Obstetric Emergencies PDF

Nursing Midwifery #  Obstetric emergencies Dr Sanaa Abujillban, RN,RM,PhD  Obstetric emergencies I Vasa previa 2 Presentation and prolapse of umbilical cord 3 Shoulder dystocia Y Rupture of theLoading… uterus S Amniotic fluid emblism...

Nursing Midwifery #  Obstetric emergencies Dr Sanaa Abujillban, RN,RM,PhD  Obstetric emergencies I Vasa previa 2 Presentation and prolapse of umbilical cord 3 Shoulder dystocia Y Rupture of theLoading… uterus S Amniotic fluid emblism 6 Acute inversion of the uterus 7 shock  1. Vasa previa A fetal blood vessel lies over the os in front of presenting part Vasa previa Loading…  1. Vasa previa: Diagnosis May be diagnosed antenatally using ultrasound Palpable through vaginal examination if no ROM Can be diagnosed by speculum examination May be ruptured whenever the membranes ruptured: need urgent C/S in minuts  1. Vasa previa diagnosis Fresh vaginal bleeding at the same time of membranes rupture Fetal distress depend on the amount of blood loss  1. Vasa previa Management urgent situation Pediatrician should be present Continuous FHR monitoring If alive fetus and 1st stage: urgent C/S If died fetus or 2nd stage: vaginal delivery If delivered alive baby: need – resuscitation, – blood transfusion, – Hb level  2. Presentation and prolapse of umbilical cord Cord presentation: – Umbilical cord lies in front of the presenting part, with intact membranes Cord prolapse: – Umbilical cord lies in front of the presenting part, with ruptured membranes Occult cord prolapse: – Cord lies alongside not in front of the presenting part  2. Presentation and prolapse of umbilical cord Predisposing factors: – High or ill-fitting presenting part: if ruptured membranes the cord will descend, trapped and occluded – High parity: delay engagement – Prematurity: small baby in relation to pelvis – Malpresentation: footling breech, shoulder, compound and transverse – Multiple pregnancy: for the 2nd twin – Polyhydamnios: gush of liquor if membranes ruptured  Cord presentation Diagnosis: – Vaginal examination, – decelerations Management: Loading… – No ROM – Continuous electronic fetal monitoring – A mother position that reduce the cord compression – C/S birth  Cord prolapse Diagnosis: – After rupture membranes vaginal examination should be done to exclude prolapse – Examine FHR: bradycardia, variable or prolonged deceleration – Vaginal examination: cord is palpable in the vagina or os Cord prolapse  Cord prolapse Risks for fetus: – Hypoxia and – death Greatest risks for premature baby and LBW Immediate action: – Urgent assistance – Stop oxytocin – Replace the cord into the vagina if its out: to prevent spasm, maintain temperature and prevent drying – Give O2  Cord prolapse Relieving pressure on the cord: – Hold the presenting part away from the cord by hand during contraction – Chest-knee position: fetus gravitate toward diaphragm – Trend-len-burg position – Exagg-erated Sim’s position – Bladder filling : 600 ml saline filling by Foley’s catheter which elevate the presenting part 2 cm Chest-knee position Trend-len-burg position Exagg-erated Sim’s position  Cord prolapse if in 1st stage: Need urgent C/S If in 2nd stage and multiparous woman: – vaginal delivery with episiotomy – Forceps or ventouse  3. Rupture of the uterus Most serious complications Often fatal for fetus and mother Types: – Complete: tear in the uterine wall with or without expulsion of the fetus – Incomplete: tear of the wall but not the perimetrium – Dehiscence: – rupture of scared uterus, – fetal membranes remain intact, – fetus remain in uterus not in the peritoneal cavity  3. Rupture of the uterus causes Rare in primi Antenatally: Previous classical C/S scar Neglected labor: with previous C/S scar High parity Use of oxytocin: with high parity Use of prostaglandins: with previous C/S scar Obstructed labor: excessive thinning of lower segment Extension of severe cervical laceration upwards with assisted birth Trauma: of blast (explosion) or accident Non-pregnant Uterine perforation: result in the rupture of pregnant uterus  3. Rupture of the uterus Intrapartum signs for complete rupture – Sudden collapse of the mother – Sever abdominal pain – Increase maternal HR – Alterations of FHR: variable decelerations – Fresh vaginal bleeding – Contractions stopped – Change the contour of abdomen – Palpable fetus in the abdomen – Presenting part regressed  3. Rupture of the uterus Incomplete rupture: – Found after birth or during C/S – Common with previous C/S – Scanty blood loss: avascular tissue – Expect it when there is: mother shock is more than the blood loss Abdominal pain Postpartum Hemorrhage  3. Rupture of the uterus rupture management: – Immediate C/S – May need repair or hysterectomy – Treat shock – May need blood transfusion – May become pregnant again  3. Rupture of the uterus Rupture following previous C/S – 0.3 – 0.7 % of labors following previous C/S – Lower in lower segment C/S  4. Amniotic fluid embolism Rare: incidence 1 and 12 cases per 100,000 deliveries Unpredictable Unpreventable  4. Amniotic fluid embolism Occur when amniotic fluid enters the maternal circulation via: – the uterus or – placenta site  4. Amniotic fluid embolism: Two phases: 1. Initial phase : – Pulmonary vasospasm causing: Hypoxia Hypotension Pulmonary edema Cardiovascular collapse  4. Amniotic fluid embolism: Two phases: 2nd phase: – Development of left ventricular failure – Hemorrhage and – coagulation disorder – Loading… Further uncontrollable hemorrhage  4. Amniotic fluid embolism: High mortality and morbidity: – main cause of death – The national registry from the USA suggested a mortality rate of 61% – Need early diagnosis Transfer to ICU Emergency drill (training) for maternal resuscitation  4. Amniotic fluid embolism: predisposing factors Occur at any gestation Commonly associated with labor Amniotic Fluid enter through placental bed Raising of intra- amniotic pressure during Termination of pregnancy or Placenta abruption Artificial Rupture Of Membrane Insertion of intra uterine catheter Internal podalic version during C/S Internal podalic version  4. Amniotic fluid embolism: signs and symptoms Restlessness Abnormal behavior Respiratory distress Cyanosis Hypotension Uterine hypertonus: in response to uterine hypoxia Cardiopulmonary arrest: in few minutes Blood coagulopathy  4. Amniotic fluid embolism: emergency action Resuscitation Outcome is poor High level of oxygen May suffer neurological impairment  4. Amniotic fluid embolism: complications DIC within 30 min Amniotic Fluid suppress the