CMT06210

APP. IN OBSTETRICS
AND
GYNECOLOGY
2023

Thursday, July 13, 2023 Mlela 1

 “O Lord, Nothing is easy except what you have made easy.”
Amen.

Thursday, July 13, 2023 Mlela 2

 INFERTILITY
Session 1

Thursday, July 13, 2023 Mlela 3

Learning tasks
At the end of this session, students are expected to be
able to:
• Explain aetiology/risk factors of infertility
• Outline epidemiology of infertility
• Explain clinical features of infertility
• Establish the diagnosis of infertility
• Provide pre-referral treatment of infertility
• Provide follow-up services of infertility
• Provide control and preventive measures of infertility

Thursday, July 13, 2023 Mlela 4

Activity: Brainstorming

What is Infertility?

Thursday, July 13, 2023 Mlela 5

Definition

Infertility:
Infertility is defined as a inability to conceive within one or more
years of regular unprotected coitus
• Couples who have never conceived are referred to as having
Primary infertility while those who had conceived before but
failure to conceive subsequently are referred to as having
Secondary infertility.

Thursday, July 13, 2023 Mlela 6

Definition cont…

The probability of achieving a pregnancy each month/menstrual

cycle is referred to as Fecundability. In a health woman this is
approximately 20% per month.
The ability to achieve a live birth within 1 menstrual cycle is
known as Fecundity. The estimated fecundity rate is 15-18%
per month

Thursday, July 13, 2023 Mlela 7

Epidemiology
Infertility affects approximately 10-15% of reproductive-aged
couples.
Incidences of infertility appear to rise woman's age increases.
In Africa, its prevalence is particularly high in sub-Sahara
ranging from 20% to 60% of couples
The percentage of infertile males in these countries varied from
2.5-12%2.
Nigeria accounts for up to 50% of all case3.
 Patterns of male infertility vary greatly among regions and even
within regions

Thursday, July 13, 2023 Mlela 8

 Etiology

Infertility is caused by male

and/or female factors.
Male factors ≈ 35%
Female factors ≈ 35%
Male and female factors combined
≈ 20%
Unknown factors ≈ 10%

Thursday, July 13, 2023 Mlela 9

Etiology cont…

Female factors
Cervical:
Stenosis
Mucus-sperm interaction abnormalities (thick, scanty,
antisperm antibodies e.t.c)

Thursday, July 13, 2023 Mlela 10

 Etiology cont…

Female factors cont…

Uterine:
 Uterine hypoplasia,
 Inadequate secretory endometrium,
 Uterine fibroid
 Eendometritis
 Uterine synechiae
 Congenital malformation of uterus

Thursday, July 13, 2023 Mlela 11

 Etiology cont…

Female factors cont…

 Ovarian:
 Anovulation or oligo-ovulation
 Decreased ovarian reserve
 Luteal phase defect (LPD)
 Luteinized unruptured follicle (LUF).

Thursday, July 13, 2023 Mlela 12

 Etiology cont…

Female factors cont…

Tubal:
 Congenital abnormalities of fallopian tubes
 Tubal Blockade
 Hydrosalpinx

Thursday, July 13, 2023 Mlela 13

 Etiology cont…

Female factors cont…

Peritoneal:
 Peritoneal infections e.g PID
 Peritoneal adhesions
 Adnexal masses
 Deep dyspareunia
 Cul-de-sac blockage

Thursday, July 13, 2023 Mlela 14

 Etiology cont…

Female factors cont…

Vagina:
 Atresia of vagina (partial or complete),
 Transverse vaginal septum,
 Septate vagina,
 Narrow introitus causing dyspareunia

Thursday, July 13, 2023 Mlela 15

Etiology cont…

Thursday, July 13, 2023 Female factors Mlela

summary 16
Etiology cont…

Male factors
Pre-testicular factors:
Endocrine: hypogonadotrophic hypogonadism,
prolactinomas, gonadotropin deficiencies, and Cushing
syndrome.
Psychosexual: Erectile dysfunction, Impotence
Drugs: Antihypertensives, Antipsychotics
Genetic alberations: 47 XXY, Y chromosome deletions,
Single gene mutations

Thursday, July 13, 2023 Mlela 17

Etiology cont…

Male factors cont…

Testicular factors: Impaired spermatogenesis
Immotile cilia (Kartagener) syndrome
Cryptorchidism
Infection (mumps orchitis)
Toxins: Drugs, smoking, radiation
Varicocele
Immunologic
Sertoli-cell-only syndrome
Primary testicular failure
Oligoastheno-teratozoospermia

Thursday, July 13, 2023 Mlela 18

Etiology cont…

Male factors cont…

Post-testicular factors: Inability to deposit sperm into vagina
Congenital Absence of Vas deferens (Cystic fibrosis, Young’s syndrome)
Acquired blockage of Vas deferens (Tuberculosis, Gonorrhea, iatrogenic as in
Herniorrhaphy and Vasectomy)
Ejaculatory failure
Retrograde ejaculation
Hypospadias
Bladder neck surgery

Thursday, July 13, 2023 Mlela 19

Etiology cont…
Factors affecting both Sexes
Environmental and occupational factors
Excessive radiation damages the germinal cells.
Exposure to lead, other heavy metals,
Exposure to pesticides
Tobacco and other drugs of abuse e.g marijuana, cocaine
Tobacco blocks spermatogenesis in males and interferes with
mucus and cilia functions in female
Marijuana reduces sperm count and quality and interferes
with FSH and LH secretion

Thursday, July 13, 2023 Mlela 20

Etiology cont…

Factors affecting both Sexes cont…

Chronic alcoholism:
May induce ovulatory dysfunction,
Interferes with the synthesis of testosterone and has an
impact on sperm concentration in males.
Alcoholism may inhibit sexual response and cause
impotence.

Thursday, July 13, 2023 Mlela 21

Etiology cont…

Factors affecting both Sexes cont…

Exercise
Jogging stimulates the secretion of endorphins which
when in excess interferes with the normal production of
FSH and LH,
In males, exercise has been associated with
oligospermia.

Thursday, July 13, 2023 Mlela 22

Etiology cont…

Factors affecting both Sexes cont…

Diet
Weight loss associated can induces hypothalamic
amenorrhea,
Obesity may be associated with anovulation and
oligomenorrhea in female and decreased sperm quality in
males.

Thursday, July 13, 2023 Mlela 23

Activity: Brainstorming

What are the important things to be considered

during evaluation for infertility?

Thursday, July 13, 2023 Mlela 24

Evaluation
Male infertility
• History:
Age
Duration of marriage
History of previous marriage and proven fertility if any
Medical history: STIs, DM, Mumps, bronchiectasis,
Surgical history: herniorrhaphy, operation on testes, testicular
trauma
Sexual history: impotence, premature ejaculation, change in
libido
Social habits: smoking, alcohol, recreational drugs
Thursday, July 13, 2023 Mlela 25
Evaluation cont…
Male infertility cont…
• Physical examination:
General state of health e.g BMI, Blood pressure e.t.c
Size and consistency of the testicles. volume should be at
least 20 mL.
Presence of varicocele should be elicited in the upright
position
Hypospadias
Cryptorchidism
Signs of inguinal hernia repair

Thursday, July 13, 2023 Mlela 26

Evaluation cont…

Male infertility cont…

• Investigations:
Routine investigations: urine analysis, Blood sugar,
Semen analysis
Sperm function test
Hormonal analysis: FSH, LH, Testosterone, Prolactin and
TSH
Testicular biopsy
Transrectal ultrasound
Thursday, July 13, 2023 Mlela 27
 Evaluation cont…
Male infertility cont..

Semen analysis (WHO 2010) Definition of terminologies

Thursday, July 13, 2023 Mlela 28

 Evaluation cont…
Female infertility
• History:
Age
Duration of marriage
History of previous marriage and proven fertility if any
Medical history: STIs, DM, TB, PID,
Surgical history: Abdominal and pelvic surgery
Menstrual history: hypo/oligomenorrhea, intermenstrual pain
Contraceptive history: IUCD
Past obstetric hx: number and intervals of previous pregnancies, puerperal sepsis,
uterine curettage
Sexual hx: frequency, dyspareunia, loss of libido, douching, use of lubricants
Hirsutism, frontal balding, weight changes
Social habits: smoking, alcohol, recreational drugs

Thursday, July 13, 2023 Mlela 29

Evaluation cont…

Female infertility
• Physical examinations:
General examination: BMI, Blood pressure, hirsutism,
acne, exophthalmos, thyroid enlargement, webbed neck,
Breast examination: development, masses, secretions
Abdominal examination: hypogastric masses
Pelvic examination: clitoris, pubic hair, venereal
infections, stenosis of cervix, size and position of uterus,
adnexal masses, tenderness or nodules

Thursday, July 13, 2023 Mlela 30

Evaluation cont…
Female infertility cont…
• Investigations:
Routine investigations: urine analysis, Blood sugar,
Cervical swab for Gram stain and culture
Hormone analysis: Serum progesterone, Serum LH, Serum estradiol,
Urine LH
Endometrial biopsy
™™
Sonography: Abdominal, transvaginal
Hysterosopy
Hysterosalpingography (HSG)
Saline infusion sonography
™Laparoscopy
™

