

Ovary malfunction Absence of FSH receptors in the follicle leads to failure of the ovary to
respond to gonadotrophins (resistant ovary syndrome) or there may be disturbance in the
interaction between FSH and the follicle.

37
This disturbance may result in abnormal enzyme reaction- anovulation will result and the ovary
becomes multicystic hence (polycystic ovarian syndrome).

Failure of ovulation results in absence of secretory changes in the endometrium and the
cervical mucus remains thick and impenetrable by the sperm.

No eggs or no follicles in the ovary. Can be congenital.

Premature menopause

Surgery i.e. removal of the whole ovary mistakenly as in surgery of the ovary.

Infection such as mumps can destroy the ovary substance

PID = (adhesions (Ashermans Syndrome).

- Chronic or excessive exposure to radioactive substances or xray. These could damage the ova.

DEFECTIVE TRANSPORT

- Allergy to the man’s sperms/cervical hostility – This is a condition in which the cervical mucus
is unreceptive to spermatozoa either preventing their progressive advance or actually killing
them. It may be due to infection or to the presence of sperm antibodies.

- Vaginal Ph ( acidic destroying the motility of the sperm)

PHYSICAL/ PSYCHOLOGICAL CAUSES

- Other conditions preventing union of ova and sperm in female are; Dyspareunia (painful or
difficult sexual intercourse experienced by a woman due to psychological or physical factors)
and vaginismus.

-Physical abnormality of the reproductive organs i.e retroverted uterus.

SYSTEMIC CAUSES

- Systemic diseases e.g. Diabetes Mellitus, hypertension and renal failure.

CAUSES OF INFERTILITY IN MALE

Male fertility depends on production of adequate numbers of healthy spermatozoa by the

semineferous tubules and their subsequent delivery in the upper vagina from where a small
proportion of them will penetrate the cervical mucus, travel through the uterus and then to the
ampullary portion of the fallopian tubes where fertilization normally takes place.

38
CAUSES Are discussed under the following headings

Deffective Spermatogenesis

Deffective transport

Inefective delivery of sperms

4. Systemic diseases

DEFECTIVE SPERMATOGENESIS

Poor sperm quality due to varicocele associated with high temperatures. The temp of the
scrotal contents in about 1 degree celcious below the normal body temperature so
spermatogenesis is impaired if the temperature of the testis is raised.

This can occur in undescended testes (cryptoorchism), varicocele, in cases of febrile illness and
if tight warm underclothing is worn. Long distance travelers suffer from over heated engines
with temperature killing sperms and weakening them.

Congenital lack of sperms

Testicular abnormality due to infection.

Exposure to environmental toxins like pesticides, herbicides which may affect the quality of
sperms.

Exposure to radioactive substances ie xrays.

Chronic or constant use of hot tubs

Previous vasectomy for sterilisation

Surgery on or near the testicles that result in impaired testicular circulation or previous
herniorraphy resulting in scar tissue formation.

Congenital absence of seminal vesicles and vas deferens.

DEFECTIVE TRANSPORT

Blockage of the vas deferens due to infection i.e. gonorrhea, tuberculosis and trauma.

Infection of the seminal glands by gonorrhoea and trichomonas vaginalis.

PSYCHOLOGICAL CAUSES

39
Failure of psychosexual erection of the man.

Psychological factors like job and financial stress, fatigue, depression, anxiety surrounding
sexual intercourse and illness.

INNEFECTIVE DELIVERY

Merged with physical anomalies like hypospadias and epispadias.

- Impotence

-Hydrocele

The capacity of one to release sperms is minimal because there is too much fluids and sperms
just float in it.

-Retrograde ejaculation in the bladder.

-Drug induced ejaculatory dysfunction.- Alcohol

ENDOCRINE CAUSES

- Hormonal disturbances i.e. failure of stimulation of FSH hence failure of secretion of

Androgens in male.

-Endocrine disorders ie hypothyroidism and adrenal hyperplasia.

GENETIC FACTORS

Klineflters syndrome and Turners syndrome.

KLINEFELTER’S SYNDROME

A syndrome consisting of gynaecomastia, testicular atrophy, azoospermia and infertility.

Testicular atrophy is a result of peritubular fibrosis which commence in childhood and
progresses until all seminiferous tubules are replaced by fibrous tissue. Patients have 47
chromosomes instead of 46 with an extra X chromosome so that the sex chromosome
constitution is XXY instead of XY. Loss of a Y chromosome leads to a body which is feminine.

TURNER’S SYNDROME

It is caused by either the absence of or an abnormality in one of the two X chromosomes.

Classical turner’s syndrome is a complete deletion of one X so that the karyotype is 45XO. They
are females but have ovarian failure, widely spaced nipples, cardiovascular problems, squints,

40
hypothyroidism and diabetes mellitus hence infertility. In adult life, they have problems of
oestrogen.