uterus: Uterine atony Acute renal failure : result from hypovolemia – Monitor output by Foley’s catheter I&O Urine analysis  4. Amniotic fluid embolism: effect on the fetus Perinatal mortality and morbidity Neonatal mortality is ∼70% – nearly 70% will survive delivery but 50% of the survived neonates will incur neurological damage Fetal compromise  5. Acute inversion of the uterus Complication of the third stage Rare Life-threatening 1 in 20 000 births  Classification of inversion of the uterus According to severity: – 1st degree: fundus reach internal os – 2nd degree: body of the uterus is inverted to internal os – 3rd degree: uterus, cervix and vagina inverted and visible According to timing of the event: – Acute: within 24 hrs after birth – Sub-acute: after 24 hrs and within 4 weeks – Chronic: after 4 weeks (rare) 2nd degree inversion  Causes of acute inversion Associated with uterine atony and cervical dilatation – Mismanagement of 3rd stage: excessive cord traction – Combining Fundal pressure and cord traction – Use of fundal pressure with atonic uterus – Pathological Adherent placenta – Unknown – Primiparity – Fetal macrosomia – Short umbilical cord – Sudden emptying of a distended uterus  Signs and diagnosis of inversion Profound shock Hemorrhage: blood loss 800- 1000 ml Sever abdominal pain – Pain from: Stretching of the peritoneal nerves Pulled ovaries On abdominal palpation: – Indentation (depression ) of the fundus – Uterus: May be not palpable if sever inversion – May be palpable on Vaginal examination or visible Bleeding: May or may not present depending on placental site adherence  Management of acute inversion Immediate action: – Keep woman informed, – assess V/S including level of consciousness – Call for medical help – Attempt to Replace the uterus with no delay with the hand palm toward the posterior fornex then toward the umbilicus (Johnson’s maneuver) – Then keep hand in situ until firm contraction Johnson’s maneuver  Management of acute inversion cont. Immediate action: cont. – Give oxytocin If delay: uterus become edematous – Elevate the foot of the bed if replacement is not attempted immediately – IV cannula, cross match – Analgesia as morphine – Keep placenta in situ if still attached  Management of acute inversion cont. Medical management: – Hydro static method: the pressure of the fluid builds up in the vagina and restores the uterus to the normal position Instillation of several liters of saline into the vagina by a giving set Seals off the introitus by hand or a ventouse cup – Give medication to relax the Cervical constriction ring – May need surgical correction by laparotomy  6. shock Complex syndrome Involves reduction in blood flow Cause irreversible organ damage  Classification of shock 1. Hypovolemic: result from bleeding or severe vomiting 2. Cardiogenic: impaired ability of the heart to pumb blood 3. Neurogenic: insult (abuse) to the nervous system 4. Septic or toxic: sever generalized infection 5. Anaphylactic: allergy or drug reaction  Hypovolemic shock Management: – Call for help – 2 wide-bore canuula – Cross-match – Maintain the airway: side lying with 40% O2 4-6 l/m – Replace fluid: Crystalloid (N/S, Hartmann’s, Ringers): two liters (may loss to the tissue) Then colloids (such as; Gelofusine or Haemocel): one to two liters in 24 hrs Packed RBC’s Fresh Frozen Plasma – Warmth: not too much and not too fast (cause vasodilation) – Arrest hemorrhage  Hypovolemic shock observation FHR Level of consciousness: – Glasgow coma scale: should be >12 Assess respiratory status: – Rate, pattern, pulse oximetry, ABG’s, O2 therapy BP every 30 min Continious monitor for heart rhythm Output hourly Assess skin color Hemodynamic measures Observe bleeding Hematocrit and Hb: to assess loss  Septic shock Certain organism produce toxins that cause fluid to be lost into the tissue Organisms: – Most common: Streptococcus pyrogenes (gram–ve) – E. coli – Proteus or pseudomonas Point of entry of pathogens: placental site after prolonged ROM, trauma, septic abortion or retained placenta  Septic shock clinical signs Tachycardia Pyrexia Rigors Tachypnea Change in mental state Gastrointestinal symptoms Signs of shock DIC  Septic shock management Fluids Oxygenation Full infection screening: vaginal swap, urine and blood culture IV line Indwelling catheters Intravenous antibiotic Remove any conceptus May need ICU Keep family informed Abnormal development of fibroid uterus and surgical management Dr Sanaa Abujilban, RN, RM, PhD  Uterine Fibroids Uterine Fibroids, or uterine myomas (short for leiomyoma), affect more than 30% of women. Slow growing benign tumours arising from the Loading… muscle tissue of the uterus Occur most often after age of 50 yrs Rarely become malignant Most fibroids do not cause symptoms, and do not require treatment. Shrink after menopause  Most common in African American women women Never been pregnant  Become quite large when Taking birth control pills Pregnancy Receiving hormone therapy Loading…  Causes Unknown Genetic factors may be involved  Fibroids may require treatment in the following circumstances: 1. Fibroids are growing large enough to cause pressure on other organs, such as the bladder. 2. Fibroids are growing rapidly 3. Fibroids are causing abnormal bleeding 4. Fibroids are causing problems with fertility.  Types of Fibroids Uterine Fibroids are classified by their location (see figure), which effects the symptoms they may cause and how they can be treated. 1. Intracavitary 2. Submucous myomas 3. Intramural myomas 4. Subserous myomas Pedunculated  Types of Fibroids --  1. Intracavitary Fibroids that are inside the cavity of the uterus symptoms: – will often cause bleeding between periods and – often cause severe cramping. Treatment: – Fortunately, these fibroids can usually be easily removed by a method called "hysteroscopic resection," which can be done through the cervix without the need for an incision.  2. Submucousal myomas Least common, developed in the endometrium and protrude into the uterine cavity are partially in the cavity and partially in the wall of the uterus. Symptoms: – Loading… They too can cause heavy menstrual periods (menorrhagia), as well as – bleeding between periods. Treatment: – Many of these submucous fibroids can also be removed by hysteroscopic resection.  