GYNAECOLOGICAL NURSING.pptx

GYNAECOLOGICAL NURSING Ms. KEMEI GYNAECOLOGY 22 HOURS COURSE PURPOSE: learners will acquire knowledge, skills and attitudes to be able to promote health, prevent illness, diagnose, manage and co-ordinate rehabilitation of children and adults suffering common gy...

GYNAECOLOGICAL NURSING Ms. KEMEI GYNAECOLOGY 22 HOURS COURSE PURPOSE: learners will acquire knowledge, skills and attitudes to be able to promote health, prevent illness, diagnose, manage and co-ordinate rehabilitation of children and adults suffering common gynecological problems. EXPECTED LEARNING OUTCOMES You will be able to:- Recall the anatomy and physiology of the female reproductive system Explain history taking of patient/clients with gynecological diseases /conditions Describe physical examination of patients /clients with gynecological diseases /conditions Describe common disease /conditions of the female reproductive system. COURSE CONTENT Gynaecological Emergencies: Definition, pathophysiology and management, abnormal uterine bleeding, abortions (including Comprehensive abortal care), ectopic pregnancy testicular and ovarian torsion, penile fracture. Less common gynaecological conditions : genital prolapse, metrorrhagia, common menstrual problems, menopausal disorders, sexual dysfunction, sexual variance/deviation Infertility : Definitions, magnitude, predisposing factors, classifications, causes, evaluation/ diagnosis, psycho social effects, management Abnormal uterine bleeding, dysfunctional uterine bleeding, amenorrhea, menorrhagia, metrorrhagia, polymenorhoea, oligomenorhoea, premature menopause, dysmenorrhea, pre-menstrual tension syndrome, menopause, endometriosis. Early pregnancy bleeding Abortions: classification, types, causes, clinical presentations, management (PAC), complications, ectopic pregnancy; gestational trophoblastic disease (H-mole & choriocarcinoma, placenta site tumours)  MODE OF DELIVERY: Lecture, Self-Directed Learning (SDL), e-learning, group discussions, peer learning, illustrations (charts), assignments. LEARNING RESOURCES: Classroom, skills lab, library, Models, charts, Textbooks, video shows COURSE ASSESSMENT: Summative (100%) Total 100% SUGGESTED READING CampbellS.andLeesC(2000).ObstetricbyTenTeachers,17 thEdition,London,OxfordPrintingPress. DaleR.Dunnihoo. (1990).FundamentalofGynaecology&Obstertrics:LondonJ.B.LippincottCompany.Philadelphia LawsonJ.BHarrisonK.A.andBergstrom.S. (2001).MaternityCareinDevelopingCountries:LondonRCO. Myles; (2010) Textbook for Midwives. African Edition; Churchill, Livingstone NursingCouncilofKenya(1998).ProcedureManualforNurses.3 rdEd.Nairobi.GovernmentPress. GeoffreyV.P.Chamberlain(1999).GynaecologyByTenTeachers.6 thEd.EducationalLowPricedBook sSchemefundedbytheBritishGovernment RossandWilson: (1996):Anatomy&PhysiologyinHealthandIllness.8 thEd.NewYork;Churchill,Livingstone. GYNAECOLOGICAL INVESTIGATIONS MS. KEMEI Gynaecological History History taking should place an emphasis on the gynaecological history of the patient. This does not mean that other histories should be ignored. For the sake of minimising repetition, you will not go through the whole process.  When taking a gynaecological history, you should enquire into the following: Menstruation Gynaecological operations Contraceptive History Sexual Behaviour Lifestyle Habits Summary Menstruation Menstruation, including the age at which she had her first menstrual period, that is, menarche equivalent to 'K', the length of the menstrual cycle, duration of the periods and the amount of blood loss and regularity as well as the date of the Last Normal Menstrual Period (LNMP). Gynecological Operations Take the history of any gynaecological operations, including the dates of operations. Possible gynaecological operations include dilatation and curettage, evacuation, laparotomy and hysterectomy and post-operative outcomes. Contraceptive History Take the patient's contraceptive history, especially on surgical contraceptions, including the type of contraceptive, duration of use, side effects and when she stopped using it. Sexual Behaviour Ask about the patient's sexual behaviour, noting that questions should be non- judgemental and you should not embarrass the patient. You should find out whether : she is sexually active the relationship is satisfactory and, if not, why if she has painful or difficult sex referred to as dyspareunia.  In case of infertility find out also whether intercourse is normal, frequent and what time in the cycle. if there is any post-coital bleeding or not. This information may well help you to detect any sexually transmitted diseases.  Lifestyle Habits Ask if she smokes or takes alcohol. Summary You should make a summary of the history you have taken by picking out the important positive and negative information obtained. This will guide you when performing a physical examination. PHYSICAL EXAMINATION A physical examination should be made up of: General abdominal vaginal examination. General Examination A general examination provides more information about a patient and also gives the clinician a chance to establish a rapport with the patient. General examination usually includes a check on: the vital signs the general condition of the patient. look for the development of secondary sexual characteristics, including breast development (palpate for masses) and body hair distribution, especially the pubic hair. Hair on the chest and chin in a female will mean that she has more androgens. Gynaecological tests Urine Urinalysis should be carried out to check the appearance of the urine, including colour and foam, chemical content such as protein and glucose, and micro-organisms such as bacteria and parasites. A pregnancy test, if indicated, may be performed. Blood Blood should be tested for haemoglobin levels (Hb) or full haemogram, Widal test and brucellosis test and also for VDRL (syphilis). Gynaecological tests cont’d Vagina and Cervix Urethral smears and pus swabs should be taken to test for neisseria gonorrhoea. Take a high vaginal swabs test for candida albicans, trichomonas vaginalis, and neisseria gonorrhoea. You should also perform a cytological test for cancer as well as a cervical biopsy for further histological assessment, which will be covered later in this unit. Uterus Dilation and curettage should be performed for diagnostic purposes as well as treatment in case of dysfunctional uterine bleeding. Specimens should be obtained for testing in the laboratory. Gynaecological tests cont’d Cytological Test/Papanicolao Test (Pap Smear) This is a test that should be carried out on women of reproductive age once every year. Cancer of the cervix is one of the leading causes of mortality among women worldwide. This test reveals the cancer in its early stages when it can be managed effectively. Cervical Biopsy This test can also detect problems on the cervix. It may be done as an office procedure without anaesthesia, whereby the lesion is visualised by a colposcope and one or more punch biopsies. A colposcopy is a binocular inspection of the cervix with a magnification of up to 20 times.  The patient is advised to rest for 24 hours after a biopsy and to leave the packing or tampon in place for the recommended time, usually 8 to 24 hours. Vital signs should be frequently checked and any excess bleeding reported. Sexual intercourse should be delayed until the physician indicates that it is permissible. Endoscopic Examination This examination involves entering the body organs by use of a scope. A scope is a special tubular instrument with a light attached to the end. When introduced into the hollow organs of the body they can be seen and studied. There are various types of endoscopic examinations. The pelvic endoscopy/culdoscopy involves the use of a culdoscope, which is a tubular, lighted instrument similar to a cystoscope or laparoscope. An incision is made in the posterior vaginal cul-de-sac (fornix) to admit the instrument.  It is commonly used to detect any pelvic masses. The patient is prepared as for vaginal operation and may be under local anaesthesia. The procedure is conducted in the operating room, with the patient in a knee-chest position. Laparoscopy Indications are similar to that of a culdoscopy. However, with laproscopy, it is also possible to perform minor operative procedures like tubal ligation, ovarian biopsy and lysis of peritubal adhesion.  During this examination, a scope (of about 10mm diameter) is inserted into the peritoneal cavity through a two centimetre sub-umbilical incision to allow visualisation of the pelvic structure. Dilatation and curettage follows, to position a surgical instrument, which permits manipulation of the uterus during the laparoscopy, thus affording better visualisation.  The coldlight endoscope is passed through the cannula and the inspection made. An assistant or the operator himself can move the uterus about by means of the forceps on the cervix and a dilator or Spackman's cannula in the uterus. A camera attached to the eyepiece of the laparoscope permits assistants and observers to share the surgeon's view on a video screen and permits video recording of the findings or procedure. Drapes are used during this procedure, but have been omitted in the illustration to allow unobstructed view.  Special biopsy forceps can be passed through another cannula and used to lift up any tissue that may be obstructing the view or to take ovarian biopsies. Some adhesions may be divided using laparoscopy scissors. Many procedures are now performed entirely or assisted by laparoscopy. Laparoscopy A better view of the pelvis, lower abdomen and visceral contents is also facilitated by injection of a prescribed amount of CO² intraperitoneally into the cavity (insufflation). This separates the intestine from the pelvic organs.  The procedure is performed under general anaesthesia, meaning patients have to be prepared preoperatively. The patient is carefully observed for several hours to detect any complications, for example, bleeding or burns from the coagulator. The observation includes monitoring vital signs and signs of per vaginal bleeding. Reassure the patient and discharge when the vital signs become stable. Hysteroscopy This procedure is indicated as a diagnostic measure only in complex situations, for example, infertility, unexplained bleeding and retained Intrauterine Device (IUD).  The hysteroscope is used to visualise all the parts of the uterine cavity. This procedure is best performed about five days after completion of menstruation (estrogenic phase of the menstrual cycle). This is because the fresh/new cells lining the uterine cavity can be studied properly in order to give accurate findings. Hysteroscopy cont’d Many radiological procedures, for example, x-ray films, barium enemas and intravenous urography, are helpful in the diagnosis of pelvic conditions. A few of the procedures specifically related to the diagnosis of gynaecological disorders will be covered here.  Hysterosalpingogram (Uterotubogram) This is an x-ray study of the uterus and uterine tubes after injection of a contrast medium. This is done to study sterility problems, tubal patency and/or the presence of pathological conditions in the uterine cavity.  