MALE FEMALE FERTILITY FACTORS

- Mucus sperm incompatibility

-Sperm immobility or sperm agglutinating antibodies in their blood plasma that act to destroy
sperms in the cervix or vagina

CONDITIONS THAT SHOULD BE FULFILLED IN ORDER FOR REPRODUCTION TO OCCUR

 There should be 2 lovers

 Get unprotected coitus without contraception and both should actively get involved.

 Should be using the right sexual route – vagina for a woman with a penis (male).

 Should be within the age of conception, 14 to 49 years.

 There should be release of healthy semen containing normal spermatozoa. Normal,

healthy ova must be released from the ovary.

 The ovum must unite with the sperms to be fertilized.

 The fertilized ovum must be implanted in the uterus.

NB: The term sterility should be used only when there is no treatment possible to enable a
couple to conceive (achieve pregnancy) such as when a man has no testes or a woman lacks a
uterus

The chances of a woman conceiving are strongly dependant on the age of the partner and her
age too. Chances are high in the late teens and early 20’s and declines slowly after the age of 35
years Coital frequency without contraception which should be above 4 times a week for
maximum results. Remember unprotected sex even at about the time of ovulation does not
necessarily result in conception. 25% of women should become pregnant in the 1st year of
unprotected sex; 1 month – 25%; 6 month – 60%; 9 months – 70%; 1 year – 80% 18 months -
90%.

FAILURE OF A MAN TO DELIVER SPERMS INTO THE VAGINA

Premature ejaculation

Lack of ejaculation

41
Retrograde ejaculation (instead of sperms going the correct way they are poured back into the
bladder)

Impotence

Hypospadiasis and Epispadiasis

Genetic factors e.g. turners syndrome

GENERAL INVESTIGATIONS

All couples who complain of infertility should be investigated but the length to which the
investigations should be carried out will vary.

Both partners should be seen for initial interview.

In the female

HISTORY

Menstrual history i.e. menarche and length of menstrual periods.

Previous gynecological history i.e. any previous contraceptive and its outcome, History of
dilatation and curettage, salpingectomy etc. Any History of abortions or History of suggestive
Pelvic inflammatory diseases.

Previous obstetric history i.e. previous pregnancies and number of children fathered by this
man.

History of pelvic infection.

General state of health and nutrition.

Age of both man and woman. Above 50 in female is considered as menopause.

Her weight Very lean thin and very obese woman have a problem. In the obese the ovary
cannot secrete enough oestrodiol so they secrete more of oestrone hormone.

Very thin – amenorrhoea - infertility.

C. Sight of the Woman If one has a pituitary tumor she can’t see objects on the side.

42
[Link] for excessive prolactin

E. Check for hair distribution i.e. pubic hair and general body hair distribution. If a lady has
virilism – have Androgen - more masculine

F. On V/E check for normality of the vagina confirm with ultra sound.

G. Hormonal Investigations

In a 28 cycle check for progesterme levels on day 21 to check for ovulation.

H. Serial ultra sound to see ovulation

I. Check FSH and LH especially in people with premature menopause or removal of the ovary.

J. Hystero salpingogram

K. Post coital test to check whether the woman allergic to sperms.

L. Polycystic ovary common in the Europeans

SPECIAL TESTS

BASAL BODY TEMPERATURE

Ovulation is confirmed by the lady taking her oral temperature every morning on waking and
records it on a special temperature chart. This must be done before rising or starting any
activity A rise in the basal body temperature of about 0.50 C in the last 14 days of the cycle
indicates that ovulation has occurred continued x 6/12.

EXAMINATION OF CERVICAL MUCUS

Examination of the cervical mucus in the midcycle will reveal characteristic changes if ovulation
has occurred. Ovulatory mucus is clear copious and can be drawn out into a fine thread
(spinnbarkeit). On drying it crystallizes out into the characteristic fern pattern.

A sample of blood is taken off 1 week before a period is expected I.e. Day 21 or of a 28 day
cycle a progesterone level of more than 20 mmol confirms that ovulation has taken place.

HISTOLOGY

Histological examination of a premenstrual endometrial biopsy it will show secretory changes in

the glands after ovulation.

43
LAPARASCOPY

This is a tubal patency test. It’s a premenstrual laparascopic exam of the tubes combined with
injection of a dilute solution of methylene blue through a tightly fitting cannulae placed in the
cervical canal. The uterus can be seen to be distended by the dye and if the tubes are patent
they fill with dye which finally spills from the distal ends. Distal block is recognized if there’s no
spill and medial block can be inferred if no dye enters. NB> Pregnancy should be first ruled out.

TUBAL INSUFFLATION

It is an unreliable method where co2 is used passed via the vagina to the uterus. If there’s a
problem in the uterus or tube the gas will be felt on Auscultation. An Xray is later done to Rule
out blockage or no blockage.