3. Intramural myomas Intramural myomas are within the wall of the uterus, and can range in size from microscopic to larger than a grapefruit. Symptoms: – Many intramural fibroids do not cause problems unless they become quite large. Treatment: – There are a number of alternatives for treating these, but often they do not need any treatment at all.  4. Subserous myomas Subserous myomas are on the outside wall of the uterus, and may even be connected to the uterus by a stalk (tail) (pedunculated fibroid.) Beneath the peritoneal surface Treatment: – These do not need treatment unless they grow large, – but those on a stalk can twist and cause pain. – This type of fibroid is the easiest to remove by laparoscopy.  Other types Cervical: – Developed in the cervix Developed in the broad ligaments  Signs and symptoms Bleeding Displacement of the surrounding viscera Backache Low abdominal pressure Constipation Urinary incontinence Dysmenorrhea intercourse dyspareunia painful - Nausea and vomiting (obstructing the intestine) Abdominal mass Anemia Necrotic pedunculated (twisted) cause pain  Complications During pregnancy Tumors affected by estrogen and increase in size and may cause: – Preterm labor – Miscarriage – Dystocia (Failure to progress )  Diagnosis of Fibroids 1. a pelvic exam : – Fibroids may be felt during a pelvic exam, – but many times myomas that are causing symptoms may be missed if the examiner relies just on the examination. – Also, other conditions such as ovarian cysts may be mistaken for fibroids.  2. ultrasound examination: 2. ultrasound examination: at the time of the first visit – Indications: when a woman has symptoms of abnormal bleeding or cramping, or if there is an abnormality on examination. – How it appears: On ultrasound examination fibroids are seen as round areas with a discrete border. – Types of U/S 2 Abdominal Vaginal saline enhanced sonography or sono-hystero-gram - Saline in utems For better vision  3. hysteroscopy 4. MRI – helpful in planning a myomectomy. – MRI is especially good at distinguishing between fibroids and adenomyosis (the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge). - cells mucus interfere with with muscle cells  Nursing diagnosis Anxiety related to : – Uncertain diagnosis – Fear of malignancy – Potential surgical treatment Acute or chronic pain related to myomas Sexual dysfunction related to dyspareunia  Treatment of Fibroids The vast majority of fibroids grow as a woman gets older, and tend to shrink after menopause. Obviously fibroids that are causing significant symptoms need treatment. While it is often easier to treat smaller fibroids than larger ones, most of the small ones never will need to be treated.  Treatment of Fibroids many women have successful pregnancies without removing the fibroids as long as they are not inside the uterine cavity. The location of the fibroids plays a strong influence on how to approach them.  Treatment of Fibroids 1. Treatment with medicines: 2. Surgical treatment of Fibroids:  1. Treatment with medicines: No curative treatment that will permanently shrink fibroids. 1. non-sterodial antiinflamatory drug for pain 2. birth control pills : small closes stops Large > - doses because of – Inhibit ovulation menstration and ovulation 3. GnRH agonists NO FSH LH > - , – induce a temporary chemical menopause. – In the absence of estrogen myomas usually decrease in size. – the effect is temporary, and the fibroids rapidly go back to their pre-treatment size when the medication is discontinued. – Side effects: Loss of bone mass, changes in lipid levels ↳ same as menopause  1. Treatment with medicines: cause breast cancer therapy and proflactico 4. Mifepristone,(is a progesterone receptor antagonist used as an abortifacient ): – better know as the 'French abortion pill, – may cause a decrease in size of myomas, and – often stops abnormal uterine bleeding. 5. raloxifene – Estrogen receptors modulators  2. Surgical treatment of Fibroids: Intracavitary Fibroids These can usually be removed by using a special kind of hysteroscope, or resectoscope. The resectoscope: – is a telescope with a built-in loop that can cut through tissue. – This is called hysteroscopic resection of myomas. – most myomas inside the uterus can be removed in an outpatient setting.  2. Surgical treatment of Fibroids: Submucous Fibroids 1. hysteroscopic resection. During the process of removing submucous myomas by this method the uterus contracts, and tends to push the portion of the myoma that is in the wall into the cavity of the uterus. 2. endometrial ablation(vaporisation heated fluid to destroy the uterine lining ): indications – If heavy bleeding is the main reason for desiring treatment, and – fertility is no longer desired,  2. Surgical treatment of Fibroids: Intramural and Pedunculated Fibroids not accessible to treatment through the cervix. three types of procedures: – y remove the fibroid(s), – y destroy the fibroid(s), or – - remove the uterus.  2. Surgical treatment of Fibroids: 1. Hysterectomy: – Remove the uterus – Hysterectomy is the only procedure that comes -understan with a guarantee: no more bleeding and no re- - Loading… growth of fibroids.  2. Surgical treatment of Fibroids: 2. myomectomy – Removal of the fibroid(s): – means making an incision into the uterus and removing one or more fibroids. – If the fibroid is on a stalk (pedunculated) it is not necessary to cut into the uterus to cut the stalk. – Unless the fibroid is on the outside surface of the uterus, the uterus is repaired, usually with sutures.  Types of myomectomy: 1. laparotomy: – an incision is made in the abdomen to reach the uterus. 2. laparoscopy or with a surgical robot. – - The laparoscope is a telescope placed in the abdomen through the belly button. Other instruments are inserted through small Better individual incisions in the abdominal wall. – The advantage :outpatient, and allows faster recovery than a laparotomy. – One of the disadvantages is the extended time needed to remove large fibroids from the abdomen, be more difficult to detect and remove smaller myomas.  Destruction of the fibroids: 1. myolysis, 2. embolization most > - common 3. MRI Focused Ultrasound designed to treat the myomas by destroying their blood supply instead of removing them NoBiobsy ,may be mo sever pain possible malegnant?  1. myolysis, is done through a laparoscope. In this procedure, a laser fiber, or more commonly an electrical device is used to coagulate the myoma or the blood vessels - feeding the myoma. The dead tissue is then gradually replaced with scar tissue. -  1. myolysis Advantages: – This is easier to do than a myomectomy (although it can be time consuming), and – recovery is usually rapid. Disadvantages: – * no sample (biopsy) so malignancy may not be diagnosed. – * adhesions (organs such as intestines stick to the uterus), which could cause problems later on.  2. Uterine artery embolization: - This is the newest treatment for fibroids. This procedure involves placing a small catheter into an artery in the groin and directing it to the blood supply of the fibroids. Little plugs are injected through the catheter to block these arteries.  