A patient undergoing this examination should have her intestines evacuated by enema. 'Starve' the patient for at least four to six hours. Give analgesic for comfort since some patients may experience nausea, vomiting, cramps and faintness. Briefly explain the procedure to the patient and give reassurance. Observe the vital signs.  Hysterosalpingogram (Uterotubogram) The patient may feel some discomfort after the procedure. You should continue observing her vital signs and if the patient is not nauseated, give her food as soon as she can tolerate it. You should also provide plenty of fluids to flush the urinary system.  Computerised Tomography (CT Scanning) A CT scan can reveal the presence of cancer and its extension into the retroperitoneal lymph nodes and skeletal involvement. The CT scan has several advantages over an ultrasound and it is more effective, especially with obese patients and/or patients with a distended bowel or stomach. This is because it penetrates deep into the organ targeted and reveals more information about these organs. In preparation, the patient should be 'starved' before this procedure. Ultrasound This is commonly used and does not require any special preparation of the patient, except to ensure that they have a full bladder. This is because a distended bladder usually pushes the uterus out of the pelvic cavity allowing it to be properly viewed. It is used to diagnose pelvic tumours and other abnormalities. MENSTRUAL DISORDERS MS. KEMEI 41 Introduction Menstruation is a normal body event in every woman, even though for some it may be an uncomfortable experience. On a light note, however, there is an old adage that says 'the menstrual flow is the tears of a disappointed uterus'. 42 Objectives Describe factors that influence menstruation Describe the various menstrual disorders and their management 43 Factors Influencing Normal Menstruation The events occurring in the following organs influence the mechanism of normal menstruation: The hypothalamus influences the anterior pituitary gland to produce follicle stimulating hormone. The anterior pituitary gland produces follicle stimulating hormone, which matures the Graafian follicle under the influence of the hypothalamus. It also produces the luteinising hormone, which influences the development of corpus luteum to produce oestrogen or progesterone. The ovaries develop the Graafian follicle. The uterine endometrium thickens under the influence of oestrogen and progesterone, in preparation to receive the ovum. 44 Amenorrhoea Amenorrhoea is a symptom, not a disease. It is derived from the Greek word amenrein, which translates as follows: A... without Men... month Rein... to flow It can, therefore, be interpreted to mean 'without monthly flow', thus amenorrhoea means 'absence or cessation of menstruation'. The absence of menstrual periods can be physiologically normal. 45 Periods in a woman's life when amenorrhoea is considered normal. Before puberty, when the hormones concerned have not started functioning. During pregnancy, when the hormones concerned are diverted to the growth of the fertilised ovum. During lactation (after delivery), which results in lactation amenorrhoea due to the presence of prolactin. At menopause, when the hormones diminish and cease to be produced. 46 Primary Amenorrhoea Primary amenorrhoea means that menstruation has never occurred. This is seen in a young woman who is over 17 years of age and who has not yet begun to menstruate but exhibits signs of sexual maturation. Pathological primary amenorrhoea is when the patient has never menstruated and has not developed secondary sexual characteristics. 47 Primary Amenorrhoea Hormonal Factors This is due to the malfunctioning of the pituitary gland. As a result, the hormones responsible for sex maturation are affected, which in turn affects the beginning of menstruation. In Cushing's syndrome, the excessive production of cortisols may hinder menstruation from starting. 48 Developmental Anomalies During the development of the foetus, the vagina, uterus or ovaries may fail to develop. The congenital abnormality in the vagina that causes primary amenorrhoea is an imperforate hymen. In this case, the girl experiences all the feelings and discomforts of menstrual flow.. 49  There is actually menstruation and the blood accumulates behind the hymen, (in the vagina), but does not come out. This condition is known as cryptomenorrhoea and when not treated, the uterus distends, leading to what is known as haematometra. 50 The girl may present with abdominal pain and the absence of menstruation. The condition can be cured by an incision of the hymen to allow the blood to flow out freely. After the incision you should advise the girl to maintain high standards of hygiene. 51 The vulva should be cleaned three times a day until healed. Other causes include male pseudohermaphroditism (a male develops as a female) and Turner's syndrome where one has only one x-chromosome 52 Secondary Amenorrhoea Secondary amenorrhoea simply means that the periods, which were once present, have stopped. There are some women who have a longer cycle of up to two to three months and this is considered normal as long as it is regular. However, secondary amenorrhoea occurs after a normal menarche, which then ceases for more than six months. Six months is a considerable duration for it to be abnormal. 53 Hormonal Disturbances Hormonal disturbances in the pituitary gland can lead to hypopituitarism, especially after severe postpartum haemorrhage and collapse. This leads to pituitary cachexia/Sheehan's disease. In this condition, there is temporary deprivation of blood supply to the pituitary, leading to ischaemia. 54  This impairs the functions of the pituitary gland. In addition, disturbances in the adrenal gland, thyroid gland and/or ovaries can affect the influence of the hypothalamus on the pituitary gland. 55  Debilitating Systemic Disorders Chronic diseases that cause general ill health, for example, genital tuberculosis, or severe anaemia may lead to secondary amenorrhoea. 56 Nervous Disorders Any stress can act on the hypothalamus to inhibit follicle stimulating hormone/leutinising hormone-releasing hormone. This may lead to stress or hypothalamic amenorrhoea. Minor emotional upsets related to being away from home, attending college, tension from schoolwork or interpersonal problems are the most common causes of secondary amenorrhoea, especially in adolescents. 57  Other related disorders that cause stress include longstanding psychiatric disorders, especially depression or anxiety and stress due to exercise, which leads to exercise amenorrhoea. This is especially common in marathon runners. Others include brain tumours which may destroy the hypothalamus. 58 Drugs Contraceptives may lead to post contraceptive amenorrhoea and in some individuals it may take three to six months before the return of menstruation. This is because the ovulation had been suppressed and therefore had an effect on the hormones concerned. 59  Phenothiazines, especially in large doses, may lead to amenorrhoea due to prolactinaemia and certain hypotensive agents have also been implicated. You may remember (as mentioned in lactation amenorrhoea) that these drugs stimulate prolactin. 60  Dietary Amenorrhoea Loss of weight due to prolonged fasting will affect the hypothalamic function in ways which are not yet understood. Nutritional deficiency will also affect menstruation. Ovarian Cysts Ovarian cysts, especially follicular and corpus luteum cysts, cause amenorrhoea, however these tend to regress with time and menstruation resumes. 61 Oligomenorrhoea Finally, this is a type of amenorrhoea where there is infrequent menstruation, which may occur months before menopause and, at times, due to emotional upset. A woman with this problem should be investigated thoroughly to exclude other serious conditions, for example, neoplasms. You should reassure the patient if the cause of the condition is emotional. 62 Management of Amenorrhoea First, establish the cause of the condition. In each case you must take a detailed history and then carry out a clinical examination to rule out pregnancy. You should also consider the general health of the woman, including psychological and environmental factors. In the case of a young girl who appears normal on examination, it is better to wait until she is 18 years old but in the meantime reassure her and give her health education on sexuality. 63 Mngt: Investigations History Taking This is very important as it helps you make a distinction between primary and secondary amenorrhoea and, therefore, institute appropriate management measures. Some women have very infrequent and scanty bleeding, which is virtually primary amenorrhoea. If the patient is experiencing the physical disturbances of menstruation without actually bleeding, a cyclical change in the hormone level can be assumed and the cause of amenorrhoea is likely to be in the genital tract. 64 Pelvic Examination It is essential to exclude pregnancy or uterine hypoplasia (in virgins this is usually done under general anaesthesia). A bi-manual examination can reveal gross abnormalities such as cryptomenorroea. Remember to inspect the secondary sexual characteristics during pelvic examination. 65 66 Radiological Examination You should take an x-ray of the chest and a straight skull x-ray to detect enlargement of the sella turcica (pituitary fossa). You will remember the pituitary gland plays a great role and chronic diseases like TB can affect menstruation. 67 Endocrine Tests To find out the hormonal factors, the following should be carried out: Collection of urine samples for over 24 hours to measure levels of different hormones. Estimation of blood hormone levels. The hormones investigated are follicle stimulating, leutinising and prolactin. If there is hyper-prolactinaemia, then refer the patient to an endocrinologist for pituitary tumour investigation and management. 68  Laparoscopy This is done to detect any developmental anomalies. An ovarian biopsy can also be carried out during this procedure. Dilatation and Curettage This is commonly performed, especially in countries where tuberculosis is common. The presence of the acid- fast bacilli in the endometrial cells or any other organisms may be the cause of amenorrhoea. Others More recent technologies include the ultrasound or CT scan which detect various abnormalities. It can reveal the presence of tumours in the ovaries or the adrenal gland. 69 Management of Amenorrhoea The medical treatment will depend on the cause of the amenorrhoea. 70 Clomiphene Citrate (Clomid) If ovulation is the problem, then it can be induced using clomiphene citrate. This drug should be restricted to those individuals desiring pregnancy because it acts on the Graafian follicle. It can also be used in adolescents with recurrent ovulatory bleeding in an attempt to establish regular ovulatory cycles. The dosage initially given is 50mg daily for five days and ovulation is expected to occur five to eleven days following discontinuation. If there is no response, the dose is gradually increased up to 200mg. 71 Side effects of clomid include: Hyper-stimulation leading to enlargement of the ovaries. Multiple gestation because more than one ovum may mature. Abortion is common with patients treated for infertility. Teratology, that is, the increased incidence of congenital anomalies, if conception takes place while the woman is still taking the drug. Bloating, nausea and vomiting. 