Thursday, July 13, 2023 Mlela 31

Treatment
• General measures:
Couple Assurance to relieve anxiety
Regulate body weigh accordingly to obtain optimum weight
Avoid alcohol, smoking and recreational drugs
Counsel on coital timing
Treat STIs, Sexual dysfunctions as appropriate
• Specific treatment:
Will depend on the identified factor
May include medical, surgical intervention or Assited
reproductive technology

Thursday, July 13, 2023 Mlela 32

 Treatment of male infertility
 No available treatment
 Specific treatment available
 Treatment of uncertain efficacy
 Empirical treatment-For idiopathic oligospermia/azoospermia
 clomiphene
 other hormones
 vitamins
 kallikrein
 Assisted reproductive technique
Intrauterine insemination
In vitro fertilization
Intra-cytoplasmic sperm injection
Artificial insemination with donor semen
 Potential treatment in future,egGerm cell transplantation, Human germ cell transplant
Thursday, July 13, 2023 Mlela 33
Treatment of female infertility…
1) Ovulatory disorders:
Weight modulation
Clomiphene citrate or other selective estrogen receptor
modulators (SERM)
2) Tubal factor infertility and adhesions
Tubal flushing,IVF,Tubal reconstruction,Adhesiolysis
,Salpingectomy
3) Endometriosis
laparoscopic surgery alone or with
Superovulation when surgery alone has not helped

Thursday, July 13, 2023 Mlela 34

 Cont..
4) Uterine factor infertility
Hysteroscopic myomectomy
Abdominal myomectomy
laparoscopic myomectomy
hysteroscopic resection
 septa
 synechiae
5) Assisted reproductive technologies
 Intrauterine insemination
 In vitro fertilization
 Intra-cytoplasmic sperm injection
 Gamete Intrafallopia transfer
 Artificial insemination with donor semen Mlela 35
Thursday, July 13, 2023
 Surrogate mothers to natural mother
Follow up

• 40% of infertility cases with unknown etiology will conceive

within 3 years without any specific interventions.

Thursday, July 13, 2023 Mlela 36

Prevention

Practice safer sex

Early diagnosis and management of STIs
Avoid alcohol, smoking and recreational drugs

Thursday, July 13, 2023 Mlela 37

Key points
Infertility is failure to conceive despite regular unprotected sex for at
least 12 months
It affects approximately 10-15% of reproductive aged couples
Male and Female factors contributes 35% each, while 20% results
from both male and female factors combined. The rest 10% the
causes are unknown
When evaluating infertility in a couple it is important to start with the
male before moving costly investigations for female factors
Once the cause of infertility is identified, therapy aimed at correcting
reversible etiologies and overcoming irreversible factors can be
implemented
The couple is also counseled on lifestyle modifications to improve
fertility such as smoking cessation, reducing alcohol consumption and
appropriate frequency of coitus
Thursday, July 13, 2023 Mlela 38
Review questions

1. What is Infertility?
2. Outline the male factors for Infertility.
3. Outline the female factors for Infertility?
4. Outline the general measures to be taken when
treating a couple for Infertility.

Thursday, July 13, 2023 Mlela 39

 ENDOMETRIOSIS
Session 2

Thursday, July 13, 2023 Mlela 40

Learning tasks
At the end of this session, students are expected
to be able to:
Outline epidemiology of endometriosis
Explain aetiology/risk factors of endometriosis
Outline epidemiology of endometriosisIdentify cause
and risk factors
Explain clinical features of endometriosis
Establish diagnosis/ provisional and differential diagnosis
of endometriosis
Provide pre-referral treatment of endometriosis
Thursday, July 13, 2023 Mlela 41
Activity: Brainstorming

What is endometriosis?

Thursday, July 13, 2023 Mlela 42

Definition

The proliferation and functioning of endometrial

tissue outside of the uterine cavity

Thursday, July 13, 2023 Mlela 43

Epidemiology

Ten to fifteen percent of reproductive-aged women.

Occurs primarily in women in their 20s and 30s.
Common in nulliparous woman.
Accounts for 20% of chronic pelvic pain.
One-third to one-half of women affected with infertility has
endometriosis.

Thursday, July 13, 2023 Mlela 44

Pathophsiology

The ectopic endometrial tissue is physiologically functional. It

responds to hormones and goes through cyclic changes, such
as menstrual bleeding.
The result of this ectopic tissue is “ectopic menses,” which
causes bleeding, peritoneal inflammation, pain, fibrosis, and,
eventually, adhesions.

Thursday, July 13, 2023 Mlela 45

SITES OF ENDOMETRIOSIS

Common sites
Ovary (bilaterally): 60%.
Peritoneum over uterus.
Anterior and posterior cul-de-sacs.
Broad ligaments/fallopian tubes/round ligaments.
Uterosacral ligaments.
Bowel.
Pelvic lymph nodes: 30%.

Thursday, July 13, 2023 Mlela 46

SITES OF ENDOMETRIOSIS

Less Common
Rectosigmoid: 10–15%.
Cervix.
Vagina.
Bladder.

Thursday, July 13, 2023 Mlela 47

SITES OF ENDOMETRIOSIS

Rare sites
Nasopharynx.
Lungs.
Central nervous system (CNS).
Abdominal wall.
Abdominal surgical scars or episiotomy scar.
Arms/legs.

Thursday, July 13, 2023 Mlela 48

 Sites for endometriosis

Thursday, July 13, 2023 Mlela 49

Causes

Unknown cause
Theories:
Retrograde menstruation: Endometrial tissue fragments
are retrogradely transported through the fallopian tubes
and implant there or intraabdominally with a predilection
for the ovaries and pelvic peritoneum.
Mesothelial (peritoneal) metaplasia: Under certain
conditions, peritoneal tissue develops into functional
endometrial tissue, thus responding to hormones.

Thursday, July 13, 2023 Mlela 50

Causes cont..

Vascular/lymphatic transport: Endometrial tissue is

transported via blood vessels and lymphatics. This can
explain endometriosis in locations outside of the pelvis
(ie, lymph nodes, pleural cavity, kidneys).
Altered immunity: There may be deficient or
inadequate natural killer (NK) or cell-mediated response.
This can explain why some women develop
endometriosis, whereas others with similar
characteristics do not.

Thursday, July 13, 2023 Mlela 51

Causes...

Iatrogenic dissemination: Endometrial glands and

stroma can be implanted during a procedure (eg, c-
section). Endometriosis can be noted in the anterior
abdominal wall.

Thursday, July 13, 2023 Mlela 52

Risk factors

Nulliparity

Age > 25 years

Family history

Obstructive anomalies of the genital tract

Thursday, July 13, 2023 Mlela 53

Activity 2: Brainstorming

What are clinical features Endometriosis?

Thursday, July 13, 2023 Mlela 54

Clinical features
CLINICAL PRESENTATION:
Pelvic pain (that is especially worse during menses, but can
be chronic):
Secondary dysmenorrhea (pain begins up to 48 hr prior to
menses).
Dyspareunia (painful intercourse) as a result of implants on
pouch of Douglas; occurs commonly, with deep penetration.
Dyschezia (pain with defecation): Implants on rectosigmoid.
Infertility- 30-40%
Intermenstrual bleeding.
Cyclic bowel or bladder symptoms (Haematuria)

Thursday, July 13, 2023 Mlela 55

Clinical features cont.…
SIGNS:
Fixed retroflexed uterus, with scarring posterior to uterus.
Tender uterus or presence of adnexal masses.
Nodular” uterosacral ligaments or thickening and
indurations of Uterosacral ligaments.
Ovarian endometriomas: Tender, palpable, and freely
mobile implanted masses that occur within the ovarian
capsule and bleed. This creates a small blood-filled cavity
in the ovary, classically known as a “chocolate cyst.”
Blue/brown vaginal implants (rare).

Thursday, July 13, 2023 Mlela 56

Activity 3: case study

A 31-year-old woman presents at the gny clinic with a 4year

history of inability to conceive despite unprotected sex. Her
menses began at age 12 and occurs every month. She complains
of severe monthly pain 1 week before each menses and pain with
intercourse. She denies a history of sexually transmitted diseases
and she has no history of abormal vaginal discharge. Her
husband has a child from a previous marriage.

Thursday, July 13, 2023 Mlela 57

Activity 3: case study...

1. What are the differential diagnoses?

2. How will you confirm the diagnosis?

Thursday, July 13, 2023 Mlela 58

Differential diagnosis

Chronic Pelvic inflammatory disease

Uterine fibroid
Adenomyosis
Recurrent acute salpingitis,
Adhesions,
Hemorrhagic corpus luteum cysts,
Ectopic pregnancy, and
Ovarian neoplasms.
Thursday, July 13, 2023 Mlela 59
Diagnosis

History

Pelvic examination

Laparoscopy or laparotomy: Ectopic tissue must be biopsied

for definitive diagnosis.