HYSTEROSALPINGOGRAM

Here an opaque radio aqueous solution through the cervix to the uterus and tubes is done
under radiographic control the test is performed in the 1st 5 to 10 days of the cycle after
menstrual bleeding has ceased but before Ovulation has occurred. An Xray is taken. Free spill of
dye from the distal ends of the tubes proves patency and no spill indicates site of blockage.

POST COITAL TEST (HUHNERS TEST)

Carried out at time of ovulation or 1 to 2 days before ovulation. 2-8 hours after unprotected
intercourse, the cervix is exposed by a bivalve speculum and a sample of cervical mucus is
withdrawn from the endocervical mucus with a wire loop or pipette placed on a warm slide and
covered with a coverslip. The number of progressively motile sperm in a number of high power
fields is examined. Normally a large number of active sperm will be seen.

PROLACTIN TESTS

When prolactin level is higher than 800 m/u/l computerized tomography of the pituitary fossa
is indicated to exclude a prolactin producing pituitary adenoma.

ENDOMETRIAL BIOPSY

It is done 10- 12 days after ovulation.

44
TRANSVAGINAL ULTRASOUND (TVS)

NB CONTRA INDICATIONS OF INSUFFULATION

- Presence of suspected pregnancy

-Presence of cervical erosion

-Presence of infection

-Serious heart and lung diseases.

-Patient in Menstrual periods or with Dysfunctional Uterine Bleeding

RISK

Embolism Ascending Infection

EVALUATION IN MAN (MALE)

Obesity – Diabetes Mellitus – Hypertension – Infertility

Hair distribution and development of genitalia For undescended testis – Operation before
puberty is done

Check breasts for enlargement, shows increased oestrogen

Testes, size and situation.

Decreased Androgen shows infertility.

Blood test to evaluate FSH and LH levels.

Sperm count/ seminal fluid analysis normal count is 20 million/ml. If below 10 million there’s a
problem (Oligospermia)

NORMAL FINDINGS

 Volume – more than 2mls

 pH- 7-8

 T. sperm count- more than 20 million/ml

 Liquefaction- complete in 1 hour

 Motility- 50% or more

45
 Morphology – 30% or more – normal

Some men lack sperms (Azoospermia).

Check for morphology and 60% motility (should be over 40%) there should be forward and
circular motility.

Culture and sensitivity of the semen to look for sperm antibodies – sperms will be immobilized
with cervical mucus contact

Biopsy of the testes.

TREATMENT IN GENERAL IN WOMEN

CHEMOTHERAPY

In Anovulatory Infertility, stimulate the ovary by giving Clomiphene Citrate (Clomid)

Dosage

50mgs daily for 5 days of onset of menstruation preferably on the second day or at any time if
the cycles have ceased. If ovulation does not occur a second course of 100mgs daily for 5 days
may be given starting as early as 30 days after the previous one,

In general 3 courses of therapy are adequate to assess whether ovulation is obtainable.

Clomiphene induces ovulation by stimulating the Hypothalamic pituitary system.

Key issues to note: This treatment often results into multiple pregnancy because the dose of
the drug is difficult to adjust.

Side effects

 Visual disturbance

 Abdominal discomfort

 Headache

 Insomnia

 Ovarian by hyperstimulation

 Hair loss

 Breast tenderness

46
 Depression

 Hot flushes

 Abnormal uterine bleeding

 Inter menstrual spotting

 Endometriosis

 Dizziness

 Nausea and vomiting

 Menorrhagia

2. Give Tamoxifen 20mgs daily on days 2, 3, 4 and 5 of the menstrual cycles. Dose may be
increased to 40mgs the 80mgs.

3. If patient has hyper prolactanaemic infertility give Bromocriptine (also called parlode
lactodel, dopagon or Brameston). It is used to inhibit synthesis of release of prolactin by the
pituitary gland. Dosage

Dosage

Initially 1.25mgs at bed time which is increased gradually to the usual dose of 2.5mgs 3 times a
day with food. Increased if necessary to a maximum dose of 30mgs daily.

Side Effects

 Nausea

 Headache

 Nasal congestion

 Fatigue

 Dry mouth

 Diarrhea

 Constipation

 Drowsiness

47
 Hypotension

 Dizziness

 Abdominal cramps

DRUG INTERACTION

1. Erythromycin may increase plasma concentration hence risk of toxicity of Bromocriptine.

2. Bromocriptine is antagonized by antipsychotics and domperidone plus metoclopramide.

3. In patients with hypothalmic dysfunction leutinising hormone administration is given to

induce a pituitary response.

Dosage

10-25 micrograms released via a syringe pump every 90 minutes. It’s given intravenously or
subcutaneously.

The treatment is continued throughout the menstrual cycle

The success rate of 60-70% has been shown

TUTORIAL QUESTIONS

1. Write a treatise on menstrual disorder.

2. Write a treatise on infertility.

3. Write a treatise on ectopic pregnancy.

48
49