72 Human Menopausal Gonadotrophin (HMG) and Human Chorionic Gonadotrophin (HCG) Pergonal This is a preparation of leutinising hormone and follicle stimulating hormone extracted from human menopausal urine and is available in ratio of 1:1. The therapy is indicated when there is failure to ovulate even after clomid administration for six to twelve months. The dosage is HMG 375 units daily, increasing progressively up to 1500 units daily. 73 Bromocriptine This is effective as an ovulatory agent in most patients with hyperprolactinaemia from an anaplastic source. It acts by suppressing the central and peripheral concentrations of prolactin, so that its level stimulates the production of oestrogen and progesterone. The dosage initially is 2.5mg up to four weeks. 74 Other Agents Other agents used for the induction of ovulation include glucocorticosteriods (dexamethosone 0.5mg nocte, prednisone 0.75mg) and oestradiol (estrogen). 75 Surgical Management Pituitary tumours may require excision. 76 OTHER Do not forget that emotional disturbance is one of the features that cause amenorrhoea. Such patients will require psychotherapy to relieve the tension/stress. Through history taking, you may be able to get clues to any emotional stress and try to allay the patient's anxiety. 77 Dysmenorrhoea Dysmenorrhoea means painful menstruation. Some women experience pain and discomfort during menstruation and many will learn to live with it. However, in some women the pain is severe enough to make the woman seek treatment. There are two types of dysmenorrhoea: Primary Dysmenorrhoea (also known at Spasmodic Dysmenorrhoea) Secondary Dysmenorrhoea (also known as Congestive Dysmenorrhoea) 78 Primary(or Spasmodic) Dysmenorrhoea You may have come across young girls seeking treatment due to abdominal pain during menstruation. This is a common complaint and usually starts soon after puberty, although the first few cycles may have been painless. The pain starts at the beginning of the period and lasts from a few hours to two days. This pain is 'cramp-like' and is felt in the pelvic and lower back region, and may radiate into the legs. Severe pain is sometimes accompanied by nausea, vomiting and fainting. These reactions may encourage the woman to seek treatment. The causes of this condition are not well known but several theories have been put forward. It may probably be caused by ischaemia due to prolonged contraction of the uterine muscle occurring in the first day of menstruation. The ischaemia means that oxygen to the uterine muscle is cut off accounting for the pain. In this case, it is said that childbirth may cure this condition since after the uterus has held the baby, it is more vascular and so not easily ischaemic. 79  It has also been posited that dysmenorrhoeic uteri are hypoplastic but there is no evidence. Endocrine abnormalities have occasionally been implicated, probably due to the imbalances. Prostaglandins from disintegrating endometrium may cause uterine spasms (that is why in cases of dysmenorrhoea the concentration of PGF2 in menstrual fluids is increased). Psychological factors undoubtedly aggravate symptoms, for example, there may be fear of sexual or reproductive abnormalities, leading the uterus to spasm. Cervical stenosis also seems to be a factor. It is believed that during pregnancy and delivery the stenosed cervix is dilated hence the reason the problem may disappear after delivery. 80 Management of Primary Dysmenorrhoea Unfortunately, a spontaneous cure does not occur soon enough for most women who suffer from primary dysmenorrhoea. Therefore, as part of your management, you should perform the following: Take history with special reference to the severity and duration of the pain. Perform a physical examination to exclude pelvic tumours. Give a full and frank discussion of the normal cycle as this is an important part of treatment. Share health messages on the importance of exercise and the avoidance of unnecessary restriction of general activities. Provide women suffering from dysmenorrhoea with sympathy and support. Administer a suitable drug which will alleviate the pain sufficiently to allow a normal existence during the period time. Fortunately, patients tend to improve or at least complain less as they grow older. 81  Drugs that can alleviate pain include any antipyretics and analgesics. These should be the most effective drugs to inhibit the synthesis of prostaglandin, that is, if the prostaglandin's theory is correct. These include aspirin and paracetamol, which are widely used and usually prescribed as two tablets three times daily. Mefenamic acid (ponstan) 500mg three times daily is also common. This drug is said to prevent the action of prostaglandin on muscles as well as inhibit its production. Other drugs include flufenamic acid (arlef) and indomethacin (indocid). Many of these drugs are usually prescribed for the relief of rheumatic pain but have been used with success in dysmenorrhoea. 82  Another effective management method is the contraceptive pill. In a small number of girls, when simple measures fail, they can be put on the family planning pill which, by inhibiting ovulation, will result in painless periods. These few individuals should be placed on the pill for four to six months continuously, after which the problem may disappear completely. This is achieved with a high-progesterone, low-oestrogen combined pill, for example, minovular. Surgery, in the form of pre-sacral neurectomy, may be offered as a last resort to a patient whose dysmenorrhoea cannot be relieved by any other means and is interfering with her daily life. 83 Secondary (or Congestive) Dysmenorrhoea This type of dysmenorrhoea may be caused by some pathology in the pelvis. The patient usually complains of a dull aching pain in the lower abdomen. The pain commonly begins three to four days (or sometimes up to ten days) prior to menstruation, and ceases after the flow is established or may persist throughout the period. Pain is often made worse by exercise. 84 Causes Chronic Pelvic Inflammatory Diseases (PID) Endometriosis Uterine fibroids Abnormal fibrous attachments (adhesions) Salpingitis In Kenya, the most common cause of secondary dysmenorrhoea is chronic PID and also with most women complaining of infertility. Treatment of the cause will usually relieve the dysmenorrhoea, but as you know successful treatment of chronic PID is difficult and so prevention should be emphasised. 85  Management of Secondary Dysmenorrhoea Take a full history to find out the cause of the condition, so that the patient can receive treatment according to the cause. 86 Pre Menstrual Tension Syndrome (PMT) This condition is due to a large group of symptoms, which appear regularly and predictably about 12 days before the onset of menstruation. This group of symptoms includes: Water retention leading to weight gain, painful breasts, abdominal distension and feeling of bloatedness. Pain in the form of backache, headache, tiredness and muscle stiffness. Autonomic reaction, for instance, dizziness/faintness, cold sweats, nausea and vomiting and hot flushes. Mood change, including tension, irritability, depression and crying spells. Loss of concentration, manifested as forgetfulness, clumsiness, difficulty in making decisions and insomnia (poor sleep). Miscellaneous symptoms, including feelings of suffocation, chest pains, heart pounding, numbness and tingling sensation. 87  Patients with the symptoms of PMT can be relieved by giving them diuretics, for example, chlorothiazide in the pre menstrual week. They can also benefit from oral contraceptives, for instance, progesterones like norethisterone 20mg daily from the 15th to 25th day of the cycle. Tranquillisers and psychotherapy also appear to be equally effective. Patients should be told about the physiology that is producing these symptoms because they may think they have a terrible disease and the worries may increase the intensity of these symptoms. Dietary management involves taking a low salt diet and avoiding alcohol and caffeine. Exercise is also recommended to relieve the symptoms. 88 Dysfunctional Uterine Bleeding (DUB) Dysfunctional uterine bleeding is diagnosed by exclusion of the conditions, which cause bleeding from the uterus. The conditions to be excluded include: Infection Ruptured ectopic pregnancy Trauma Uterine fibroids and polyps Genital cancers Hormonal treatment Once you have excluded the conditions mentioned above, the cause of DUB is most likely to be hormonal imbalance, which is associated with involuntary periods. As there is very little you can do, you should refer all patients with abnormal uterine bleeding to the hospital for investigations and management. 89  In the hospital, teenage girls who have just started menstruating should be given a combination of oestrogen and progesterone. The contraceptive pill is a good option and treatment should be continued for three to six cycles. After treatment is stopped, menstruation often returns to normal. For women in the reproductive age group, true dysfunctional bleeding is uncommon. The most likely cause of abnormal bleeding at this age is some complication of pregnancy. Diagnostic curettage is needed and you must remember the possibility of malignant disease. In women over 40 years of age all the organic causes of bleeding, including malignant disease, may occur. Accurate diagnosis, including curettage is essential. 90 Menorrhagia Menorrhagia is a normal cycle with an excessive loss of blood (heavy menstrual flow). The normal average volume of menstrual loss is approximately 70ml. Menstrual loss is naturally greater in parous women. Menorrhagia is clinically an important condition because this excessive bleeding results in anaemia. It is not a disease but a symptom and to treat it one must find out what is causing it. The best way to manage this condition is to refer the patient to hospital where investigations will be carried out and managed appropriately. 91 Most Common Causes Fibroids due to a larger endometrial cavity hence larger bleeding areas Chronic PID Endometrial polyps Abnormalities in the blood clotting power, for example, leukaemia, thrombocytopenic purpura Abnormal hormonal state, leading to excessively thick endometrium, which bleeds heavily when shed Emotional factors, which can sometimes cause heavy bleeding Intrauterine contraceptive devices 92 Management of Menorrhagia History taking followed by pelvic examination. Investigations of blood for abnormalities and checking Hb, grouping and cross-matching. Dilatation and curettage under general anaesthetic. This procedure may be curative if there is not any other abnormality. The patient should be prepared preoperatively and postoperative care should be provided as for any other surgical procedure. Older women can be better treated by a hysterectomy. 