Thursday, July 13, 2023 Mlela 60

Treatment

Pre-referral treatment will include:

Analgesics: Non steroidadal anti-inflammatory e.g
diclofenac 50mg 8 hourly
Oral contraceptives (OCPs)

Thursday, July 13, 2023 Mlela 61

Treatment cont…
At the hospital
Medical (temporizing).
The primary goal is to induce amenorrhea and cause regression of the
endometriotic implants.
All of these treatments suppress estrogen:
Gonadotropin-releasing hormone (GnRH) agonists (leuprolide):
Suppress follicle-stimulating hormone (FSH); create a
pseudomenopause.
Depo-Provera (progesterone [+/– estrogen]): Creates a
pseudopregnancy (amenorrhea).

Thursday, July 13, 2023 Mlela 62

Treatment cont…
Danazol: An androgen derivative that suppresses FSH/luteinizing hormone (LH),
thus also causing pseudomenopause.
Oral contraceptives (OCPs): Used with mild disease/symptoms.
Surgical
Conservative (if reproductivity is to be preserved): Laparoscopic lysis and
ablation of adhesions and implants.
Definitive: Total abdominal hysterectomy and bilateral salpingo-
oophorectomy (TAH/BSO).

Thursday, July 13, 2023 Mlela 63

Complications

Due to adhesions may lead to:

Infertility

Chronic pelvic pain

Intestinal obstruction

Thursday, July 13, 2023 Mlela 64

Key points

1. Endometriosis is one of the common gynaecological condition

and often diagnosed as pelvic inflammatory disease
2. Is a common cause of chronic pelvic pain and infertility
3. Diagnosis depend on history, pelvic findings and
Laparoscopy or laparotomy: Ectopic tissue must be biopsied
for definitive diagnosis
4. Definitive treatment is Total abdominal
hysterectomy and bilateral salpingo-oophorectomy

Thursday, July 13, 2023 Mlela 65

Evaluation

1. What is endometriosis?

2. Mention clinical features of endometriosis?

3. What are the differential diagnoses for

endomtriosis?

Thursday, July 13, 2023 Mlela 66

 MENOPAUSE
Session 3

Thursday, July 13, 2023 Mlela 67

Learning tasks
At the end of this session, students are expected to be
able to:
Explain etiology/risk factors of menopause
Outline epidemiology of menopause
Explain menopausal symptoms
Establish diagnosis of menopause
Provide pre-referral treatment of menopause
Provide follow-up services of menopause
Provide control and preventive measures of menopause

Thursday, July 13, 2023 Mlela 68

Activity: Brainstorming

What is menopause?

Thursday, July 13, 2023 Mlela 69

Definition

Menopause:
• Menopause is the permanent caseation of
menstruation at the end of reproductive life due to
loss of ovarian follicular activity.
• It is the point of time of the last menstruation.
• It is diagnosed after 12 months of amenorrhea

Thursday, July 13, 2023 Mlela 70

Epidemiology

The age of menopause ranges between 45 to 55

with the average being 50years
This age is genetically pre-determined and is not
related to age at menarche, parity or race
Early menopause may occur in:
 Severe malnutrition
 Smoking
 Autoimmune disorders
 Radiotherapy
 Chemotherapy

Thursday, July 13, 2023 Mlela 71

Etiology

• Physiological menopause occurs after depletion of ovarian

follicles rendering the ovary insensitivity to gonadotropin
stimulation

• Surgical menopause results from surgical removal of ovaries

(oophorectomy)

Thursday, July 13, 2023 Mlela 72

Etiology cont…

Pre-mature ovarian failure (menopause at <40years) may result

from
Idiopathic causes (50-80%)
Autoimmune diseases
Thyroid disease
Diabetes mellitus
Chemotherapy
Radiotherapy
Fragile X syndrome

Thursday, July 13, 2023 Mlela 73

Activity: Brainstorming

What are the Menopausal symptoms?

Thursday, July 13, 2023 Mlela 74

Menopausal symptoms
• Majority experience caseation of menstruations alone and no other
symptoms.
• Some may however experience some of the following additional
symptoms:
Vasomotor symptoms:
• Hot flushes:
 K.K by sudden feeling of heat followed by profuse sweating
 May be associated with palpitation, fatigue and weakness
 Lasts for 1-10minutes

Thursday, July 13, 2023 Mlela 75

Menopausal symptoms cont…
Genitourinary symptoms:
• Dyspareunia
• Dry vagina
• Vaginal itching
• Vaginal infections
• Leucorrhea
• Dysuria
• Urgency
• Recurrent urinary tract infections
• Stress incontinency

Thursday, July 13, 2023 Mlela 76

Menopausal symptoms cont…

Hair, skin and soft tissue changes:

• Wrinkling of skin
• Loss of elasticity
• Thinning of skin
• Loss of some of pubic hair
• Slight balding
• Breast atrophy
• Breast tenderness

Thursday, July 13, 2023 Mlela 77

Menopausal symptoms cont…
Psychological symptoms:
• Anxiety
• Headache
• Insomnia
• Irritability
• Dysphasia
• Depression.
• Mood swing
• Impaired concentration
• Impaired memory

Thursday, July 13, 2023 Mlela 78

 Menopausal symptoms cont…

Bone changes:
• Osteoporosis leading to:
 Bone pain
 Kyphosis
 Loss of height
 Pathological fractures

Kyphosis and loss of height

Thursday, July 13, 2023 Mlela 79
Menopausal symptoms cont…

Sexual dysfunction:
• Decreased libido
• Dyspareunia
• Delay to attain orgasm

Thursday, July 13, 2023 Mlela 80

Menopausal symptoms cont…

Cardiovascular changes:
• Increased atherosclerosis and thrombosis thus at high risk of:
Stroke
Ischemic heart diseases

Thursday, July 13, 2023 Mlela 81

Diagnosis of Menopause

Diagnosis of menopause base on:

• Clinical presentation:
Cessation of menses for 12 consecutive months
Appearance of menopausal symptoms

• Lab investigation:
Decreased serum oestradiol : < 20 pg/ml.
Elevated serum FSH and LH: >40 mlU/ml
Thursday, July 13, 2023 Mlela 82
Treatment

Pre-referral treatment
• Reassurance may help to reduce anxiety, insomnia and depression
• Lifestyle modification including:
 Physical activity (weight bearing, walking, jogging)
 Reduce coffee intake,
 Avoid smoking
 Avoid alcohol.
• Balanced diet rich in calcium and protein: e.g 300 mL of milk daily
Thursday, July 13, 2023 Mlela 83
Treatment cont…

Pre-referral treatment cont…

• Reducing medications that causes bone loss e.g corticosteroids
• Calcium supplements
• Vitamin D supplements
• Exposure to sunlight to help Vitamin D3 synthesis

Thursday, July 13, 2023 Mlela 84

Treatment cont…

Other treatment Options:

• Hormonal replacement therapy
• Bisphosphonates

Thursday, July 13, 2023 Mlela 85

Indication of hormonal replacement therapy:

Treatment of menopausal symptoms like hot flashes

Prevention of osteoporosis
To maintain the quality of life in menopausal years.

Thursday, July 13, 2023 Mlela 86

Pharmacological treatment

Use hormone replacement therapy

Tibolone 2.5 mg tabs one tab/day for 30 days to be installed after
12 months of last menstruation for prevention of osteoporosis,
atrophic changes of vagina, hot flushes and increase of libido.
 Estrogen (oral, transdermal patch, lotion or gel) alone if the
woman have had hysterectomy.
Estrogen plus progesterone (as the combination therapy)if the
woman still has her uterus to avoid endometrial cancer

Thursday, July 13, 2023 Mlela 87

Complication

Endometrial cancer
Coronary heart disease
Breast cancer and DVT

Thursday, July 13, 2023 Mlela 88

Follow up

Follow-up for evaluation for possible complications associated

with menopause and/or treatment (hormonal replacement
therapy)

Thursday, July 13, 2023 Mlela 89

Preventive measures of Menopause

Physiological menopause cannot be prevented or delayed as is

the ultimate end of every woman
Artificial menopause such as that induced by surgery or
radiotherapy can however be delayed or avoided

Thursday, July 13, 2023 Mlela 90

Key points
Menopause means cessation of menstruation.
It normally occurs at ages between 45-55 years
Apart from cessation of menstruation, menopause may be
associated with other genitourinary, bone, psychological,
vasomotor and soft tissue symptoms.
Diagnosis of menopause is established upon cessation of
menses for consecutive 12 months in the absence of other
pathology
Management involves Reassurance, lifestyle and dietary
modifications with or without hormonal therapy

Thursday, July 13, 2023 Mlela 91

Review questions

1. What is Menopause?
2. Outline the menopausal symptoms
3. How is the diagnosis of menopause reached at?
4. Outline the management of menopause

Thursday, July 13, 2023 Mlela 92

Assignment

Describe hormonal replacement therapy in relation to

management of menopause under the following subheadings:
a. Definition
b. Indications
c. Contraindications
d. Complications

Thursday, July 13, 2023 Mlela 93

 BARTHOLIN'S CYST
&
ABSCESS
Session 4

Thursday, July 13, 2023 Mlela 94

Learning tasks

At the end of this session, students are expected

to be able to:
Outline epidemiology of Bartholin's cysts
Explain aetiology/risk factors of Bartholin's cyst
Explain clinical features of Bartholin's cyst
Establish diagnosis/ provisional and differential
diagnosis of Bartholin's cyst
Provide the treatment of Bartholin's cyst

Thursday, July 13, 2023 Mlela 95

Activity 1: Brainstorming

What is a bartholin cyst?