2. Uterine artery embolization: > - treatment type for cancer very painfull -  2. Uterine artery embolization: This causes the fibroids to shrink, although there may be pain for a short time afterwards requiring the use of narcotics. Temporrary amenorrhea or early menopause - can occur ↳ couple months no samples are sent for biopsy, although the > chance of malignancy in fibroids are low.  2. Uterine artery embolization What to expect post operatively: from fibroid degeneration – Pelvic pain – Fever – Malaise – Nausea and vomiting  2. Uterine artery embolization Post operative care: – Bleeding in the groin – Taking vital signs – Assessing pain level – Checking the pedal pulse – Neurovascular condition of the leg Pedal pulse  2. Uterine artery embolization Home care – Take medication – Call Dr if: bleeding, hematoma at puncture site, fever more than 39 c, urinary retention – Normal diet: with fiber and fluids infection Risk – No tampons, douche, coitus for 4 wks Gragina flashing ↳ intercours – No straining with bowel movement > - laxtive  3. MRI Focused Ultrasound In this technique an MRI is used to focus an intense beam of ultrasound through adjacent - tissues to destroy the fibroid. Many women can not be treated because of the location, and the reduction in size is minimal — much less than Uterine artery embolization. Hysterectomy Hysterectomy Vaginal Vs abdominal hysterectomy Abdominal hysterecromy  Hysterectomy Removal of the entire uterus (some times the cervix not removed) Types: depends on the size and location of the tumor 1. Abdominal Hysterectomy: vertical or transverse incision 2. Vaginal Hysterectomy 3. Laparoscopic assisted vaginal hysterectomy 4. Laparoscopic assisted supracervical Hysterectomy: cervix remain in place  Hysterectomy Procedure: – Uterus is removed from the supporting ligaments – Then ligaments attached to the vaginal cuff  Hysterectomy: preoperative care Assess woman knowledge of – treatment options – Fertility desire – Benefits and risk of procedure – Pre-operative and post-operative procedures – Recovery process Psychological assessment – Significance of uterus loss – Misconceptions about effects of surgery – Support system  Hysterectomy: preoperative procedures Physical examinations: vaginal Lab tests: CBC, cross match, UA Chest x-ray ECG Pre-operative teaching: – Turning, coughing, deep breathing – Passive and active leg exercise – Early ambulation – Pain relief options  Hysterectomy: preoperative procedures NPO Enema if ordered Douche if ordered Shaving Removal of makeup, nail polish, glasses, lenses, dentures ID band Signed consent from chart Empty bladder  Hysterectomy: postoperative care V/S Maintain unobstructed airway Turn, cough, deep breathing (Q 2 hrs for 24 hr) Incentive spirometry Leg exercise Assess homan’s sign Assess bleeding: abdominal, vaginal (1 saturated pad /hr is bleeding Hematocrit Assess lungs  Hysterectomy: postoperative care Assess bowl sounds I&O Assess incision for infection Assess for complications (urine retention) Pain relief: pharmacological ( narcotics for 24hrs)and non-pharmacological Psychological assessment: depression, support, sexual concern)  Ovarian cysts Dr Sanaa Abujilban, RN,RM,PhD ovarian cysts Loading… Ovarian cysts  ovarian cysts is any collection of fluid, surrounded by a very thin wall, within an ovary. Any ovarian follicle that is larger than about two centimeters is termed an ovarian cyst. An ovarian cystLoading… can be – as small as a pea, or – larger than an orange. Dependent on hormonal influences associated with menstrual cycle  Ovarian cysts 1. follicular cysts 2. corpus luteum cysts 3. theca- lutein cysts 4. polycystic ovary syndrome 5. Dermoid cysts: 6. Ovarian fibromas:  Ovarian cysts: 1. follicular cysts Result of – mature graafian follicle failing to rupture Asymptomatic unless ruptures (severe pelvic pain) If not ruptured: – shrinks after 2-3 menstrual cycles  Ovarian cysts: 2. corpus luteum cysts Occur after ovulation Caused by an increased secretion of progesterone that results in an increase of fluid in the corpus luteum S/S: – Pain – Tenderness over the ovary – Delayed menses – Irregular or prolonged menstrual flow If rupture: causes intra peritoneal hemorrhage Disappear after 2-3 menstrual cycles without treatment  Ovarian cysts: 3. theca- lutein cysts Uncommon, bilateral 50% associated with hydatidiform mole Result from: – prolonged stimulation of the ovary from hCG – Ovulation induction drugs – Large placenta – DM S/S: – Pelvic fullness if large – Asymptomatic  Ovarian cysts: collaborative care Expectant management: – Monitor the size of cyst – analgesics for pain Oral contraceptives to suppress ovulation Surgical removal: If the cyst: – more than 8 cm and – not shrinked  Ovarian cysts: collaborative care Nursing care: – Education: treatment options, pain management, comfort measures (heat, relaxation) – For surgery: Loading… Pre-post op care Post op: – S/S of infection, – incision care, – recurrence, – follow-up  Ovarian cysts: 4. polycystic ovary syndrome Occurs when – Endocrine imbalance (high levels estrogen, testosterone, LH; low levels FSH) Associated with – Hypothalamic-pituitary-ovarian axis – Androgen producing tumors Can be transmitted as X-linked dominant or autosomal dominant trait  Ovarian cysts: 4. polycystic ovary syndrome  Ovarian cysts: 4. polycystic ovary syndrome Multiple follicular cysts developed In one or both ovaries Produce excess estrogen Ovaries are double in size Diagnosed in adolescence  4. polycystic ovary syndrome Clinical manifestations: – Obesity, acne – Hirsutism (excessive hair growth) – Irregular menses – Amenorrhea – Infertility – Impaired glucose tolerance – Hyper-insulin-emia (40 % of them) – Risk for type 2 DM – Risk for cardiovascular diseases – Depression, anxiety, social fear  Ovarian cysts: PCOS care 1. Life style modifications: losing wt 2. Management of presenting symptoms 3. Oral contraceptives for , 1. irregular menses, For 2. acne, For 3. hirsutism (excessive hairiness on women) 4. Gonadotropin-releasing hormone analogs for hirsutism 5. If pregnancy desired: Ovulation inducting medications 6. Metformin: for DM  Ovarian cysts: PCOS care Education: about – syndrome, – long term effect, – Life style modifications, – exercise, – diet, – medication Psychological support: express feelings Information about support groups  Ovarian cysts 5. Dermoid cysts: – germ cell tumors (hair, bone); – removed surgically 6. Ovarian fibromas: 1. connective tissue; 2. solid; 3. in menopause; 4. range in size, up to 23 (34) kg; 5. unilateral; 6. if large cause pelvic pressure; 7. removed surgically  Oophorectomy Definition Oophorectomy is the surgical removal of one or both ovaries. It is also called ovariectomy or ovarian ablation. If one ovary is removed, a woman may continue to menstruate and have children. If both ovaries are removed, menstruation stops and a woman loses the ability to have children.  