93 Metrorrhagia This is menstrual bleeding lasting too long. It is caused by irregular shedding of the endometrium because the corpus luteum degenerates too slowly and the progesterone effect persists. Some secretory endometrium is still present early in the following cycle. The causes of this disorder are: The possibility of cancer of the genital tract with this kind of bleeding. Uterine polyps projecting into the vagina may cause bleeding. Incomplete evacuation after abortion. Hydatid form mole. Chorion carcinoma. Occasionally women on oral contraceptives may have what is called 'break through bleeding'. 94 Management of Metrorrhagia Taking a detailed history. Performing a digital examination and speculum to visualise the cervix and even take a Pap smear, therefore, the patient should be referred to the gynaecologist as soon as possible. 95 Epimenorrhoea This is when normal menstruation occurs too often due to a shortened luteal phase by early degeneration of the corpus luteum. 96 Management of Epimenorrhoea A detailed history to establish the cause. Refer all patients with abnormal bleeding to hospital for investigations and treatment. In the hospital teenage girls who have just started menstruating should be treated with a combination of oestrogen and progesterone contraceptive pill, which should be continued for three to six cycles. Meanwhile the patient should also be given iron to help replace any blood lost. In women of the reproductive age group, diagnostic curettage is needed. Remember the possibility of malignant diseases. Curettage may cure the condition, but if it does not, a hysterectomy may be the best option leaving the ovaries intact. 97 Hypomenorrhoea This is when the period occurs on a regular basis but is minimal. For example, there are rare cases whereby a woman menstruates regularly twice or thrice in a year. This is considered to be normal although you may be able to guess what problems this woman may have? 98  Client D a form 2 student presents to the clinic with complains of painful period. What interventions would you institute as a nurse Describe the health messages you would give to this client 99 BLEEDING DISORDERS IN PREGNANCY Ms. Kemei Objectives State the different types of abortion Specify the causes of abortions Describe the management of at least three types of abortion Describe signs and symptoms of ruptured ectopic Describe the management of ruptured ectopic Bleeding in Early Pregnancy Vaginal bleeding in early pregnancy refers to any bleeding per vagina that occurs before the 28th week of pregnancy. In the early months of pregnancy, bleeding may be due to a number of factors or conditions. Conditions that cause bleeding in early pregnancy a) Abortion b) Ectopic pregnancy c) Hydatidiform mole d) Chorion carcinoma The most common cause of bleeding in early pregnancy is abortion. Abortion accounts for 95% of all bleeding in early pregnancy, whilst all the others account for only 5%. ABORTION Abortion is defined as the loss or expulsion of the foetus before the 20th week of pregnancy. Abortion is significant not only because of the loss of a wanted pregnancy, but because it is a major cause of maternal death from the haemorrhage and sepsis that may follow a mismanaged abortion. The definition of abortion generally accepted for legal purposes is 'the delivery of a foetus at less than 20 weeks gestation or with foetal weight of less than 500gm'. Many people tend to look upon abortion as pregnancy that has been terminated criminally and miscarriage as a spontaneous occurrence. As a result, abortion is stigmatised, however, the two are the same thing. CAUSES OF ABORTION Maternal causes of abortion account for about 25% of the known cases of abortions and they include the following: General diseases like hypertension or chronic heart disease. Acute febrile illnesses, for example, malaria, acute pyelonephritis, pneumonia. Endocrine disorders, for example, thyrotoxicosis, poorly controlled diabetes mellitus. Local conditions such as under development of the uterus, fibroids and congenital abnormalities of the uterus. The fibroids can cause abortions, especially if they are submucous or deeply intramural. The congenital abnormalities of the uterus include a septate uterus and a bicornuate (uterus divided into two) uterus. Cervical incompetence which may be due to either congenital weakness of the circular muscle fibres of the cervix, or previous splitting of the cervical sphincter due to obstetrical trauma, or high amputation of the cervix due to cervical lesions.  Foetal causes of abortion account for about 75% of the known cases and they often result in early abortion, that is, first trimester abortions. Foetal causes may be due to: Chromosomal or genetic abnormalities. Abnormal attachment of the placenta, that is, defective implantation or activity of the trophoblast.  In addition to maternal and foetal causes, there are those that are grouped as miscellaneous causes. These include: Accidents, for example, falls, and injuries. The incidence of abortion among these cases varies enormously from individual to individual after the accidents. Criminal interference, using various instruments, local herbs and plastic catheters, which are inserted into the cervical canal. An Intrauterine Contraceptive Device (IUCD). An abortion, especially in the second trimester can occur if conception occurs despite the presence of an IUCD. Note that ectopic pregnancy, antepartum haemorrhage, premature rupture of the membranes and manual removal of the placenta occurs more commonly in pregnancy with an IUCD. Therefore, the IUCD should be removed as soon as pregnancy is diagnosed. Causes of Abortion Most of these abortions occur in the first three months of the pregnancy, before the placenta is mature. Abortion is the detachment of the products of conception, which is accompanied by bleeding that may be profuse. Blood loss is accompanied by painful contractions of the uterus, dilation of the cervix and expulsion of the foetus and its membranes. Slight or even moderate bleeding does not, however, mean that the foetus is no longer alive. As a health worker you must do all you can to save life at all times. Types of Abortion Threatened Abortion Inevitable or Imminent Abortion Missed Abortion Habitual Abortion Septic Abortion Induced Abortion Threatened Abortion The patient with threatened abortion will have slight vaginal bleeding and abdominal discomfort. When you examine her you will find the os of the cervix closed. While many patients will successfully carry this type of pregnancy to term, others may not. It is essential, therefore, to make the patient realise that nothing can be done to prevent an abortion. Threatened Abortion Slight placental separation, slight bleeding, os closed. Threatened Abortion Here are some essential measures to take: Reassure the patient that, if she continues with the pregnancy, the foetus will not be at greater risk of abnormalities and that it will continue to grow just like in a normal pregnancy. Ensure bed rest and allay anxiety (of losing the pregnancy) by administering tabs. Phenobarbitone 30 to 60 mgs tds, morphine 10 mgs or pethidine 100 mgs.If the pain is stronger, some doctors may use progesterone. Warn the patient to notify the medical team if the cramps become worse or the bleeding becomes heavy. Ask her to save the pads as well as any tissue or clots that she might expel, for examination. Advise her to take a low residue diet and avoid aperients and enema because this will stimulate the contractions. Advise her to remain in bed for at least three days after the bleeding stops. Advise her to avoid heavy physical activities and especially sexual exciteme Inevitable or Imminent Abortion Inevitable or imminent abortion means that nothing else can be done. The foetus must come out. The abortion becomes inevitable if, in addition to vaginal bleeding and abdominal discomfort, the uterine contractions become strong and painful and lead to dilatation of the cervix. This is followed by either complete abortion or incomplete abortion. The primary measure taken is to save the life of the patient since there is often profuse bleeding, especially in patients who end up with an incomplete abortion. Take the patient's history to determine if the products of conception have been expelled. Incomplete Abortion Placenta and membranes are retained. Foetus is expelled.  Inevitable or Imminent Abortion Many patients will come to the hospital due to severe bleeding, which means that the products of conception have been retained. Since there is essentially no chance of the pregnancy progressing any further under these circumstances, the uterus should be emptied immediately.  If the patient has excessive blood loss, hasten the evacuation by administering an oxytocic drug. Bleeding that does not cease after the expulsion of the products of conception will require administration of ergometrine 0.5mg stat. Take blood for grouping and cross-matching then fix a drip of plasma expanders or normal saline/Hartman's solution. Give a strong analgesic to relieve pain. Severe pain can lead to shock.  Complete abortion Placenta, foetus and membranes are all expelled.  Inevitable or Imminent Abortion Save anything passed per vagina to inspect if all products of conception have been passed. Observe infection prevention principles while performing vaginal examinations to remove any placenta tissues distending the cervix. A finger or sponge forceps is used to remove the products of conception. Observe bleeding and if the temperature is normal after the evacuation of contents, the patient can be discharged. Incomplete abortions occur when some, but not all, of the products of conception are expelled from the uterus. The retained products prevent the uterus from contracting completely, which results in bleeding from uterine blood vessels.  Patients generally experience severe cramping and profuse bleeding, and receive intravenous (IV) fluids and possibly blood products. Generally, a D&C is performed to remove the retained products of conception. Additionally, patients may receive medications such as oxytocin (Pitocin) or methylergonovine (Methergine) to contract the uterus and stop the bleeding. Complete abortions occur when all of the products of conception including the fetus and placenta are expelled from the uterus. The cervix closes, and cramping and bleeding stop. patient is advised to notify her healthcare provider of any additional bleeding, pain or symptoms of infection, such as fever or foul-smelling vaginal discharge. Missed Abortion This means that the products of conception are not expelled despite the signs and symptoms of abortion. It occurs when abortion is threatened but the bleeding ceases and all is apparently well, except that signs of pregnancy subside, breast activity stops, and the uterus does not grow bigger. After some time (about eight weeks) a brownish discharge from the vagina appears. This shows that the foetus is dead but still in the uterus. It degenerates into a solid mass of mostly organised blood clot called a carneous mole. This mole will in time be expelled with little or no loss of blood. This may be hastened by the administration of ergot and stilbesterol by mouth.  