Thursday, July 13, 2023 Mlela 96

Definition

Bartholin’s glands are the two pea sized (2 cm)

glands, located in the groove between the hymen and
the labia minora at 5 O’Clock and 7 O’Clock position
of the vagina.

A Bartholin’s cyst is a fluid-filled sac within one of

the Bartholin’s glands of the vagina due to duct
obstruction.

Thursday, July 13, 2023 Mlela 97

Epidemiology

The exact incidence of Bartholin’s cysts and

abscesses is uncertain, but abscesses account for
2% of all gynaecological visits a year.
Asymptomatic cysts may occur in up to 3% of
women, although they often do not present to health
care services.
The incidence increases with age until menopause

Thursday, July 13, 2023 Mlela 98

Aetiology and pathophysiology

Infection is an important cause of obtruction of the

duct of the gland leading to cyst formation

The cyst itself can become infected, and if

untreated, develop into an abscess.

Thursday, July 13, 2023 Mlela 99

Aetiology and pathophysiology

The infective organisms are:

Gonococcus
Escherichia coli
Staphylococcus,
Streptococcus,
Chlamydia trachomatis
Other causes
inspissated mucus
congenital narrowing of the common duct

Thursday, July 13, 2023 Mlela 100

Predisposing factors

Bartholin’s cysts characteristically occur

in nulliparous women of child-bearing age.
Personal history of Bartholin’s cyst
Sexually active (STIs can cause a Bartholin’s cyst or
abscess)
History of vulval surgery

Thursday, July 13, 2023 Mlela 101

Activity: Brainstorming

What are clinical features of bartholin's cyst?

Thursday, July 13, 2023 Mlela 102

Clinical features

Symptoms:
Small Bartholin’s cysts are often asymptomatic.
If they become large, they can cause vulvar pain
(particularly when walking and sitting),
and superficial dyspareunia (pain during sexual
intercourse).
Bartholin’s abscesses typically present with acute
onset of pain, and/or difficulty passing urine.

Thursday, July 13, 2023 Mlela 103

Clinical features

On examination:
A unilateral labial mass will be observed. This typically arises
from the posterior aspect of the labia majora, although a large
cyst or abscess can expand anteriorly.
Bartholin’s cyst – typically soft, fluctuant and non-tender
Bartholin’s abscess – typically tense and hard, with surrounding
cellulitis

Thursday, July 13, 2023 Mlela 104

 Bartholin's cyst

Thursday, July 13, 2023 Mlela 105

Differential diagnosis

Bartholin’s gland carcinoma

Bartholin’s benign tumour – such as adenomas and nodular
hyperplasia.
Other types of cyst – e.g. sebaceous cyst, Skene’s duct cyst,
mucous cyst
Other solid masses – e.g. fibroma, lipoma, leiomyoma

Thursday, July 13, 2023 Mlela 106

Treatment

Primary treatment consists of incision and cyst or

abcess drainage, preferably with marsupialization or
insertion of word catheter (inflatable bulb tipped
catheter)

Thursday, July 13, 2023 Mlela 107

Treatment cont…

Marsupialisation:
A vertical incision is made into the vaginal wall and
the cyst, behind the hymenal ring, allowing for
spontaneous drainage of the cavity.
The cyst wall is then everted and approximated to
the end of the vaginal mucosa by sutures.
This can be done under local anesthesia

Thursday, July 13, 2023 Mlela 108

 Marsupiliasation

Thursday, July 13, 2023

Mlela 109
Treatment cont…

Word Catheter
An incision is made into the cyst or abscess, and a
catheter is inserted.
The tip is inflated with 2-3ml of saline. It is left in place
for 4-6 weeks to allow epitheliasation of the surgically
created tract.
This technique is not suitable for deep cysts or
abscesses.
It can be performed under local anesthesia in a clinic.

Thursday, July 13, 2023 Mlela 110

Complications

Bartholin’s abscess

Thursday, July 13, 2023 Mlela 111

Key points

Bartholin's are common in nullparous women

Primary treatment consists of incision and cyst or

abcess drainage, with marsupialization or insertion of
word catheter

Thursday, July 13, 2023 Mlela 112

Evaluation

1. What is a barholin' cyst?

2. What are the clinical features of bartholin's cyst?

3. What is the best management of bartholin's cyst?

Thursday, July 13, 2023 Mlela 113

 PELVIC ORGAN PROLAPSE
Session 5

Thursday, July 13, 2023 Mlela 114

Learning tasks
At the end of this session, students are expected to be
able to:
• Explain aetiology/risk factors of pelvic organ prolapse
• Outline epidemiology of pelvic organ prolapse
• Explain clinical features of pelvic organ prolapse
• Establish diagnosis/ provisional and differential diagnosis of pelvic
organ prolapse
• Provide pre-referral treatment of pelvic organ prolapse
• Provide follow-up services of pelvic organ prolapse
• Provide control and preventive measures of pelvic organ prolapse
Thursday, July 13, 2023 Mlela 115
Activity: Brainstorming

What is pelvic organ prolapse?

Thursday, July 13, 2023 Mlela 116

Definition
Pelvic organ Prolapse:
Is the protrusion of the pelvic organs into or out of the vaginal
canal.
Is the abnormal descent or herniation of the pelvic organs
from their normal attachment sites or their normal position in
the pelvis.
The entity includes descent of the vaginal wall and/or the
uterus.
The pelvic structures that may be involved include the uterus
(uterine prolapse) or vaginal apex (apical vaginal prolapse),
anterior vagina (cystocele), or posterior vagina (rectocele).

Thursday, July 13, 2023 Mlela 117

Epidemiology

Pelvic organ prolapse (POP) affects millions of women

worldwide.
Genital prolapse occurs in about 10-30% of multiparous
women and in 2% of nulliparous women
The lifetime risk for woman undergoing surgery for genital
prolapse or incontinence is 11%.
Some studies show that the prevalence of pelvic organ
prolapse increases steadily with age (Olsen, 1997; Swift,
2005)

Mlela 118

Thursday, July 13, 2023

Etiology
Most cases are the result of damages to the vaginal and pelvic support tissues
due to childbirth or due to chronically elevated intra-abdominal pressure
Repeated childbirth may result into stretching and injury of:
Ligaments (see p. 204)
Endopelvic fascia (see p. 204)
Levator muscle (myopathy)
Perineal body
Nerve (pudendal)
Muscle damage

Thursday, July 13, 2023 Mlela 119

Risk factors
Child birth
Postmenopausal atrophy
Poor collagen tissue repair with age
Increased intra-abdominal pressure as in chronic lung disease and
constipation
Occupation (weight lifting)
Asthenia and undernutrition
Obesity
Increased weight of the uterus as in fibroid or myohyperplasia

Thursday, July 13, 2023 Mlela 120

Activity: Brainstorming

What are clinical features of Pelvic organ prolapse?

Thursday, July 13, 2023 Mlela 121

Clinical features
History:
• Feeling of something coming down per vaginum, especially while moving about.
• Backache or dragging pain in the pelvis.
• Dyspareunia.
• Urinary symptoms
Difficulty in passing urine. The patient has to elevate the anterior vaginal
wall for evacuation of the bladder.
Increased frequency
Urgency
Painful micturition (in case of cystitis)
Stress incontinence is usually due to associated urethrocele.
Retention of urine may rarely occur

Thursday, July 13, 2023 Mlela 122

Clinical features cont…

History cont…
• Bowel symptom (in presence of rectocele).
Difficulty in passing stool. The patient has to push back
the posterior vaginal wall in position to complete the
evacuation of feces.
Fecal incontinence may be associated.
• Excessive white or blood-stained vaginal discharge due to
associated vaginitis or decubitus ulcer.

Thursday, July 13, 2023 Mlela 123

 Clinical features cont…

Physical examination:
• Rectocele:
 A bulge of the anterior vaginal wall, which
increases with straining
 Has positive cough impulse
 Is reducible
• Cystourethrocele:
 Bulging of ant. Vaginal wall involves the
lower 1/3
 There may be stress incontinence

Thursday, July 13, 2023 Mlela 124

 Clinical features cont…

Physical examination cont…

• Rectocele and Enterocele:
 Often co-exist
 A bulge of the posterior vaginal wall with
sulcus btn them
 Rectovaginal examination: enterocele is
close to the cervix and cannot be reached
at by the rectal finger

Thursday, July 13, 2023 Mlela 125

 Clinical features cont…

Physical examination cont…

• Uterine prolapse:
 First degree: Cervical descent below ischial
spine on straining
 2nd and 3rd degree: Mass protruding out
through the introitus leading part being
external os
 Decubitus ulcer or dark pigmentation at the
leading part
 Shallow vaginal orifices
 Increased length of uterine cavity on
introducing uterine sound
Third degree uterine prolapse
Thursday, July 13, 2023 Mlela 126
Differential diagnosis

Cystocele:
Gartner’s cyst
Inclusion dermoid cyst
Urethral diverticulum
Uterine prolapse:
Congenital cervical elongation
Chronic uterine inversion
Fibroid polyp
Thursday, July 13, 2023 Mlela 127
Investigations

Mid-stream urine for analysis and culture .