Oophorectomy : Purpose Oophorectomy is performed to: – remove cancerous ovaries – remove the source of estrogen that stimulates some cancers – remove large ovarian cysts in women with polycystic ovarian syndrome (PCOS) – excise an abscess – treat endometriosis – lower the risk of an ectopic pregnancy – lower the risk of cancer in a woman with a family history of ovarian or breast cancer  oophorectomy In an oophorectomy, – one or a portion of one ovary may be removed or – bilateral oophorectomy : When oophorectomy is done to treat ovarian cancer or other spreading cancers, both ovaries are always removed. – Preventative oophorectomy, called preventative bilateral oophorectomy (PBO): ovary removal in preventing both breast and ovarian cancer  Oophorectomy: Description done under general anesthesia. type of incision, either vertical or horizontal the abdominal muscles are pulled apart Then the ovaries, and often the fallopian tubes, are removed. Oophorectomy can sometimes be done with a laparoscopic procedure. The ovaries can also be cut into smaller sections and removed.  Oophorectomy: The advantages and disadvantages of abdominal incision The advantages of abdominal incision are: – if a woman has many adhesions from previous surgery. – check the surrounding tissue for disease. – A vertical abdominal incision is mandatory if cancer is suspected. The disadvantages are – bleeding – more painful – the recovery period is longer. – be in the hospital two to five days – three to six weeks to return to normal activities.  Oophorectomy: Preparation blood and urine tests ultrasound or x rays A colon preparation may be done, if extensive surgery is anticipated. should eat a light dinner, then take nothing by mouth, including water or other liquids, after midnight.  Oophorectomy: Aftercare feel some discomfort. hormone replacement therapy to ease the symptoms of menopause Antibiotics are given to reduce the risk of post- surgery infection. Return to normal activities takes anywhere from two to six weeks, When women have cancer, chemotherapy or radiation counselling and support groups  Oophorectomy: Risks From the surgery reaction to anesthesia, internal bleeding, blood clots, accidental damage to other organs, and post-surgery infection. symptoms of menopause: changes in sex drive, hot flashes, increased risk for cardiovascular disease and osteoporosis. psychological difficulties after the operation. Disorders of pelvic floor, prolapse incontinence Loading…  pelvic organ prolapse Pelvic relaxation – is a weakness or laxity in the supporting structures of the pelvic region. – Bladder, rectal, or uterine tissue may then bulge into the vagina. priority in women’s health. Should routinely screen patients for the symptoms, correct prolapse conditions and the urinary incontinence that often results. By age 80, more than 1 in every 10 women will have undergone surgery for prolapse.  Types of pelvic organ prolapse 1. Cystocele and urethrocele. 1. A cystocele occurs when the bladder protrudes into the front wall of the vagina. 2. A similar defect, known as a urethrocele, develops when the urethra presses into the front vaginal wall. 2. Rectocele. 1. Part of the rectum bulges into the back wall of the vagina, sometimes causing difficulty with defecation. 3. Uterine prolapse. 1. The uterus drops down into the vagina. 2. In women who have undergone a hysterectomy, a similar condition known as vaginal vault prolapse can occur: 1. the top of the vagina protrudes into the lower vagina. Pelvic organ prolapse conditions  What causes pelvic organ prolapse? Pelvic support comes from – pelvic floor muscles, – connecting tissue (fascia), and – thickened pieces of fascia that serve as ligaments. When pelvic floor muscles are weakened, – the fascia and ligaments have to bear the force of the weight. – Eventually, they may stretch and fail, allowing pelvic organs to drop and press into the vaginal wall.  Risk factors Women who have had multiple vaginal births are at greatest risk for pelvic organ prolapse, particularly after menopause. Other risk factors include – surgery to the pelvic floor, – connective tissue disorders, and – obesity.  What are the symptoms? no symptoms at all: – Women with mild prolapse discovered during a routine pelvic exam may have no symptoms at all.  What are the symptoms? But others experience considerable discomfort and a range of symptoms, including: 1. Pressure and pain. – The most common complaints are a feeling of pelvic pressure, or bearing down, leg fatigue, and low back pain. 2. Urinary symptoms. Cystocele, urethrocele, and uterine prolapse can cause – stress incontinence and – difficulty in starting to urinate.  What are the symptoms? 3. Bowel symptoms. – A rectocele may cause problems with defecation by forming a pocket just above the anal sphincter. – Stool can become trapped, causing pain, pressure, and constipation. 4. Sexual problems. – A prolapse can cause irritated vaginal tissues or pain during intercourse, as well as – psychological stress.  Treating prolapse no or very mild symptoms don’t need treatment, although they should avoid anything that might worsen the prolapse.  How to prevent prolapses from progressing Losing weight if necessary, avoiding lifting heavy objects, and quitting smoking Kegle’s excercise  Surgery If experiencing major discomfort or inconvenience, is the only definitive way to relieve symptoms and improve quality of life  less invasive treatments But if symptoms are mild or want to delay or avoid surgery: 1. Kegel exercises. – Kegel exercises are a series of contractions that strengthen the pelvic floor. – squeeze two sets of pelvic floor muscles at the same time: – those would use to prevent self from passing gas and those would tighten to stop urinating. – Avoid contracting stomach muscles. – do 30–40 pelvic contractions each day; – divide them into three or four groups of 10 each, spread throughout the day. – Squeeze and hold the contraction for 3–5 seconds; then rest for the same length of time. – Build up to 10-second contractions, with 10 seconds of rest in between.  