Refer all suspected cases of missed abortion to hospital for management as it may be necessary to carry out a surgical evacuation as well as to check the uterus for any abnormalities by performing an ultrasound.  Missed Abortion Foetus is dead and there is retained placenta. There is also a brown vaginal discharge.  Habitual Abortion This is when a woman has had three or more successive abortions. In the majority of cases, the cause is not obvious. Some of the known causes however, include the following: Chronic illness, for example, diabetes mellitus. Abnormalities, for example, septate uterus and cervical incompetence being the most common, especially in late abortions. Endocrine or genetic causes, especially if it occurs before 14 weeks. Infections, for example, syphilis. Habitual Abortion In the management of this patient, the following is performed: Take history and carry out a physical examination to establish the cause. Deal with the causes that can be managed, for example, if it is syphilis then treat. Advise on proper dietary intake, together with thyroid and hormonal supplements (but not diethylstilbestrol or other oestrogens). Establish a therapeutic supportive relationship with the patient to help her overcome the loss of her pregnancy. Surgically correct the obvious abnormalities of the genital tract, like removal of myomas and repair of an incompetent cervix. Provide appropriate pre and postoperative care as for any other surgical patient. Septic Abortion In the past, this type of abortion was associated with the criminal interference of a pregnancy. However, it may occur in a spontaneous abortion, if there has been bacterial contamination. Septic abortion is usually caused by gram-negative Escherichia Coli (E. Coli) but sometimes gram-positive streptococci and staphylococci are also involved. In most cases, the infection is mild and limited to the uterus. The infection may be limited to the tubes or it may spread to the peritoneal cavity and cause peritonitis. Severe E. Coli infection may lead to septicaemic shock due to endotoxins released by the organism, thus leading to total vascular collapse (death). S/S Fever due to the infection Fast, rapid pulse rate due to the infection and fever Offensive smelling vaginal discharge Tender lower abdomen on palpation Bright red blood continues to be lost Septic Abortion The management will include: Resuscitating with intravenous fluids. Administering antibiotics, both broad spectrum and perinatally. Evacuating infected products of conception as soon as possible. Taking history with an emphasis on why the abortion was performed. Taking relevant specimens for investigation. Ruling out infection in other systems. Assessing urinary output to rule out renal function interference. Monitoring vital signs carefully since a high temperature and rapid pulse will indicate the severity of the infection. Taking cervical swab for culture and sensitivity in order to institute treatment according to the findings. Encouraging plenty of fluid intake in order to flush the system of the toxins and correct dehydration. Performing vulva toilet four hourly with antiseptic. Administering tetanus toxoid or anti-tetanus serum 0.5 mls for treatment. Induced Abortion Induced abortion is an abortion that is intentionally caused. It is commonly associated with young unmarried women, especially schoolgirls or even married women who get pregnant due to contraceptive failure. However, an induced abortion can also be performed for medical reasons. There are two types of induced abortion: Therapeutic (which is performed on medical grounds) and Criminal (which is illegal). Criminal abortions Criminal abortions are sometimes attempted by an unqualified person. The operation is often hurried and lacking asepsis. The complications of criminal abortions include: Haemorrhage. Sepsis, which is usually severe and can lead to septicaemia and endotoxin shock. Haemolysis and renal damage may occur secondary to the septicaemia. Injuries to the birth canal and pelvic organs. Sudden death due to extreme syncope as a result of dilatation of the cervix and in some cases from amniotic embolism. Therapeutic abortion According to medical ethics, a therapeutic abortion may be carried out only if two registered medical practitioners are of the opinion that the pregnancy should be terminated. There are two specific circumstances when this can be done. These are: If the continuance of the pregnancy would involve a risk to the life of the pregnant woman or of injury to her physical or mental health. If there is a substantial risk that the child, when born, would suffer from physical or mental abnormalities and be seriously handicapped.  Induced Abortion The illustration below shows the outcome of therapeutic and threatened abortions. Note that threatened abortions are usually spontaneous. Post-Abortal Care (PAC) PAC comprises the comprehensive health care provided to patients with problems of incomplete abortion. It has three interrelated components, which are: Emergency treatment of complications arising from spontaneous or induced abortion. Family planning counselling and services. Access to comprehensive reproductive health care. These are the major components for PAC, which various health care providers/groups may provide. You should ensure the control and prevention of cross-infection when performing procedures.  Care After Manual Vacuum Aspiration (MVA) You should check the patient's vital signs, severe vaginal bleeding and general condition and allow the patient to rest comfortably. Patients that have been treated should receive after care guidance, which includes: Explain/counsel patient before discharge that she will be at risk of repeat pregnancy for up to two weeks following treatment. Counsel her on a variety of safe contraceptive methods that can be used immediately to avoid pregnancy for the body to return to its normal state. Explain where and how to get family planning. Counsel on all available family planning methods to enable the patient to make an informed choice of family planning methods. Explain how to use the selected family planning method. Explain that family planning methods, other than condoms do not provide protection against STI/HIV/AIDS. SPECULUM EXAMINATION Care after MVA As mentioned on the previous page, patients that have been treated should receive after care guidance, which also includes: Informing her about symptoms that would require the patient to return immediately to the facility and the action she should take. Advising her on signs of recovery when normal menstruation may resume. Advising her on personal hygiene and when to resume sex. Providing the method of choice to the patient. Helping the patient to cope with the pregnancy loss. Allowing grieving. NURSING CARE identifying and controlling bleeding and hypovolemic shock. The nurse should anticipate the need for oxygen therapy and fluid and blood replacement. administering medications; for example, oxytocin (Pitocin) may be used to help in expelling the products of conception or to control bleeding. monitor vital signs, oxygen saturation, intake and output, and laboratory results according to institutional policies. If a patient experiences a threatened abortion but the fetus does not die, the nurse may be responsible for monitoring fetal heart sounds and the overall well- being of the fetus depending on gestational age. administer prescribed Rhogam to Rh-negative patients within 72 hours to prevent isoimmunization. help the patient explore her feelings regarding an actual or potential loss. ECTOPIC PREGNANCY MS. KEMEI Ectopic Pregnancy (Extrauterine Pregnancy) The term ectopic is derived from a Greek word, which means 'out of place'. Ectopic pregnancy is a condition in which the zygote becomes implanted in a place outside the uterine cavity. The most common site of ectopic gestation is inside one of the fallopian tubes and this is called a tubal pregnancy. Other sites where the zygote can implant outside the uterine cavity The ovary The cervix The abdominal cavity Location & occurrence frequency KEY A Ampulla Cx Cervix F Fimbrial I Interstitial Ov Ovary C Cornua Is Isthmus Ab Abdominal Cavity Ectopic pregnancy cont’d The most common type of ectopic pregnancy is the tubal pregnancy, occurring in at least 55% of ectopic pregnancies. This type of pregnancy is common in the tropics because of the high incidence of blocked tubes due to gonorrhoea, puerperal and post abortal sepsis, and Pelvic Inflammatory Diseases (PIDs). Ectopic pregnancy cont’d The ovum is fertilised in the fallopian tube but the zygote is unable to reach the uterine cavity because of loss of mobility and ciliary action. Therefore, the ovum may be arrested at: The fimbriated end of the tube, which is an uncommon site. The ampulla which is the most common site. The isthmus which is the most dangerous site because of the frequency of tubal rupture at about four to five weeks. The interstitial part of the tube in which rupture begins at second trimester. It is also an uncommon site. Ectopic pregnancy In many African countries, including Kenya, ruptured tubal pregnancy is the most common surgical emergency in women. Consequently, it is very important that you know how this condition presents and how it is managed. Common Causes Previous inflammatory process in the tube or acute PID, which will heal with scarring tissue and block the tube. Peritoneal adhesions secondary to previous surgery due to, for example, appendicitis, may cause occlusion. Endometriosis whereby the endometrial tissue is lodged in the tube and occludes the tubal lumen. Congenital anatomical irregularity often due to presence of diverticula of the uterine tube. Tubal surgery. Pathophysiology Once the implantation has occurred in the tube, the sequence of events associated with pregnancy follows. The corpus luteum remains and grows, producing progesterone, which increases the thickness of the endometrium and ensures that it is not shed, so that the patient misses the period. The tube is not, however, able to nourish the ovum for long and bleeding detaches the ovum. The ovum may be ejected into the peritoneal cavity through the fimbriated end. The onset of pain may be gradual or it may occur dramatically. Symptoms and Signs Unfortunately, an ectopic pregnancy causes very few symptoms until the foetus has become large enough to rupture the fallopian tube. This, therefore, makes it very difficult to diagnose an ectopic pregnancy before it ruptures. That is why it is very important that you refer a patient to hospital on the slightest suspicion of ectopic pregnancy. The muscle wall of the tube does not have the capacity of the uterine muscle for hypertrophy and distension and tubal pregnancies nearly always end in rupture and the death of the ovum. Symptoms and Signs of Ectopic Pregnancy Before Rupture You should suspect an ectopic pregnancy before rupture if a woman comes to you with the following complaints: Amenorrhoea of two or three months (common in about 80% of cases). The patient may sometimes present with a ruptured ectopic even before the expected date of the next period. Vague lower abdominal pain, which the patient might ignore. This is due to slight leakage of blood from the tube, which causes localised peritoneal irritation. It may also be due to the distension of the tube by the growing foetus. On examination the patient is usually healthy. You might feel a slightly enlarged uterus or a mass on one side of the uterus. Symptoms and Signs of Ectopic Pregnancy After Rupture When the tubal pregnancy ruptures, usually after two to three months, the patient presents with the following complaints. For the acute type of rupture, also known as fulminating, they complain of: Sudden onset of low abdominal pain. Vomiting and fainting because of the sudden intraperitoneal bleeding. Vaginal bleeding, this may not develop until many hours after the rupture. If bleeding is rapid it may lead to hypotension and shock. For the chronic leaking type, the patient complains of: Suffering for some time from abdominal uneasiness. Pain. Occasional fainting. Haemorrhagic slight bleeding. Symptoms and Signs of Ectopic Pregnancy The chronic rupture is the most common type of rupture of tubal pregnancy that you are likely to encounter. Unfortunately, in many cases, whenever health workers talk about an ectopic pregnancy, they only think of the acute type, that is a woman who develops sudden severe abdominal pain and collapses. You must remember that not all ectopic pregnancies present in the acute type. In fact, in clinical practice, some of these patients have been wrongly managed as either threatened abortion or acute pelvic inflammatory disease. That is why an ectopic pregnancy has been called 'the great deceiver'. Acute Rupture of Ectopic Pregnancy On examination you might detect the following signs:  The patient is in agonising pain and is restless.  