Renal ultrasound and IVU in cases of procidentia and severe
cystocele to exclude hydroureter & hydronephrosis which may occur
as a result of kinking of the ureters
Cystometry in cases of incontinence in order to exclude urge
incontinence
Cystourethroscopy

Thursday, July 13, 2023 Mlela 128

Treatment

Pre-referral treatment:
• Treat underlying cause as appropriate
• Treat complications such as UTI as appropriate
• Pelvic floor exercises in an attempt to strengthen the muscles
(Kegel exercises).
• For 2nd and 3rd degree genital prolapse;
Cover with gauze soaked with normal saline for safe
transfer/referral
Thursday, July 13, 2023 Mlela 129
Treatment cont…

Specific treatment:
• Estrogen replacement therapy may improve minor degree
prolapse in postmenopausal women
• Pessary
• Surgery

Thursday, July 13, 2023 Mlela 130

 Treatment cont…

Pessaries

Thursday, July 13, 2023 Mlela 131

Complications

Urinary tract infection: Cystis and pyelonephritis

Incarceration: At times, infection of the para-vaginal and
cervical tissues makes the entire prolapsed mass edematous
and congested. As a result, the mass may be irreducible.
Peritonitis: Rarely, pelvic peritonitis may occur through the
posterior vaginal wall.
Carcinoma: Carcinoma rarely develops on decubitus ulcer

Thursday, July 13, 2023 Mlela 132

Follow up

Evaluations for symptoms and signs and development of

complications of the disease and/or complications

Thursday, July 13, 2023 Mlela 133

Prevention
• General measures
To avoid strenuous activities, chronic cough, constipation and
heavy weight lifting.
To avoid future pregnancy too soon and too many by
contraceptive practice
• Prevention of postmenopausal atrophy of pelvic support by:
 Balanced diet
 Exercise
 Calcium
 Increased use of HRT.

Thursday, July 13, 2023 Mlela 134

Prevention cont…

Adequate antenatal and intranatal care

Avoiding of: prolonged labour , bearing down before full
cervical dilatation and difficult instrumental delivery
Adequate postnatal care
To encourage early ambulance.
To encourage pelvic floor exercises by squeezing the
pelvic floor muscles in the puerperium.

Thursday, July 13, 2023 Mlela 135

Key points
Pelvic organ prolapse is the protrusion of the pelvic organs into or out
of the vaginal canal
It is a result of injury to the pelvic support by conditions such as
childbirth or increased intra-abdominal pressure. Other factors
includes obesity, menopause and undernutrition
Common presentation includes sensation of something in the vagina
and lower back pain both which tend to be relieved on lying down
Treatment involves correction of unerlying causes/factors, use of
pessaries and surgery
Treatment involves correction of underlying causes/factors, use of
pessaries and surgery
POP can be prevented by avoiding the risk factors, proper antenatal,
intranatal and postnatal care

Thursday, July 13, 2023 Mlela 136

Review questions

1. What is Pelvic organ prolapse?

2. Outline the risk factors for Pelvic organ prolapse.
3. What are the clinical presentation of Pelvic organ
prolapse?
4. Outline the management of Pelvic organ prolapse.

Thursday, July 13, 2023 Mlela 137

 UROGENITAL FISTULA
Session 6

Thursday, July 13, 2023 Mlela 138

Learning tasks
At the end of this session, students are expected to
be able to:
Outline epidemiology of urogenital fistula
Explain aetiology/risk factors of urogenital fistula
Explain clinical features of urogenital fistula
Establish diagnosis/ provisional and differential
diagnosis of urogenital fistula
Provide pre-referral treatment of urogenital fistula
Provide control and preventive measures of urogenital
fistula

Thursday, July 13, 2023 Mlela 139

Activity 1: Brainstorming

What is a fistula?

Thursday, July 13, 2023 Mlela 140

Definition

A fistula: is an abnormal connection between two or more

epithelial surfaces.

Urogenital fistula: Abnormal communications between urinary

and genital organs.

Thursday, July 13, 2023 Mlela 141

Epidemiology
Obstetric fistula affects about two million women per year, almost all
in developing countries (particularly in Africa and the Indian sub-
continent).
Account for about 0.2 - 1% gynaecological admission
The magnitude of the problem in Tanzania is not well known due to
under-reporting.
Most of births take place at home (home delivery), but it is estimated
that the incidence of obstetric fistula may be as high as 1200 new
cases per year
Obstetric cause is the commonest cause of urogenital fistula in
developing and account for about 80 to 90 %

Thursday, July 13, 2023 Mlela 142

Types of urogenital fistula

Bladder
Vesicovaginal - Abnormal communication between the
epithelium of the urinary bladder and vagina, this is the
commonest type of obstetric fistulas.

Vesicouterine-Abnormal communication between the

epithelium of the urinary bladder and uterus

Thursday, July 13, 2023 Mlela 143

Types...

Bladder
Vesicocervical - Abnormal communication between the
epithelium of the urinary bladder and cervix.

Vesicourethrovagina - Abnormal communication between the

epithelium of the urinary bladder , urethra and vagina,

Thursday, July 13, 2023 Mlela 144

Types.....

Ureter
Ureterovaginal - Abnormal communication between the
epithelium of the ureter and vagina.
Ureterouterine - Abnormal communication between the
epithelium of the ureter and uterus
Ureterocervical - Abnormal communication between the
epithelium of the ureter and cervix

Thursday, July 13, 2023 Mlela 145

Types....

Urethra
Urethrovaginal - Abnormal communication between the
epithelium of the urethra and vagina.

Thursday, July 13, 2023 Mlela 146

Thursday, July 13, 2023 Mlela 147
Causes
Acquired:
Obstetrical
Gynaecological
Accidental
Malignancy
Infenction
Radiotherapy

Congenital: very rare

Thursday, July 13, 2023 Mlela 148

Causes
Obstetrical causes
Prolonged obstructed labour lead to compression of soft tissues
between head and brim of a narrow pelvis.
 → ischaemia, pressure necrosis & sloughing of base of the
bladder.
 Urethra is also often involved.
Slough takes some days to separate
→ Incontinence develops 5-10 days after labour
Such fistulae are often surrounded by dense fibrosis

Thursday, July 13, 2023 Mlela 149

Thursday, July 13, 2023 Mlela 150
Causes cont..

Obstetrical cause
Instrumental delivery like forceps delivery
Caesarean section

Thursday, July 13, 2023 Mlela 151

Causes...

Gynaecological causes:
Bladder may be injured during vaginal operation as anterior
colporrhaphy or during abdominal operations as hysterectomy
Urethra may be injured during vaginal operation as anterior
colporrhaphy
Ureter may be injured during during abdominal operations as
hysterectomy

Thursday, July 13, 2023 Mlela 152

Causes cont…

Accident:
Road traffic accident-crush injuries to the pelvis

Neoplastic fistula
Cancer of the cervix
Cancer of urinary bladder
Cancer of the vagina

Thursday, July 13, 2023 Mlela 153

Causes cont…
Radiotherapy
Infections
Granulomatous infections, like TB
Syphilis
Schistosomiasis

Thursday, July 13, 2023 Mlela 154

VESICOVAGINAL FISTULA
(The Commonest)

Thursday, July 13, 2023 Mlela 155

Risk factors
Contracted maternal pelvis
Teenage pregnancies (pelvis is not yet matured)
Malnutrition in early childhood
Acquired contracted pelvis: accident/traumatic,
infections like polio or TB
Poor access and quality of emergency obstetric care
Women may undergo prolonged labour, which places
stress on the reproductive organs, and may contribute to
fistula development

Thursday, July 13, 2023 Mlela 156

Risk factors...

Low socioeconomic status

Women with VVF come almost exclusively from
poor families

Thursday, July 13, 2023 Mlela 157

Activity 2: Brainstorming

What are clinical features of VVF?

Thursday, July 13, 2023 Mlela 158

Clinical features

Incontinence of urine which normally develops within one

week after delivery

Symptoms of vulvitis/dermatitis:
Pruritus, burning pain due to continuous discharge of
urine.

Cystitis -Due to ascending infection from vulva

Thursday, July 13, 2023 Mlela 159

Clinical features...

History of difficulty labour

Pelvic bone pain
Foot drop, unsteady gait
Psychologically depressed
Menstrual disturbance especially amenorrhea
Often mothers may end up with loss of babies

Thursday, July 13, 2023 Mlela 160

Diagnosis

History of incontinence following labour or operation.