less invasive treatments 2. Pessary. For women who aren’t good surgical candidates or want to delay surgery (perhaps if planning to have more children), a device similar to a diaphragm or cervical cap that’s inserted in the vagina to help support the pelvic area and the uterus (see illustration). Pessary  Surgical treatment need a thorough pelvic exam, to ensure that all problems have been identified. Surgical techniques. – Pelvic reconstruction surgery may be performed through: 1. the vagina or 2. abdominally; both procedures are equally effective. 3. A newer option is laparoscopic surgery,  Surgical treatment – The prolapsed organ will be repositioned and secured with stitches to the surrounding tissues and ligaments. – The vaginal defect will be repaired, sometimes using a piece of synthetic material, called a graft. – Women can usually leave the hospital within one to three days.  Surgical Complications. urinary tract infection, temporary or permanent incontinence, infection, bleeding, and — rarely — damage to the urinary tract that requires additional corrective surgery. Some women may develop chronic irritation or pain during intercourse from a suture or scar tissue.  Surgical Complications There’s also a risk of recurrence, which seems to be highest for cystocele and lowest for rectocele. Fortunately, recurrence rates are dropping: – as surgical techniques and preoperative planning improve. – if a woman avoids stress, such as heavy lifting or straining during a bowel movement, and – performs Kegel exercises regularly before and after surgery. Benign and malignant breast disorders Dr Sanaa Abujilban, RN, RM, PhD  Anatomy of the Breast: Lobules: glands for breast milk production Ducts: tubes connecting lobules to the nipples Fatty and connective tissue, blood vessels and lymph vessels Cancer can start in the ducts (most common), lobules and other tissue. Cancer invading lymph vessels can spread to the lymph nodes (axillary nodes) under the arm, and are then more likely to spread to other organs. Anatomy of the Breast: Loading…  Breast Profile: A: Ducts. B: Lobules. C: Dilated section of the duct to. D: Nipple. E: Fat. F: Pectoralis major muscle. G: Chest wall/rib cage. Enlargement: A: Normal Duct cells. B: Bassement membrane. C: Lumen (Center of duct).  Anatomy of the Breast Lymph Nodes Lymph Vessels Anatomy of the Breast  Types of breast lumps: A. Benign breast lumps: Fibro-cystic growths of – fluid-filled sacs or – scar tissue. 80% of lumps are benign. Sign of breast problems: The most common sign is a palpable mass  Benign breast lumps: Benign conditions of the breast 1. Fibrocystic changes 2. Fibroadenomas 3. Lipomas 4. Nipple discharge 5. Mammary duct ectasia 6. Intraductal papilloma 7. Macromastia and micromastia  1. Fibrocystic changes Most common lump, Unknown cause Between 20 -30 yrs May related to imbalance between estrogen (increase) and progesterone (decrease) Risk factors: Loading… Nulliparity Low parity Late menopause Estrogen therapy  1. Fibrocystic changes Clinical manifestations: – Lumpiness in both breast – Pain (dull, heavy ) increase 1 wk before mens. and stop 1 wk after mens. – Tenderness – Fullness – May develop cysts before menopause: soft, well diffentiated and movable cysts  1. Fibrocystic changes Diagnosis: – Ultrasound to determine if it is fluid filled or solid – Fluid filled: aspirated – Solid: mammography is obtained; fine needle aspiration (FNA); core biopsy  1. Fibrocystic changes: Therapeutic management Conservative treatment Diuretics Restriction of salt and fluid Vitamin E supplements Restrict caffeine; no research support Avoid smoking and alcohol Pain- relief: analgesics NSAIDs Wearing bras Applying heat Danazol: relief pain Oral contraceptives; not all women Some times: surgical removal  2. Fibroadenomas Next most common composed of fibrous and glandular tissue. Mass: – solid, – encapsulated, – non tender: some tenderness with mens. – often found in the upper outer quadrant – Lass than 3 cm in diameter  2. Fibroadenomas Increase in size during pregnancy, shrink with age Not increase in size with mens. (while cyst increase in size)  2. Fibroadenomas Diagnosis: – Taking history – Physical examination – Mammogram – Ultrasound – MRI – FNA Treatment: – Surgical removal: if suspicious; sever symptoms – Follow up  3. Lipomas S&S: – Palpable Soft tumor ; – Composed of fat – Have discrete border – Mobile – Nontender In woman older than 45 yrs Diagnosed by mammogram Treatment: may be by surgical removal  4. Nipple discharge Types: 1. bilateral serous discharge: , by stimulation; Normal; woman need reassurance 2. Galactorrhea: bilateral, spontaneous, milky, sticky discharge Normal in pregnancy Medications: oral contraceptives,  4. Nipple discharge: Galactorrhea Diagnosis: – Prolactin level; sample took between 8-10 am, – Microscopic analysis of the discharge – Thyroid profile – Pregnancy test – mammogram  5. Mammary duct ectasia Inflammation of the ducts behind the nipple Cause: unknown, chronic inflammation, dilation of the ducts Occurs often in perimenopausal women S&S: – thick, sticky nipple discharge, white, brown, green, or purple in color – Burning pain, itching, palpable mass  5. Mammary duct ectasia Diagnostic work up: – Mammogram – Aspiration of fluid – Culture of fluid Management: – Reassurance – Antibiotic – Drainage for any abscess – Excision of the affected duct  6. Intraductal papilloma Rare, benign Unknown cause Between age 30 -50 yrs composed of gland and fibrous tissue, as well as blood vessels Size: small (less than 0.5 cm) Nipple discharge: uni-lateral, spontaneous, serous, bloody discharge Management: eliminate malegnancy, excision of the affected segment (duct)  7. Macromastia Breast hyperplasia; big breasts Problems: – Pain in the breast, back, neck, shoulders – Disruption in psychosocial functioning and body image – Thoracic kyphosis – Headache – Paresthesia (numbness) of upper extremity – Shoulder grooving from bra straps Treatment: reduction mammoplasty  8. Micromastia Very small breast Negatively influence the body image Management: – Augmentation mammoplasty by inserting implants between the breasts and the chest wall – 2 types of implants: Filled with normal saline Filled with silicone gel Saline tissue expander, implant  Care for benign conditions 1. History: – Risk factors – Events related to breast mass; how, when and by whom the mass was discovered – Health maintenance practices – Breast self examination – Access to care  Care for benign conditions 1. History cont.: – Presence of pain – Whether symptoms increase with menses – Dietary habits – Smoking – Oral contraceptive use – Emotional status: stress level, fears, concerns, coping abilities  Care for benign conditions 2. physical examination: for the breast – Symmetry – Masses (size, number, consistency, mobility) – Nipple discharge Loading…  Patient care Educate about breast self examination Breast screening (clinical examination, mammogram) Written educational material Encourage the verbalization of fears and concerns Information about ; diet, drug, comfort measures, stress management, surgery Effective pain control Discuss Feeling about body image Support group Types of breast lumps:  Malignant conditions of the breast: Introduction Breast cancer is one of the leading causes of death among women in Jordan it is three times more common than all gynecologic cancers combined; 1 in 9 women will be diagnosed with invasive breast cancer during their lives, The most common diagnosed cancer in women  Malignant conditions of the breast Incidence increase each year because of: – Better detection of early stages – Obesity – Postmenopausal hormonal therapy  Introduction the key to a better quality life is – early detection and – screening  Impact of breast cancer on women Physiologic alteration Self- concept threat : sexual being concept Coping threats  components of Early detection of breast cancer 1. Risk Factors. 2. Anatomy of Breast. 3. Types of breast lumps. 4. Red flags and symptoms. 5. Prevention and early detection. 6. Screening. 7. Steps to perform clinical breast examination.  Risk factors (20): Women with one or more risk factor are of vital importance to fit in the regimen of screening and early detection. In addition, it is essential to identity high risk group so as to decrease the mortality rate.  Risk factors: 1. Gender: Women at more risk than men (have more breast cells) 2. Age Incidence correlates with age. – Increase with age (after 50 y) , much more aggressive in younger women. 3. Family History – 20%-30% of those diagnosed have a family member with breast cancer; First degree relative 2-3 times higher risk 4. Menarche and Menopause: – menstruating before 10 years old, menopause after 55 years old.  Risk factors 5. Previous breast Cancer: – 3-4 times higher risk in the contra-lateral breast; Previous abnormal breast biopsy with benign growths 6. Pregnancy – never had children. – first full-term pregnancy occurred after age 35 years. 7. Estrogen Replacement Therapy- – 26% percent increase in breast cancer.  Risk factors 8. Obesity: 9. Physical activity – Brisk walking (12 minutes /km)1.5 – 2.5 hours a week reduced risk by 18%. 10. Breast feeding – Some evidence suggests a slightly lower risk after 1.5 – 2 years of breast feeding, although other studies suggest no correlation  Risk factors 11. Hormonal Replacement Therapy (HRT) Specifically, long term use estrogen AND progesterone. – Recent reports of an increased risk of breast cancer in women taking continuous combined hormone replacement therapy (HRT). – However with a recent study done by Weiss and colleagues 2003 “published in the Amercina Family Physician” March1, 2003 stated The only significantly increased risk in this study was with use of continuous combined HRT for five years or more.  Risk factors 12. Alcohol; 2 – 5 drinks per day = 1.5 times more risk than women who do not drink. 13. Rumored and/or unsupported: – Antiperspirants. – Underwear bras – induced abortion. – Breast implants.  Risk factors 14. Inconclusive: – Antibiotics. – Night work. – Smoking (no conclusive link between smoking and breast cancer in particular). – Environmental pollutant.  Risk factors 15. inherited genetic mutation for BRCA1 AND BRCA 2: 5% to 10 % of cancer cases 16. high breast tissue density 17. high dose radiation to the chest 18. previous history of ovarian, endometrial, colon, or thyroid cancer 19. Race (Caucasian women have highest incidence) 20. High socioeconomic class  Chemo prevention medications in preventing cancer Example of medication: – Raloxifene (Estrogen receptors modulators ), – anastrazole (inhibiting the synthesis of estrogen), – Tamoxifen (oral antiestrogen medication) Need more studies to identify which women would most benefit from administration of these medication  Pathophysiology Genetic alteration in the DNA (deoxyribonucleic acid) of breast epithelial cells of 1. ductal or 2. lobullar tissue Genetic alteration may be: 3. Inherited 4. spontaneous  Pathophysiology Start in the epithelial cells of the ducts Growth of cancer depends on – estrogen and progesteron effect Types of cancer: – Invasive (infiltrating) – Noninvasive (in situ)  Invasive types Ductal carcinoma Lobular carcinoma Nipple carcinoma (Paget’s disease)  Invasive ductal carcinoma Most common Originates in the lactiferous ducts and invade surrounding breast structures Invasive ductal Tumor : – Unilateral – Not well delineated (outlined) – Solid – Nonmobile – Nontender  Invasive lobular carcinama Originates in the lobules of the breasts Bilateral Non palpable  Menstrual disorders Dr Sanaa Abujilban, RN, RM, PhD  Factors that affecting menstruation Anatomic abnormalities Physiologic imbalance Life style Loading…  Menstruation Episodic uterine bleeding in response to cyclic hormonal changes Characteristics of normal menstrual cycles: Menarche: onset, average 11-13 yrs; may range 9-17yrs Interval: average 28days, may 26-34 days Duration: average 4-6 days, may 2-7 days Amount: 30-80 ml per cycle, saturating pad within 1 hrs is heavy bleeding Color: dark red (blood, mucus, and endometrial cells) Odor: similar to that of marigolds  Common Menstrual Disorders 1. Amenorrhea 2. Hypogonadotropic amenorrhea 3. Cyclic perimenstrual pain and discomfort (CPPD) Loading…  1. Amenorrhea – Absence of menstrual flow – Absence of menarche and secondary sex characteristics by age 14 yrs – Primary amenorrhea: Absence of menses by age 16 yrs – Secondary amenorrhea : 3-6 months absence of menses after a period of menstruation – A sign of a disease  2. Amenorrhea: causes 1. Often a result of pregnancy 2. Anatomic abnormalities: 1. Out flow tract obstruction 2. Anterior pitutary disorder 3. Endocrine disorders: such as; Poly-cystic ovary syndrome; hypothyroidism; hyper thyroidism 4. Chronic disease: type 1 DM 5. Medications: phyntoen (antiepileptic) 6. Drug