She is sweating, yet her skin feels cold and her palms are wet.  She yawns frequently as if hungry for air.  The radial pulse is rapid, weak and thready. The blood pressure may be very low or unrecordable.  The temperature is usually normal.  The abdomen is very tender with muscle guarding. Signs of free fluid in the peritoneal cavity, such as a fluid thrill and shifting dullness, might be detected if the patient can tolerate the examination. However, the absence of these signs does not mean that there is no free blood in the Acute Rupture of Ectopic Pregnancy On EXAMINATION: A pelvic examination is very painful and it is difficult to palpate the organs properly so it is important that you remember to be very gentle. There is extreme pain on moving the cervix with the examining fingers, that is, the cervix is excitable. The uterus is often slightly enlarged and a tender mass might be felt on one side of the uterus. A tender mass may also be palpated in the pouch of Douglas if blood is clotted there. This is also known as pelvic haematocele. The patient is usually anaemic.  Differential Diagnosis of the Acute Ruptured Ectopic Pregnancy A ruptured ectopic gestation may be confused with many other conditions such as acute pelvic inflammatory disease, rupture of a gastric or duodenal ulcer, fulminating appendicitis, torsion of the pedicle of an ovarian cyst, acute pyelonephritis and/or rupture of a corpus luteum with intraperitoneal haemorrhage. An abortion, bleeding usually precedes pain, while in ruptured tubal pregnancy pain almost invariably precedes bleeding. Chronic Leaking Ectopic Pregnancy In this type of pregnancy, it is very important to note the clinical history of the patient. You should check for the following: Abdominal pain and uneasiness, where the pain is generally situated low down in the abdomen and, often, is more marked on one side. It is continuous and is not relieved by pressure, as is the case in intestinal colic. Sometimes the act of emptying the bladder initiates a bout of pain. In a few cases the patient complains of a frequent inclination to go and pass stool. Amenorrhoea is usually present, with irregular vaginal bleeding, which is usually slight and often dark brown in colour. It is not uncommon to attribute this discharge to threatened abortion. Occasionally there is expulsion of a decidual cast, especially if the pregnancy has gone beyond two months. The patient will give you an impression that she had a miscarriage. In some cases the health worker may carry out an evacuation thinking the patient has experienced an incomplete abortion. Occasionally there is a feeling of nausea, vomiting and fainting attacks. Remember that sudden faintness is a characteristic symptom of ectopic gestation.  Chronic Leaking Ectopic Pregnancy When you examine the patient you are likely to find the following signs: Anaemia of variable degrees. Rapid pulse. Normal or low blood pressure. General tenderness and guarding in the lower abdomen, which is more marked on one side. There may be a tender, firm mass in one of the iliac fossae. On vaginal examination you will feel a tender mass in one of the fornices.  Management of Ectopic Pregnancy A patient with tubal pregnancy will require an emergency operation. The patient should be immediately referred to a hospital. Start an intravenous drip of normal saline before transferring the patient. During the transfer, ensure that you treat the patient for shock and administer analgesics like morphine or pethidine for the pain. Potential blood donors should accompany the patient to hospital where possible. In the hospital, the following diagnostic tests may be performed: Ultrasonography. Culdocentesis whereby non-clotting blood will be aspirated from the cul-de-sac. Human Chorionic Gonadorophin (HCG), which involves urine testing. Mngt cont’d Blood is taken for grouping and cross-matching and a blood transfusion is started. An emergency laparatomy is then performed to ligate the bleeders. The affected tube is usually removed by salpingectomy or salpingotomy, which involves making an opening in the tube. It may be possible to give an auto-transfusion to a patient with a fresh rupture of a tubal pregnancy. Auto-transfusion involves scooping blood from the opened abdomen with a small gallipot and pouring it through a filter made of three or four layers of gauze into a sterile bowel or jug containing sodium acid citrate solution, which is an anti-coagulant. When 500ml of blood have been collected it is decanted into a sterile bottle, which is then set up on a drip that is already running. Sometimes the blood is aspirated directly from the peritoneal cavity into a plastic transfusion bag containing sodium citrate solution. Mngt cont’d Auto-transfusion is not advisable if: The history of the patient suggests that heavy bleeding began more than 24 hours before the operation. The blood appears discoloured or haemolysed. There is an offensive odour when the abdomen is opened. The advantages of auto-transfusion include: No risk of transmitting HIV. Blood is easily available and perfectly compatible. Mngt cont’d However serious the patient's condition appears to be, this operation has an excellent success rate. Post- operatively, the patient should be managed in the same manner as for any other abdominal operation. After surgical treatment, there are several potential outcomes. Another tubal pregnancy will occur in about 10% of the cases treated. Infertility develops in approximately half of the patients who have undergone surgery for the treatment of an ectopic pregnancy. Of these about 30% become sterile. Normal pregnancies are achieved in about half of patients who have one ectopic pregnancy.  Patient B presents to the outpatient department with a ddx of ruptured ectopic pregnancy A. describe the immediate nursing management for this client B. what health messages will you give patient B on discharge C. state 3 possible complications of ruptured ectopic pregnancy ENDOMETRIOSIS MS. KEMEI DEFINITION Endometriosis is most simply defined as the presence of endometrial surface epithelium and/or the presence of endometrial glands and stroma outside the lining of the uterine cavity. One of the first definitive descriptions of endometriosis as a specific clinical condition was by Sampson in 1921.  These ectopic endometrial tissues respond in varying degrees to the clinical changes in ovarian hormones. Unlike normal endometrium, they do not have an ordered blood supply, but there is an in-growth of new capillaries. Cyclical bleeding can occur within, and from, the endometriotic deposits and this contributes to a local inflammatory reaction.  With healing and subsequent fibrosis, overlying peritoneal damage will lead to adhesions between associated organs. Ovarian implants lead to the formation of chocolate cysts or endometriomas. Endometriosis occurs only in tissues adjacent to the Mullerian systems (a pair of ducts in the female foetus which develop into reproductive system). The theories, which explain the occurrence of endometriosis include that it may be disseminated by means of the lymphatic and vascular system, which is why endometrial tissue may be found in the umbilicus, forearm and thigh. SUBTYPES Free implants Enclosed implants Healed lesion Ovarian endometriosis  Endometriosis is also strangely common in social groups where childbearing is delayed to the late twenties or early thirties. This might explain why it is rarely diagnosed before the age of 20 years and not apparent after menopause. Physical signs will depend on the site of the disease and they include: SYMPTOMS Site Symptoms Female reproductive tract- Dsymenorrhoea Lower abdominal and pelvic pain Dyspareunia Rupture/torsion endometrioma Low back pain Infertility Urinary tractCyclical haematuria/ dysuria Ureteric obstruction Gastrointestinal tractDyschezia Cyclical rectal bleeding Obstruction Surgical scars/umbilicus- Cyclical pain and bleeding Lung- Cyclical haemoptysis Haemopneumothorax DIAGNOSIS vaginal examination – thickening or nodularity of the uterosacral ligaments tenderness in the pouch of Douglas an ovarian mass or masses a fixed retroverted uterus.  Ultrasound MRI laparascopy MANAGEMENT Analgesics Combined oral contraceptives Danazol/ gestrinone Progestogens Gonadotrophin releasing hormone agonists SURGERY Conservative- laser Definitive RAPE RAPE: DEFINITION Rape is defined as any sexual act performed by one person on another without consent. It may result from the use of force, the threat of force, or from the victim's inability to give consent. Rape victims do not "entice" their victims; rape is an act of conquest and control.  One in three women will be a victim of sexual assault sometime in her life; 7 to 10 percent of rape victims are male. One in four women will experience rape or attempted rape during her college years. Only 10 to 15 percent of all sexual assaults will be reported to police. About 50 percent of rape victims have some acquaintance with their attackers.  