Several days after labour necrotic obstetric fistula
Immediately after difficult labour traumatic fistula.
Palpation of anterior vaginal wall:
Large fistula Can be felt
Small fistulas cannot be felt, but surrounding fibrosis is usually
palpable

Thursday, July 13, 2023 Mlela 161

Diagnosis...

Inspection of the anterior vaginal wall in Sims’ position or left

with the use of Sims’ speculum.

For small and high fistula Dye test: Injection of methylene blue
into bladder by a catheter to outline the fistula while anterior
vaginal wall is inspected by use of Sim’s speculum.
DD: uretrovaginal fistula

Thursday, July 13, 2023 Mlela 162

Thursday, July 13, 2023 Mlela 163
Classification according to size

Small < 2 cm

Medium 2-3 cm

Large 4-5 cm

Extensive > 6 cm

Thursday, July 13, 2023 Mlela 164

Classification

According to anatomic\physiologic location.

I:Not involving the closing mechanism
II:Involving the closing mechanism.
A:without(sub) total urethra involvement.
without circumferential defect.
with circumferential defect.
B:with(sub) total urethral involvement
without circumferential defect.
with circumferential defect.

Thursday, July 13, 2023 Mlela 165

 Classification-closing mechanism

Thursday, July 13, 2023 Mlela 166

 Type I fistula

Thursday, July 13, 2023 Mlela 167

 Type IIAa fistula

Thursday, July 13, 2023 Mlela 168

 Type IIAb fistula

Thursday, July 13, 2023 Mlela 169

Complications of obstetrical fistula
Physical complications:
Bladder prolapse
Wasting of pelvic muscles
Chemical vaginitis, UTI and sepsis
Partial or complete loss of the labia minora/vagina,
varying from loss of the anterior
vaginal wall to vagina stricture, circular stenosis and even
atresia
Anaemia (due to reduced intake of food)
Possible infertility

Thursday, July 13, 2023 Mlela 170

Complications of obstetrical fistula...

Psychosocial complications:
Possible future inability to carry a child
Social and psychological pain that may lead to suicidal ideation
Divorce
Family abandonment/isolation

Thursday, July 13, 2023 Mlela 171

 POSTOPERATIVE COMPLICATIONS.

Early complications Late complications

Postoperative death-due to Stress and/ urge incontinence
pulmonary thromboembolism, Overflow incontinence.
urosepsis.
Fistula recurrence.
Blockage of the catheter.
Bladder stone formations.
Urine retention
Vaginal stenosis/atresia.

Thursday, July 13, 2023 Mlela 172

Management of Obstetric Fistula

Urethral catheterization - 40-60% of small fistulas

heal following four to six weeks of catheterization
Plenty of fluid, minimum of 6-8L/day
Oral haematinics and high protein diet
Psychological support/counselling
Refer to hospital for VVF repair

Thursday, July 13, 2023 Mlela 173

Prevention of Obstetric Fistula

Primary Prevention
Prevention of prolonged and obstructed labour through Proper
use of partogram in labour wards
Prevent teenage pregnancies through reproductive health
education and community awareness and life skills - Family
planning
Proper attendance at antenatal clinic which will facilitate
screening women at risk big babies, contracted pelvis, encourage
hospital delivery

Thursday, July 13, 2023 Mlela 174

Prevention of Obstetric Fistula..

Encourage women to deliver at health care facilities

Improve infrastructures:
Roads, communications (radio calls, phones and
ambulances for health facilities), ensure that health facilities
are accessible
Improve health facilities that will enable to provide emergency
obstetric care

Thursday, July 13, 2023 Mlela 175

Prevention of Obstetric Fistula..

Ensure availability of trained health personnel

Economy
 Alleviate poverty
Socially; improve women’s decision making power
Promotion of good health

Thursday, July 13, 2023 Mlela 176

Prevention of Obstetric Fistula..

Secondary Prevention
Prevent fistula following obstructed labour by:
Early intervention for patients with obstructed labour by
doing caesarean section
Post delivery bladder catheterization

Thursday, July 13, 2023 Mlela 177

Prevention of Obstetric Fistula..

Tertiary Prevention and Rehabilitation

When fistula has already occurred, prevention is aimed at
providing good environment for either spontaneous healing or
successful repair, strategies include:
Early diagnosis of fistula
Measures for early treatment
Encourage training on fistula surgery

Thursday, July 13, 2023 Mlela 178

Prevention of Obstetric Fistula..

Psychotherapy
Occupational therapy
Family planning
Encourage hospital delivery in subsequent pregnancy

Thursday, July 13, 2023 Mlela 179

Key points

The commonest cause of urogenital fistula is

obstetrical cause
Vesicovaginal fistula is a commonest urogenital fistula
The range of physical and psychological problems
associated with obstetric fistula adversely affects the
quality of women’s lives in numerous ways.
Obstetric fistulae are preventable.

Thursday, July 13, 2023 Mlela 180

Evaluation

1. What are the types of urogenital fistula?

2. what is the common cause of urogenital fistula?

3. How will you prevent obstetric fistula?

Thursday, July 13, 2023 Mlela 181

 IMPERFORATE HYMEN
Session 7

Thursday, July 13, 2023 Mlela 182

Learning tasks
At the end of this session, students are expected to be
able to:
Explain etiology/risk factors of imperforate hymen
Outline epidemiology of imperforate hymen
Explain clinical features of imperforate hymen
Establish diagnosis/ provisional and differential diagnosis of
imperforate hymen
Provide pre-referral treatment of imperforate hymen
Provide follow-up services of imperforate hymen
Provide control and preventive measures of imperforate hymen
Thursday, July 13, 2023 Mlela 183
Activity: Brainstorming

What is imperforate hymen?

Thursday, July 13, 2023 Mlela 184

Definition

Imperforate hymen:
Is a congenital abnormality of the vagina in which
the hymen completely obstructs the vagina with no
opening.
Imperforate hymen is a solid membrane interposed
between the proximal uterovaginal tract and the
introitus
Is the most common form of vaginal outlet flow
obstruction

Thursday, July 13, 2023 Mlela 185

Epidemiology

Imperforate hymen is the most frequent cause of

vaginal outflow obstruction
Occurs in 0.1% of infant girls.
Mostly unnoticed until age of 14-16 years

Thursday, July 13, 2023 Mlela 186

Etiology

Specific etiologies for the failure to establish patency are not

evident.
May be related to failure of apoptosis due to a genetically
transmitted signal, or it may be related to an inappropriate
hormonal milieu.
Familial inheritance in successive generations has been
described

Thursday, July 13, 2023 Mlela 187

Activity: Brainstorming

What are clinical features of Imperforate hymen?

Thursday, July 13, 2023 Mlela 188

 Clinical features

Neonates
Whitish bulging membranes between
the labia
Palpable uterus at suprapubic area

Whitish bulging hymen

Thursday, July 13, 2023 Mlela 189
Clinical features cont…
Adolescents
History:
• Periodic lower abdominal pain which may be continuous,
• Primary amenorrhea
• Urinary symptoms such as
Frequency
Dysuria
Urine retention of urine due to elongation of urethra
• Back pain
• Constipation

Thursday, July 13, 2023 Mlela 190

Clinical features cont…

Adolescents cont…
Physical examination:
• Suprapubic mass, which may be uterine or full bladder.
• Tense bluish bulging membrane on vulva inspection
• Bulged vagina on rectal examination

Thursday, July 13, 2023 Mlela 191

 Tense bulging hymen due to hematocolpos
Thursday, July 13, 2023 Mlela 192
Differential diagnosis

Transverse vaginal septum

Complete vaginal agenesis,
Malignancies of the upper or lower genital tract.

Thursday, July 13, 2023 Mlela 193

Investigations

Abdominal and pelvic ultrasound: to rule out hematocolpos or

hematometrocolpos

Thursday, July 13, 2023 Mlela 194

 Treatment

Surgery: Cruciate incision is made in

the hymen

Escape of black tarry blood after

Thursday, July 13, 2023 Mlela
surgery 195
Complications

• Endometriosis secondary to retrograde menstruation

FOLLOW-UP
• For evaluation of the patient's menstrual cycle

Thursday, July 13, 2023 Mlela 196

Key points

Imperforate hymen is a congenital condition characterized

by vaginal outflow obstruction
It is often detected during adolescence
Common clinical presentations includes cyclic abdominal
pain, primary amenorrhea, urinary symptoms, constipation
and a bulging hymen between labia
Management is by surgery

Thursday, July 13, 2023 Mlela 197

Review questions

1. What is Imperforate hymen?

2. Outline causes of Imperforate hymen
3. What are the clinical presentation of Imperforate
hymen?
4. Outline the management of Imperforate hymen

Thursday, July 13, 2023 Mlela 198

 UTERINE FIBROIDS
Session 8

Thursday, July 13, 2023 Mlela 199

Learning tasks
At the end of this session, students are expected to be
able to:
Explain aetiology/risk factors of uterine fibroid
Outline epidemiology of uterine fibroid
Explain clinical features of uterine fibroid
Establish diagnosis/ provisional and differential diagnosis of uterine
fibroid
Provide pre-referral treatment of uterine fibroid
Provide follow-up services of uterine fibroid

Thursday, July 13, 2023 Mlela 200

Activity: Brainstorming

What is Uterine fibroid?

