gynecological disorders in pregnancy

1. GYNECOLOGICAL DISORDERS IN
PREGNANCY

2. 1.Abnormal Vaginal Discharge
• Increased cervical secretions and vaginal
transudate during pregnancy : Increased
vacularity and hyperestrogenic state.
• T/T : Improvement in personal hygiene.

3. 2.Trichomonas Vaginalis
• Infection is not increased during pregnancy
• Clinical features remains same as in
nonpregnant state.
• T/T : Metronidazole 200mg x TDS x 7
days.(Should be avoided in first trimester)

4. 3.Monilia Vaginitis
• Growth is favoured by high acidic PH of
vaginal secretions and frequent presence of
sugar in the urine during pregnancy.
• More prevalent in diabetic
• T/T : miconazole vaginal cream,one applicator
full high in vagina at bedtime x 7 nights.

5. 4.Cervical Ectopy
• Due to hyperestrenism in pregnancy marked
hyperplasia of the endocervical mucosa.
• Downgrowth of columnar epithelium to variable
extent beyond the extrnal os replacing the
squamous epithelium : Pregnancy ectopy.
• Appears first time in pregnancy, circumoral in
position and NO bleeding on touch
• Spontaneous regression 6-8 weeks post partum

6. 5. Cervical Polyp
• Pregnancy—increased vascularity hence pre-
existing polyp bleeds
• Diagnosis confirmed by per speculum
examination
• Polyp should be removed as done in non-
pregnant state and the specimen should be
sent for HPE

7. 6. Acquired abnormality in the cervix
• May be scarred following amputation during
fothergill type of operation for prolapse, deep
cauterization or diathermy
• May fail to dilate during labour and hence
cesaerean section may be needed in such
situations

8. 7. Congenital malformation of Uterus
and Vagina
• Severe degrees: infertility
• Minor degree: little to no effect on pregnancy
• Moderate degree: adverse effect on pregnancy
and labor
1. Recurrent mid-trimester abortion
2. Rupture pregnant rudimentary horn
3. Malpresentation
4. Abnormal uterine action
5. Preterm labour

9. 6.Fetal growth restrition
7. PPH
8. Retained placenta
9. Obstructed labour
10. Increased incidence of operative procedures

10. • Common types of malformations are:
1. Arcuate
2. Subseptate
3. Bicornuate

11. 8. Carcinoma Cervix with Pregnancy
• Incidence: 1 in 2500 pregnancies
• Diagnosis:
Asymptomatic- cytologic screening of all
pregnant mothers is a routine during
antenatal checkup, if dyskaryotic smear:
colposcopic guided biopsy recommended
Symptomatic- biopsy from the lesion to confirm
the diagnosis

12. • Problems arising in diagnosis:
1. Indurated feel of malignancy may not be
apparent
2. Beningn lesions such as ectopy or polyp may
bleed to touch
3. Extension to the parametrium may not be
well defined

13. • Effects of pregnancy on carcinoma cervix:
- Malignant process unaffected
- May have rapid spread follwoing vaginal
delivery and induced abortion
• Effects of carcinoma on pregnancy:
- increased incidence of: abortion, premature
labour, secondary cervical dystocia, injury to
cervix leading to PPH, lochiometra and
pyometra, uterine sepsis

14. • Treatment:
- Carcinoma In Situ: pregnancy to be followed up
with periodic cytologic and colposcopic
evaluation, no contraindication to vaginal delivery
- Microinvasive disease: conservative management
until delivery
- Early Invasive( stage IB and IIA): treatment option
depends on gestational age, tumour stage,
metastatic evaluation and maternal desire to
continue pregnancy

15. First trimester: radical hysterectomy with the fetus in
uterus, pelvic lymphadenectomy and aortic node
sampling are done, oophoropexy at the time of
hysterectomy may be done.
Third trimester: Radical Hysterectomy, pelvic
lymphadenectomy after classical cesaerean delivery
Second trimester: options are
1. Neoadjuvant chemotherapy—continuation of
pregnancy for7-15 weeks until fetal maturation—
classical cesarean delivery and radical
hysterectomy
2. Abdominal hysterectomy

16. - Advanced Invasive Disease(stage III or stageIV)
First trimester:chemotherapy and external beam
irradiation—spontaneous abortion—
brachytherapy
Second or third trimester:classical cesarean
delivery—neoadjuvant chemotherapy and
irradiation
Labour and delivery with vaginal route is
avoided