The medical assessment of rape victims must include several domains: Assessment and treatment of physical injury with special focus on the genitalia Psychological assessment and support Pregnancy assessment and prevention Evaluation, treatment, and prevention of sexually transmitted disease Forensic evaluation  Acute evaluation should be done by providers specifically trained to care for victims of sexual assault when possible. Many institutions have established SANE (Sexual Assault Nurse Evaluation) models or related programs for acute care. Trained providers are particularly skilled in the collection of forensic evidence. Providers must adhere to specific procedures in collecting this evidence and must understand the legal issues in maintaining the "chain of evidence." Trained providers are also particularly sensitive to the psychological trauma experienced by rape victims. EVALUATION- History The history should focus upon explicit details of the sexual assault for forensic purposes in the event of rape prosecution. Details will also guide the trauma assessment and will help to assess the risk of pregnancy and sexually transmitted disease. Histories must be obtained in a sensitive and supportive manner given the nature of the questions asked.  The following details of the history should be obtained: Circumstances of the assault, including use of weapons, force, restraints, or threats The assailant's physical description along with the assailant's use of drugs or alcohol Specifics regarding oral, vaginal, or rectal penetration along with presence or absence of ejaculation and/or condom use  Areas of trauma should be ascertained focusing especially upon the victim's mouth, breasts, vagina, and rectum Bleeding on the part of either assailant or victim may be relevant in assessing the risk of hepatitis or HIV transmission Activities of the victim following the assault are relevant in that they can lower the yield of forensic specimen collection. Victims should be asked if they have showered or bathed, changed clothing, eaten, used toothpaste or mouthwash, used enemas, urinated, defecated, douched, or had consensual intercourse since the assault. Physical examination The patient should undress for the examination with a sheet beneath her to capture any falling debris for medical evidence. The physical examination should describe the patient's emotional state. The examiner should document any evidence of trauma. If possible, photographs of injuries should be taken. The breasts, external genitalia, vagina, and rectum should be carefully examined. Common sites of vaginal injury include the posterior vagina and the labia minora. Genital trauma occurs more commonly in postmenopausal women Forensic evaluation Forensic evaluation requires collection of numerous specimens. Providers should use evidence collection kits with careful attention to guidelines for specimen collection. Collected samples include: The victim's clothing Swabs from the buccal mucosa, vagina, and rectum Combed specimens from the scalp and pubic hair Fingernail scrapings Control samples of the victim's hair  When completed, kits must be closed, labeled, and stored using protocol techniques to ensure rigor in maintaining an unbroken chain of evidence. Samples are examined for spermatozoa and for acid phosphatase as an assay for semen; it is recommended that these analyses be performed in forensic laboratories. Collected samples can also be analyzed for DNA. The yield of evidentiary exams generally decline with time and with specific behaviors like changing clothes, showering, and brushing teeth. In some published series, evidentiary examinations have been done only up to 36 hours after the assault. Evidence may be collected, however, as long as five days after the assault. Laboratory testing Laboratory evaluation is focused on trauma assessment, testing for sexually transmitted diseases, and pregnancy testing. Radiographic imaging will be guided by the history and physical. Any sites of contact (vagina, rectum, mouth) should be sampled for gonorrhea and chlamydia. A wet prep vaginal smear should be examined to look for bacterial vaginosis and trichomonas  Pregnancy testing and baseline serologic tests for syphilis and hepatitis B should be done. Baseline HIV test counseling should occur with options of confidential and anonymous testing offered and explained. Drug screening for flunitrazepam (Rohypnol, the "date rape drug") and gamma-hydroxy butyrate (GHB) should be done selectively if the victim has amnesia for any time surrounding the event. TREATMENT Initial therapy Fractures, soft tissue injuries, and other traumatic injuries should be treated appropriately. The remainder of the initial treatment regimen should focus upon sexually transmitted diseases (including hepatitis B and HIV) and pregnancy. Sexually transmitted diseases However, the Centers for Disease Control and Prevention (CDC) and others recommend empiric antibiotic prophylaxis since many assault victims will not return for a follow-up visit, and treatment based upon culture results is therefore problematic. In addition, patients often prefer immediate treatment. The risk of acquiring a sexually transmitted disease is difficult to measure due to the poor follow-up in many studies, and the fact that a sexually transmitted disease may be present during the baseline examination since the initial evaluation can occur as long as 60 hours after the event. The risk of chlamydial infection is estimated to be 3 to 16 percent, with an 11 percent risk of pelvic inflammatory disease and bacterial vaginosis, and a 7 percent risk of trichomoniasis. Empiric therapy includes ceftriaxone 125 to 250 mg IM for gonorrhea and azithromycin 1 gram PO (single dose) or doxycycline 100 mg bid for 7 days for chlamydia. Metronidazole 2 grams PO is also recommended to treat trichomoniasis and bacterial vaginosis. Hepatitis B infection Empiric treatment for hepatitis B following rape is controversial. The CDC recommends postexposure hepatitis B vaccination without HBIG as adequate protection against HBV, but there are little data regarding the efficacy of this regimen excluding HBIG, and many programs continue to use HBIG as prophylaxis in addition to vaccination. Follow-up doses of hepatitis B vaccine should be administered one and six months after the first dose. Vaccination is not necessary if the patient has had previous hepatitis B vaccine and documented immunity. HIV infection Prophylactic treatment with antiviral drugs for HIV following rape is controversial The risk of acquiring HIV from an unknown assailant is estimated at 2/1000; the risk is thought to increase when there is genital trauma, bleeding, and/or ulcerative lesions. There is no evidence on the efficacy of antivirals in this setting, but most believe that they should be offered.  Generalizing from the model of occupational HIV exposure, it is thought that antivirals are best started within four hours of assault, and should probably not be prescribed if greater than 72 hours has passed. The usual regimen is Combivir or its equivalent (300 mg zidovudine [AZT] and 150 mg lamivudine [3TC]) administered BID for four weeks. Addition of a protease inhibitor should be considered and is recommended for high-risk exposures Pregnancy Postcoital emergency contraception should be offered Many patients will experience nausea and vomiting from the combination of antibiotics and contraceptives; antiemetics should be offered. Psychosocial issues Rape victims require extensive emotional support and should be offered mental health services. Many victims experience the rape-trauma syndrome. In the early phase of the first days to weeks, symptoms may include anger, fear, anxiety, physical pain, sleep disturbance, anorexia, shame, guilt, and intrusive thoughts. The second phase, termed "reorganization," may last for months and includes physical and emotional symptoms. Patients may experience musculoskeletal, genital, pelvic and/or abdominal pain. Anorexia and insomnia can persist. Dreams and nightmares are common, and phobias may develop. Victims may find it very difficult to resume their habits, lifestyles, and sexual relationships  Patients may develop posttraumatic stress disorder, depression, or anxiety syndromes The medical evaluation and evidence collection process itself can be traumatizing and may compound the victim's sense of shame and loss of control. Providers should not force evaluation or treatment and should allow the victim some control in the evaluation process. A chaperone or advocate should be present during the evaluation. Acute crisis counseling should include safety planning. Victims should be referred for ongoing counseling ideally through rape crisis programs. Legal issues Legal definitions and procedures vary by state. Some states do not define sexual assault of male victims as rape; in that scenario prosecution must occur under sodomy or other statutes. In most states, providers must report rapes in which children or elders are victims; reporting is otherwise at the discretion of the victim. Victims are not required to file police reports immediately, but prosecution may be more successful with immediate reporting.  Evidence should be collected at the time of the initial evaluation and stored securely even if the patient is not planning to report the rape. Victims must sign consent forms prior to evidence collection. Many states have witness assistance programs, which can provide advice on the pros and cons of reporting, assistance in navigating the legal system, and victim financial compensation. Conviction rates range from 8 percent to 20 percent. Follow-up care A medical visit should occur within two weeks of the acute evaluation. Ongoing psychosocial support and counseling should be offered at that time. Pregnancy testing should be performed (even if the patient received postcoital contraception). Testing for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis should occur in all patients who declined prophylactic treatment at the initial evaluation, for symptom evaluation, and for those who request testing.  Serologic reexamination be done at 12 and 24 weeks only Patients should be counseled to consider condom use until serologic testing is completed. Hepatitis B vaccination should be given at one month and six months to complete primary vaccination.  INFERTILITY AND CLIMACTERIC CRISIS MS. KEMEI OBJECTIVES Describe infertility and climacteric crisis Specify causative factors of infertility Describe the management of infertile couples Specify climacteric symptoms Describe the management of a woman who presents with menopause INFERTILITY Most normal couples achieve a pregnancy within a few months of trying. However, failure to do so after one year may be arbitrarily defined as infertility, provided that normal intercourse is taking place not less than twice a week. But what is the difference between infertility and sterility?  Infertility is 'the inability to achieve a pregnancy or to carry a pregnancy to term after one year of unprotected intercourse'. Sterility is 'the inability to produce offspring, i.e. the inability to conceive (female sterility) or to induce conception (male sterility)'.  There are two types of infertility; primary and secondary. In primary infertility, no conception has taken place at all. In secondary infertility, there may have been some conception even if it ended in a spontaneous abortion.  There are several causes of infertility, which will be covered here under three broad categories - general factors female factors male factors.  General Factors Affecting Fertility Age In the female conception occurs at any time after menarche and before menopause. It is rare in the first few cycles and the last few cycles before menopause because the cycles are usually anovular.  