Thursday, July 13, 2023 Mlela 201

Definition

Uterine fibroid:
Is a benign tumor originating from uterine smooth
muscles
Also known as Myoma, Leiomyoma, Fibromyoma
Commonest benign solid tumor in females
Affects 20%-30% of women in reproductive age

Thursday, July 13, 2023 Mlela 202

Classification

Thursday, July 13, 2023 Mlela 203

Risk Factors
• The exact aetiology is unknown
• Leiomyomas arise from overgrowth of smooth muscles in the uterus
• Child bearing age >30 years
• Low parity/ infertility
• Hyperestrogenic state- There is an oestrogen link because Fibroids are
oestrogen dependent.
• In infertility there is long standing
• Unopposed estrogen effects leading to Ver proliferation of uterine smooth
muscles
• Obesity
• Family history/ genetic predisposition

Thursday, July 13, 2023 Mlela 204

Classification of Uterine Fibroids
Fibroids are classified based on their sites:
 Submucousal: Fibroids found within or underneath the
endometrium.
 Intramural: Fibroids found within uterine muscles -
myometrium.
 Subserosal: Fibroids found above the outer lining of the
uterus.
 Pedunculated: When fibroids develops from the uterus with
a pedicle containing blood vessels.

Thursday, July 13, 2023 Mlela 205

 Anatomical Classification of Fibroids

Thursday, July 13, 2023 Mlela 206

Etiology

Idiopathic
Overgrowth of uterine smooth muscles

Thursday, July 13, 2023 Mlela 207

Activity: Brainstorming

What are clinical features of Uterine Fibroid?

Thursday, July 13, 2023 Mlela 208

Clinical features
Symptoms
Asymptomatic in ≥ 50%
Abnormal uterine bleeding: menorrhagia, metrorrhagia
Dysperunia
Dysmenorrhoea
Lower abdominal Pain: May result from
Degeneration
Infection
Torsion if pendunculated
Uterine contraction (submucosa fibroid)
Thursday, July 13, 2023 Mlela 209
Clinical features cont…

Symptoms Cont…
Infertility (27-40%)
Recurrent abortion
Pressure symptoms
Urinary symptoms: ↑ frequency, retention
Constipation
Lower limb edema
Uterine contraction (submucosa fibroid)

Thursday, July 13, 2023 Mlela 210

Clinical features cont…

Physical examination
Uterine mass
Spherical
Firm
Smooth
Cannot go below it
Mobile (subserousa pedunculated)
Non tender
Thursday, July 13, 2023 Mlela 211
Differential diagnosis

Adenomyosis
Pregnancy
Endometriocarcinoma,
Leiomyosarcoma
Ovarian tumours/cysts

Thursday, July 13, 2023 Mlela 212

Investigations

Abdominopelvic ultrasound
Transvaginal ultrasound
FBP/Hb in case of abnormal bleeding

Thursday, July 13, 2023 Mlela 213

The major indications for management of
fibroids include
Abnormal uterine bleeding
Rapid growth
Growth after menopause
Sub fertility
 Recurrent pregnancy loss
 Pain or pressure symptoms e.g. urinary tract symptoms
obstruction
Iron deficiency anaemia secondary to chronic blood loss.

Thursday, July 13, 2023 Mlela 214

Treatment
If asymptomic- Expectant management
Pre-referral treatment:
Emergency resuscitation if haemodynamically
unstable due to bleeding
Haematenics if pale
Analgesics if in pain
Specific treatment
Medical therapy with GnRH: to relieve symptoms
Surgical therapy: e.g Myomectomy, Hysterectomy e.t.c

Thursday, July 13, 2023 Mlela 215

 Complications
In Non-pregnant Women
Anaemia
Torsion leading to acute abdomen
Secondary polycythermia (rare)
Degenerations:
Atrophic degeneration,
Hyaline degeneration,
Myxoid (fatty) degeneration,
Cystic degeneration,
Calcific (calcareous) degeneration,
Sarcomatous transformation (<3%)
Sub fertility

Thursday, July 13, 2023 Mlela 216

Complications cont…
In Pregnant Women
Abortions
Premature labour
Labor Dystocia
Malpresentations
Malpositions
Post partum haemorrhage
Ectopic pregnancy
IUGR

Thursday, July 13, 2023 Mlela 217

Key points

Uterine fibroid is a benign tumor of the myometrium

The exact etiology is unknown but tend to be associated
with nuliparity, obesity, high estrogenic state, family
history and black race
>50% of affected women are asymptomatic. Common
symptoms includes abnormal PV bleeding, Lower
abdominal pain, dysperunia and pressure symptoms
Asymptomatic cases can be treated conservatively.
Definitive treatment is surgical
Thursday, July 13, 2023 Mlela 218
Evaluation: Case Scenario

A 32-year-old lady presents at the health center with complaints

of abnormally heavy menses for 6 months. This has been
accompanied by lower abdominal pain and painful intercourse.
She has no child despite being in marriage for 2 years. On
examination: Awake, severe pallor, temp=36.9℃, PR=126b.p.m,
BP=85/60mmHg, palpable pelvic mass which is firm, smooth,
cannot go below it. Discuss the management of this lady and
possible complications.

Thursday, July 13, 2023 Mlela 219

 ENDOMETRIAL POLYPS
Session 9

Thursday, July 13, 2023 Mlela 220

 Learning tasks
At the end of this session, students are expected to be able
to:
Define Endometrial and Cervical polyps
Outline epidemiology of Endometrial and Cervical polyps
Explain aetiology/risk factors of Endometrial and Cervical polyps
Explain clinical features of Endometrial and Cervical polyps
Establish diagnosis/ provisional and differential diagnosis of gynaecological
polyps
Provide pre-referral treatment of gynaecological polyps
Provide follow-up services of gynaecological polyps
Provide control and preventive measuresMlela
of gynaecological polyps 221
Thursday, July 13, 2023
Activity 1: Brainstorming

What is an endometrial polyp?

Thursday, July 13, 2023 Mlela 222

Definition
Endometrial polyp:
Benign localised hyperplastic overgrowth of endometrium ( glands and
connective tissue), covered by epithelium projecting into the uterine
cavity.
Most common located on the fundus
May protrude into vagina and may cause bleeding
May be single or multiple and variable in size
Flat to long (pedunculated)
Has a pedicle

Thursday, July 13, 2023 Mlela 223

Thursday, July 13, 2023 Mlela 224
Epidemiology

Prevalence is about 24%

More common in women age between 40-50 years
Endometrial polyps are frequently seen in subfertile
rare among adolescents

Thursday, July 13, 2023 Mlela 225

Causes

Unknown

Thursday, July 13, 2023 Mlela 226

Risk factors

Age of 40 and above

Obesity
Use of tamoxifen
Use of hormonal replacement therapy- estrogen

Thursday, July 13, 2023 Mlela 227

Activity 2: Brainstorming

What are clinical features of endometrial polyp?

Thursday, July 13, 2023 Mlela 228

Clinical features
Mostly are asymptomatic, mostly are detected by
sonography
The following are classical features:
Common manifestation is Intermenstrual bleeding in
perimenapaue or postmenopausal bleeding
Menorrhagia
Fertility problem
Postcoital for polyps protruding through the cervix
abdominal cramps

Thursday, July 13, 2023 Mlela 229

Differential diagnosis

Submucous myoma
Adenomyosis
Retained products of conception
Endometrial hyperplasia
Endometrial carcinoma
Uterine sarcoma

Thursday, July 13, 2023 Mlela 230

Investigations:

Hysteroscopy and dilatation curettage – samples for

histology
Transvaginal ultrasound examination (TVUS)
Pelvic ultrasound ruling out other pathology
Hysterosalpingography– shows a filling defect
Full blood count - anaemia

Thursday, July 13, 2023 Mlela 231

Treatment

Optimal management is removal by Hysteroscopy

with Dilatation and Curretage
25 % disappears by itself
 If the patient is anaemic provide ferrous sulphate
200mg twice a day plus folate 5mg once a day for a
month then re-asses

Thursday, July 13, 2023 Mlela 232

Complication

Anemia
Infertility
Abortions
Turning into malignancy – endometrial carcinoma

Thursday, July 13, 2023 Mlela 233

 ENDOMETRIAL CARCINOMA

Session 10

Thursday, July 13, 2023 Mlela 234

Learning tasks
At the end of this session, leaners are expected to be able to:
Define Endometrial carcinoma
 Outline the epidemiology of Endometrial carcinoma
 Explain the causes/risk factors of Endometrial carcinoma
Explain clinical features of Endometrial carcinoma
Establish the differential diagnoses of Endometrial carcinoma
Provide pre-referral management to a patient with Endometrial carcinoma
Provide follow-up services of Endometrial carcinoma
Provide control and preventive measures of Endometrial carcinoma

Thursday, July 13, 2023 Mlela 235

Activity 1: Brainstorming

What is Endometrial carcinoma?