17. 9. Leiomyomas with pregnancy
• Incidence: 1 in 1000
• Effects on pregnancy:
Depends upon location,
1. May be none
2. Pressure symptoms due to impaction
3. Bladder: retention of urine
4. Rectum: constipation
5. Abortion
6. Malpresentation
7. Non-engagement of presenting part
8. Preterm labour and prematurity
9. Red degeneraion
10. Disruption of pregnancy

18. • Effects on labour:
1. Unaffected
2. Uterine inertia
3. Dystocia
4. Obstructed labour
5. PPH
6. Difficult cesarean section
• Effects on Puerperium:
1. Subinvolution
2. Sepsis
3. Secondary PPH
4. Inversion of uterus
5. Lochiometra and pyometra

19. • Effects of pregnancy on fibroid:
1. Increased size due to increased vascularity
2. Changes in position
3. Changes in shape: becomes flattened
4. Degenerative changes esp red degeneration
5. Torsion of pedunculated subserous fibroid
6. Infection and polyploidal changes

20. • Red degeneration:
-Predominanly in large fibroid
- During second trimester of pregnancy
- Actually a hemorrhagic infarction
- Microscopically, evidences of necrosis are present,
vessels are thrombosed but extravasation of blood
is unlikely
- Clinical features: acute onset of pain, malaise or rise
in temperature, dry tongue, rapid pulse,
constipation, tenderness and rigidity over the
tumour, leucocytosis
- Treatment: conservative with IV antibiotics,
analgesics and sedatives

21. • Treatment:
1. Basic principle: not to do anything to fibroid
whenever possible
2. During Pregnancy:
- uncomplicated: usual antenatal care, cases
reassesed at 38 WOG
- Impaction in early months:manual correcion- if
fails, laparotomy and myomectomy
- Red degeneration: medical management

22. 10. Ovarian tumours in Pregnancy
• Incidence: 1 in 2000
• Incidence of germ cell tumour increased two fold
during pregnancy compared to the non-pregnant
state
• Effects of tumour on pregnancy: increased chances
of
1. Impaction leading to retention of urine
2. Mechanical distress
3. Malpresentation
4. Non-engagement of head
5. On labour: increased chance of obstructed labour

23. • Effects on the tumour:
1. Relocation of tumour
2. Torsion of the pedicle
3. Intracystic hemorrhage
4. Rupture
5. Infection
• Diagnosis:
-Ultrasound
-May present with symptoms of:
1. retention of urine
2. Mechanical stress due to large tumour
3. Acute abdomen

24. • Treatment:
- During pregnancy: principle is to remove the
tumour as the diagnosis is made
- Uncomplicated: best time of elective operation is
between 14th and 18th week
- Complicated: the tumour should be removed
irrespective of the period of gestation
- During Labour: 1. if the tumour is well above the
presenting part---watchful expectancy for vaginal
delivery
2. If tumour impacted in pelvis: cesarean section
- During puerperium: the tumour should be removed
as early as possible

25. 11. Genital Prolapse In Pregnancy
• Pregnancy common in 1st degree UV prolapse with
cystocoele and rectocoele
• Pregnancy uncommon: if the cervix lies outside the
introitus
• Effects on prolapse:
1. On pregnancy: miscarriage, discomfort , PROM,
Chorioamnionitis
2. During Labour: Early rupture of membrane, cervical
dystocia, prolonged labour due to non-dilatationof
cervix and obstruction due to sagging cystocoele and
rectocoele, operative interference
3. During Puerperium: subinvolution, uterine sepsis

26. • Treatment:
- If cervix is outside the introitus; replace inside the
vagina and ring pessary should be kept until 18-20
weeks of gestation
- If the cervix remains outside the introitus in later
months, admit the patient at 36 weeks
- During Labour: patient should be in bed to avoid
early rupture of membrane
: intravaginal plugging soaked with glycerine and
acriflavin
: prophylactic antibitoics if PROM
: manual stretching of the cervix

27. :if the head is deeply engaged with the cervic
remaining thin but undilated, delivery may be
facilitated by duhrssens incision at 2O clock and 10
O clock position followed by ventouse or forceps
application
: if the head is high up or the cervix remains
edematous and undilated- cesarean section
-Puerperium: the patient should lie flat on bed, the
mass should be covered with gauge soaked in
glycerine and acriflavin; a ring pessary amy be put
until the involution is completed; prophylactic
antibitoics

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