abuse: alcohol, tranquilizers, opiates, marijuana, cocaine 7. Oral contraceptive use  2. Hypogonadotropic amenorrhea – Problem in central hypothalamic-pituitary axis Results from: very rare: Pituitary lesion or genetic inability to produce FSH and LH Most common: hypothalamic suppression: eg. – stress, body fat-to- lean ratio – Anorexia nervosa – Athletic training  2. Hypogonadotropic Amenorrhea: assessment – History: not pregnant, age, perimenopausal – Diagnostic test: – FSH, – TSH, – prolactin levels, – x-ray or CT scan, – progestational challenge – Physical examination  2. Hypogonadotropic Amenorrhea: management If hypothalamic disturbances: reversible – Counseling and education; Stress management : relaxation technique Medications that affect menstruation Correct weight Increase nutrition intake Calcium and Vitamin D supplements (for bone density) Low dose oral contraceptives  3. Cyclic perimenstrual pain and discomfort (CPPD) Include; 1. Dysmenorrhea, 2. pre-menstrual syndrome and 3. premenstrual dysphoric disorder Symptoms: Loading… – mood swings, – pelvic pain, – physical discomfort – Mild to sever pain – May pain takes from 1 to 14 days  Common Menstrual Disorders (cont.) 3.1. Dysmenorrhea – Primary dysmenorrhea – Secondary dysmenorrhea  3.1. Dysmenorrhea Pain during or shortly before menstruation 15 % of women have severe dysmenorrhea Interfere with women’s functioning for 1-3 days a month Associated with; – early menarche, nulliparty, stress Location of pain: suprapubic area, or lower abdomen Pain; sharp, cramping, gripping, dull ache – May radiate to lower back or upper thighs -  Primary dysmenorrhea Abnormally increased uterine activity; induced by prostaglandins Prostaglandins; Physiologic alteration – causing vasospasm resulting in ischemia – Backache, – Sweating – Weakness – GI symptoms; anorexia, nausea, vomiting, diarrhea – CNS symptoms: dizziness, syncope, headache, poor concentration  Primary dysmenorrhea 6 -12 months after menarche Anovulatory bleeding: is painless Decline with age  Primary dysmenorrhea: management Information and support Non pharmacologic technique: – Heat: vasodilation, relaxation, decrease ischemia – Massaging the lower back; relax the muscle and increase blood supply – Yoga, acupuncture , meditation – Exercise: vasodilation – Dietary changes; decrease salt and refined sugar before mens: Will decrease fluid retention Increase fluid intake and Natural diuretics (parsly) Decrease red meat (causes uterine muscles to contract)  Primary dysmenorrhea: management Medications: 1. NSAIDs; prostaglandins synthesis inhibitors – 2-3 days before menstruation – Or with 1st sign of bleeding 2. Combined contraceptive Pills 2. Prevent ovulation, decrease amount of menstrual flow, decrease prostaglandins Herbal preparations  Secondary dysmenorrhea Acquired menstrual pain Associated with pelvic pathology: eg. adenomyosis, endometriosis, Pelvic inflammatory disease, polyps, myomas – If associated with heavy menstrual flow: myoma, adenomyosis, polyps – If begins few days before menses; endometriosis  Secondary dysmenorrhea Diagnosis: – History: Pain; dull, lower abdominal aching, radiating o the back or thighs Bloating or pelvic fullness – Pelvic examination – U/S – D&C – Endomertial biopsy – laparoscopy  Secondary dysmenorrhea Treatment: – Removal of the cause – Medication as for primary dysmenorrhea  3.2. Premenstrual syndrome (PMS) Cyclic symptoms occurring in luteal phase of menstrual cycle Affect lifestyle or work Symptoms: – Fluid retention: bloating, fullness, edema of LE, breast tenderness, wt gain – behavioral and psychologic symptoms; depression, crying, irritability, panic attack, impaired ability to concentrate – Cravings; sweets, salt, increased appetite, – Headache, fatigue, backache  Premenstrual syndrome (PMS) Age: all age group, common among 20s- 30s women Related to ovarian function  Premenstrual dysphoric disorder (PMDD) Severe variant of PMS; 3-8% Symptoms: – Most common; mood disturbances – Marked irribility – Dysphoria (anxiety, depression, or un-ease) – Mood lability (marked fluctuation of mood) – Anxiety, – fatigue – Appetite changes Management – Diet and exercise – Herbal therapies  Causes of PMS, PMDD Not known related to ovarian functions May related to biologic and neuroendocrine Biologic, pscychosocial, sociocultural factors  Management of PMS, PMDD History, daily log; mood fluctuations for several cycles Education and life style changes – Not smoke, – decrease refined sugar, salt, red meat, alcohol, and caffeine (prevent sleep) – Healthy eating in 6 small frequent meals and snacks – Natural diuretics to decrease fluid retention  Management of PMS, PMDD Supplements: calcium, magnesium, Vitamin B6 Herbal therapies Regular exercise Non-pharmacological therapy; yoga, acupuncture, hypnosis Support groups Medications: diuretics, NSAIDs, progesterone, OCPs, serotonin reuptake inhibitors (antidepressants )  Endometriosis Presence and growth of endometrial tissue outside of the uterus Affecting 6 – 10 % of women Risk factors: – Asian women, familial tendency  Sites of Endometriosis Pelvic organs Vulva, perineum, bladder, gallbladder, heart, thoracic cavity, chocolate ovarian cyst Loading… Respond to hormones and bleeds causing; inflammatory response with subsequent fibrosis and adhesions Sites of Endometriosis  Causes of Endometriosis Poorly understood Transtubal migration or Retrograde menstruation theory: endometrial tissue is regurgitated during menstruation  Endometriosis: Major symptoms – pelvic pain and heaviness radiating to thigh – Dysmenorrhea – Deep pelvic dyspareunia (painful intercourse) – Abnormal menstrual bleeding – Infertility: adhesions for uterus and tubes – Bowel symptoms: diarrhea, pain with defecation, constipation – Abnormal bleeding – Pain during exercise – Endocrine disorders – Autoimmune disorders  Endometriosis: Management No treatment; for women with no pain , do not want to become pregnant Counseling and education Support group: www.resolve.org  Endometriosis: Management Drug therapy: – NSAIDs (for pain), OCPs, – hormonal antagonists (suppress ovulation): » GnRH agonists : (chemical menopause) Suppressing gonadotropin (FSH,LH) secretion; decrease estrogen result in hot flashes and decrease bone density » Danazol: androgenic synthetic steroid; suppress LH, FSH Surgical intervention; for sever, acute symptoms – Hysterectomy – Laser or surgical removal of endometrial tissue  Alterations in cyclic bleeding 35 1. Oligomenorrhea glig 2. Hypomenorrhea flores 3. Metrorrhagia is " 4. Menorrhagia flow s % 4