Fertility in women is at its height in the late teens and early twenties. It declines slowly after 30 years of age. In the male, spermatogenesis commences actively at puberty and continues throughout life but ageing reduces fertility to a variable extent. Health and Nutrition Good health is associated with fertility but bad health is not an absolute barrier to conception, except when ovulation and spermatogenesis are directly affected. Deliberate dieting (condition known as anorexia nervosa) will lead to loss of weight, which in turn will lead to amenorrhea, hence failure to ovulate.  On the other hand, sometimes obesity and infertility seem to be connected in women, probably because obese women ovulate and menstruate less frequently. Chronic alcoholism or drug addiction may also lead to infertility. For example, morphine tends to depress ovarian activity Psychological Factors Anxiety and tension seem to be responsible for infertility in some individuals. They manifest through changes in the neuroendocrine control of ovulation. Female Factors Affecting Fertility Congenital Also known as Mullerian agenesis, where there is no uterus or ovaries. Another factor is vaginal atresia, which is the narrowing or stenosis of the vagina. Infections leading to tubal blockage, for example, sexually transmitted infections (gonococcal, chlamydia), tuberculosis, salmonella, enterobias vermicularis and postabortal or puerperal sepsis.  Endocrine due to pituitary adenoma with increased prolactin leading to inappropriate galactorrhoea which is associated with amenorrhoea and anovulation. Hormonal imbalance with increased oestrogen will lead to endometrial hyperplasia hence irregular period (metropathia haemorrhagica) or prolonged periods and cycles. Hypothyroidism is generally associated with infertility Diabetes mellitus, if uncontrolled or in those with severe complications may impair fertility. Female Factors Affecting Fertility cont’d Uterine fibromyoma, especially if it is large enough to distort the uterine cavity or block interstitial parts of the tube, may also cause recurrent abortion. Cervical hostility, whereby the cervical mucus is unreceptive to spermatozoa and either prevents their progressive advance or actually kills them. It may be due to infection or the presence of sperm antibodies.  Cervical incompetence is almost always a cause of mid-trimester abortion and will lead to secondary infertility. Endometriosis because of the menorrhagia may lead to infertility. Male Factors Affecting Fertility Congenital, for example, hypospadias (ventral external urethra meatus) where the opening is congenitally malformed. Undescended testes, where the testes either remain in the abdominal or inguinal canal or are retractile, that is, tend to go back in the abdomen.  Take note that the temperature of scrotal contents is about 1° Centigrade below the normal body temperature. Spermatogenesis is impaired if the temperature of the testes is raised and this is often the case with undescended testes. The temperature can also be raised by frequent hot baths, the use of thick, tight underclothes as well as living at high altitudes for too long.  Male Factors Affecting Fertility cont’d Infections of bacterial origin, for example, gonococcal chlamydia will block the vas deferens after healing with scarring. Viral infection, especially mumps, can cause orchitis, interfering with spermatogenesis. Therefore, a male child suffering from mumps should be observed keenly for this complication..  Auto-immune problems whereby the cervix can be hostile to the sperm of a man and produce antibodies. Impotence where there is no erection for unknown reasons. Ignorance of coitus and in some cases excessive coitus. Less sperm count (oligospermia ) or no sperms at all (azoospermia). Endocrine disorders, for example, pituitary failure, adrenal hyperplasia or thyroid deficiency Management of Infertility Infertility is a very stressful condition with a continuous cycle of hope and disappointment. Life centres around trying to conceive a baby and nothing else seems important. Partners blame each other and become frustrated and guilty.  Patients should be managed by a gynaecologist, whose scope of intervention will depend on the services or technology available. The couple should be investigated based on their general reproductive history. Clinical examination of each partner is carried out separately and any worries should be elicited and confidential information obtained from each partner. Management of Infertility cont’d In the male partner the following should be done. Take a history of sexual function, erection and ejaculation. Any past history of orchitis or STDs should be noted. It is important to establish how often intercourse takes place, whether there is any experience of difficulty in either partners, discomfort or lack of satisfaction (the male orgasm which brings about ejaculation of the semen is essential for fertilisation).  A clinical examination should also be done and should include an assessment of the size and consistency of the testes and epididymis on each side. You should also assess for the presence or absence of varicocele or hernia and the size of the prostate. Plan for action after the initial history and examination will include semen analysis. This should normally be the first step in an investigation because if there are no sperms present in the semen, it is pointless to investigate the female.  Prior to semen analysis, in preparation to collect specimen, the man abstains from coitus for three to five days and a masturbation specimen is then collected. It should be received in the laboratory within half an hour. In semen analysis, examine colour (if sturdy, then it is infected), viscosity, bacteriology (if pus cells present), motility (progressive, sluggish or no movement), morphology (the ideal is 50%) and sperm count (40 to 370 million sperms per cc). Note that in Kenya 20 million is considered an acceptable sperm count.  If the serum contains sperm antibodies, the spermatozoa become immobilised when they come into contact with the cervical mucus. The test should be done three times. Once the seminal fluid analysis has been done and found to be normal, then the next step is to test for ovulation and tubal patency in the female. female partner In the female partner, attention should be paid to any endocrine abnormality. A routine pelvic examination should also be performed.  During history-taking, the following should be ascertained: Any illness which might have caused peritonitis, for example, tuberculosis. This could mean the tubes were also affected. Menstrual history, for instance, whether menstruation is scanty or irregular. Any abortion or sicknesses should be noted. Outcomes of previous pregnancies should also be noted. Marital history, including duration of marriage and how  The plan of action after taking down the patient's initial history and examination should include a Hysterosalpingography (HSG), which remains a useful investigation for tubal patency. A laparoscopy plus dye test does not only allow assessment of tubal patency but also gives proof that the tube is normal in appearance, the fimbriae are healthy and that the tubal movement is adequate.  Ovulation may be confirmed in several ways, including the temperature method, the examination of cervical mucous, progesterone level on blood sample taken one week before a period is expected (day 21 of 28 day cycle) and a level of more than 20 mmol/L, which confirms that ovulation has taken place. An ultrasound may detect follicular growth and ovulation. A histological examination of the endometrium should also be performed just before menstruation in order to assess the response to progesterone secretion by corpus luteum and to exclude tuberculosis. Treatment of Infertility Not all couples that complain of infertility need to be investigated and treated. For short periods of infertility in a young couple, simple clinical assessment and reassurance that they appear normal is all that is required. Emphasise to the couple that if no abnormality is found, that pregnancy is always possible even after many years.  Treatment may take several forms. Tubal blockage can be treated by salpingolysis, which is the most successful tubal operation and consists of dividing peritubal adhesions around the ampullary ends of the tube.  Salpingotomy involves making an opening into the distal end of a hydrosalpinx and is usually better for fimbrial blockage. During in vitro fertilisation, the oocytes from the mature ovarian follicle are retrieved, fertilised with the partner's sperm and the developing embryo is replaced into the woman's uterus. Treatment of Infertility In the male there are also various forms of fertility treatment, depending on the specific condition. Semen problems, such as azoospermia, secondary to lack of gonadotrophic stimulation, are curable by the administration of Human Menopausal Gonadotrophin (HMG). However, there is no treatment for azoospermia due to congenital anomalies or chromosomal abnormalities.  Synthetic androgens, for example, mesterolone (proviron), have a direct action on spermatogenesis. They should be administered at a dose of 50 mgs daily for three months. Oligospermia will often respond to an improvement in the patient's general health and fitness, therefore, exercise and a good diet should be encouraged. The patient should also be advised to avoid excessive consumption of alcohol, tobacco and caffeine. Additionally, the excision of varicocele, if present, is commonly done for oligospermia. Treatment of Infertility cont’d Artificial Insemination (AIH) with the partner's semen is widely used for infertility due to impotence or anatomical abnormality in the male, especially in cases of hypospadias, which prevents normal ejaculation of sperm into the upper vagina.  You should also counsel the patient on general measures that may be helpful like refraining from excessive coitus obtaining adequate sleep weight-loss advice for obese patients need to avoid excessive and prolonged exposure of the scrotum to heat by avoiding hot bath, tight underwear or prolonged sitting in hot environments.  Some of the problems infertile couples may face will include: Poor social standing that is, not having respect from friends, relatives and the community as a whole. The stress of infertility makes one be unproductive economically. Sexual disinterest due to dyspareunia. Treatment of Infertility cont’d The frantic effort of wanting children will complicate the infertility leading to domestic disharmony, separation and divorces and/or promiscuity which may increase the risk of STI/HIV. Climacteric Crisis In women climacteric crisis is the period of menopause (while in males it is known as andropause). Menopause is a period in a woman's life when menstruation ceases naturally. There is progressive ovarian failure, which is preceded by complete absence of menstruation. Menopause is declared after one year of no menstruation.  A considerable number of women will undergo physical or emotional upsets but the majority will not be significantly affected. To some, menopause is a threatening period that declares the end of their femininity, while to others it is a time when ma