Thursday, July 13, 2023 Mlela 236

Definition

Endometrial carcinoma: is a malignancy arising from

the lining of the uterus.
And it is common gynaecological maliganancy in
postmenopause women.
Adenocarcinoma is a common histological type

Thursday, July 13, 2023 Mlela 237

Thursday, July 13, 2023 Mlela 238
Epidemiology
Most common gynaecological malignancy.
8th leading site of cancer-related mortality.
2-3% of women develop it in lifetime.
Disease of postmenopausal women.
75% of postmenopausal women with bleeding have endometrial
cancer.
Mean age is 60 years.
Uncommon before age of 35 years.
Adenocarcinoma account for about 80%

Thursday, July 13, 2023 Mlela 239

Causes

Estrogen—Persistent stimulation of endometrium

with unopposed estrogen is the single most
important factor for the development of endometrial
cancer.
Therefore any agent/factor that rises the level or
time of exposure to estrogen is a risk factor for
endometrial carcinoma
Thursday, July 13, 2023 Mlela 240
Risk factors

Risk factors for endometrial carcinoma include:

Obesity due to increased production of estrogen
Diabetes mellitus and hypertension- because the
condition are associated with obesity
High fat diet increases estrogen
Early age at menarche and late menopause(>52 years)
Nulliparity - increased exposure to estrogens
Old age
Thursday, July 13, 2023 Mlela 241
Risk factors...

Use of tamoxifen - has weak estrogenic effects

Endometrial hyperplasia precedes carcinoma in about 25
percent cases
Endogenous unopposed estrogen (ie, polycystic ovarian
syndrome [PCOS])
Estrogen-producing tumors (ie, granulosa cell tumors).
Familial predisposition
History of cancer of the breast, colon and ovaries

Thursday, July 13, 2023 Mlela 242

Disease spread

Direct extension - cervix, vagina, parametrial tissues, bladder,

rectum
Lymphatics
Transtubally to fallopian tubes
Haematogenous (Lungs, Liver)

Thursday, July 13, 2023 Mlela 243

Activity 2: Brainstorming

What are the clinical features of Endometrial

carcinoma?

Thursday, July 13, 2023 Mlela 244

Clinical features

Patient profile: The patient is usually a nullipara,

likely to be postmenopausal. There may be history of
delayed menopause. She may be obese; likely to
have hypertension or diabetes.

Thursday, July 13, 2023 Mlela 245

 A case of postmenopausal bleeding
is considered to be due to
endometrial carcinoma unless
proved otherwise.

Thursday, July 13, 2023 Mlela 246

Clinical features...

Symptoms:
Post-menopausal bleeding is diagnostic criteria (75%) which may be
slight, irregular or continuous. The bleeding at times may be excessive.
In premenopausal women, there may be irregular and excessive
bleeding.
At times, there is watery and offensive discharge due to pyometra.
Colicky abdominal Pain due to uterine contraction trying to expel the
product

Thursday, July 13, 2023 Mlela 247

Clinical features...

Signs:
There may be varying degrees of pallor on general examination
Pelvic examination:
Speculum examination reveals the cervix looking healthy and the blood or
purulent offensive discharge escapes out of the external os.
Bimanual examination reveals—The uterus is either atrophic, normal or may be
enlarged due to spread of the tumor, associated fibroid or pyometra.
The uterus is usually mobile unless in late stage, when it becomes fixed.

Thursday, July 13, 2023 Mlela 248

Thursday, July 13, 2023 Mlela 249
FIGO CLASSIFICATION & STAGING

1: Limited to the endometrium / myometrium (corpus)

1a: confined to the endometrium
1b: it invades less than half of the myometrium
1c: it invades more than half of the myometrium

2: Involves the corpus & cervix (but not outside uterus)

2a: involves the endocervical glandular tissue
2b: involves the cervical stromal cells

Thursday, July 13, 2023 Mlela 250

 Staging

Thursday, July 13, 2023 Mlela 251

3. Extended outside uterus but not outside true pelvis
3a: involves the serosa, adnexa, and positive peritoneal cytology
3b: vaginal metastasis
3c: pelvic and/or para-aortic lymph nodes
4. Extended outside true pelvis or bladder mucosa
involvement
4a: bladder and rectal mucosa
4b: distant metastasis and/or inguinal lymph nodes

Thursday, July 13, 2023 Mlela 252

Thursday, July 13, 2023 Mlela 253
Thursday, July 13, 2023 Mlela 254
Activity 3: Case scenario

A 54 years old para 1 woman presents with a 3-month

history of intermittent vaginal bleeding. She completed
menopause years ago.

What are the differential diagnoses?

Thursday, July 13, 2023 Mlela 255

Differential diagnoses

Exogenous estrogen
Atrophic endometritis/vaginitis
Endometrial or cervical polyps
Endometrial hyperplasia
Coagulopathy

Thursday, July 13, 2023 Mlela 256

Investigations
Investigations at primary health facility level
Full blood count or heamoglobin concentration estimation
At Hospital level
Endometrial biopsy to confirm the diagnosis
Chest X-Ray for metastasis
Abdominal and pelvic Ultrasound
Abdominal–pelvic CT scan and/or pelvic MRI for lymph
node metastasis
Liver enzymes and serum creatinine

Thursday, July 13, 2023 Mlela 257

Treatment

Pre-referral
If the patient is anaemic:
provide haematenics; ferrous sulphate 200mg
twice a day plus folate 5mg once a day
If the patient has pelvic pain
provide analgesics such as diclofenac 50mg
12hourly

Thursday, July 13, 2023 Mlela 258

Treatment

Specific treatment:
Surgery is the main stay of treatment in early stages of the
disease - Total abdominal hysterectomy and salpingo-
oophrectomy
for ineoperable tumor radiotherapy and or chemotherapy can
be offered as neo-adjuvant prior to surgery
Hormonal therapy for recurrent tumor

Thursday, July 13, 2023 Mlela 259

Follow-up

Thorough physical examination, CXR

Regular serum CA-125 estimation.
Mammography, CT, MRI: When indicated.
Every 4 months for the first 2 years.
Every 6 months for the next 2 years.
Thereafter annually.

Note: done at ocean road cancer institute

Thursday, July 13, 2023 Mlela 260

Preventions

Primary prevention includes:

Strict weight control beginning early in life.
To restrict the use of estrogen after menopause in
nonhysterectomized women. If at all it is needed, cyclic
administration of progestogen preparations are added and
continued under supervision.
Education as regard the significance of irregular bleeding per
vaginum in perimenopausal and postmenopausal period.

Thursday, July 13, 2023 Mlela 261

Preventions...

Secondary prevention includes:

Screening of ‘high risk’ women at least in menopausal
period to detect the premalignant or early carcinoma

Thursday, July 13, 2023 Mlela 262

PROGNOSIS

Prognosis depends on
Stage of the disease
Grade of the tumour and
Overall health of the patient.
Cancer that is confined to the uterus can be cured surgically in 60–70% of
cases.
Metastatic endometrial cancer and uterine sarcoma, which have a high rate of
recurrence
Carry a poor prognosis

Thursday, July 13, 2023 Mlela 263

Prognosis (% 5 year survival).

Stage I……………………….. 82.9%

Stage II ……………………… 70.8%

Stage III …………………….. 39.2%

Stage IV …………………….. 27.3%

Thursday, July 13, 2023 Mlela 264

Key points

This is predominantly a disease of old women and

adenocarcinoma is the commonesthistological type.
 Risk factors for endometrial carcinoma include
obesity, diabetes, high fat diet, early age at menarche,
nulliparity and late age at menopause, old age and
use of tamoxifen.
Abnormal vaginal bleeding in a postmenopausal
female is a diagnostic criteria

Thursday, July 13, 2023 Mlela 265

Evaluation

1. What is Endometrial carcinoma?

2. What is the commonest clinical presentation of

Endometrial carcinoma?

3. Mention important risk factors foctors for the

development of Endometrial carcinoma

Thursday, July 13, 2023 Mlela 266

 CERVICAL POLYPS
Session 11

Thursday, July 13, 2023 Mlela 267

Activity: Brainstorming

What is a cervical polyp?

Thursday, July 13, 2023 Mlela 268

 Definition

Cervical polyp:
Benign hyperplastic overgrowth of endocervical tissue nd they originate
from endocervical canal and commonly asymptomatic.
Thursday, July 13, 2023

Mlela 269
Epidemiology

Common Benign cervical lesion

Occurs in about 2 to 5% of women
Common 40 -60 years
Most common in parous and perimenopausal
women

Thursday, July 13, 2023 Mlela 270

Causes/risk factors

The aetiology is unclear, but suggested causes are:

Chronic cervicitis
High level of estrogen
Clogged (localised congestion) cervical blood vessel

Thursday, July 13, 2023 Mlela 271

Activity 4: Brainstorming

What are clinical features of cervica polyps?

Thursday, July 13, 2023 Mlela 272

Clinical features

Most asymptomatic just identified during pelvic

examination
Abnormal vaginal bleeding: Intermenstrual bleeding,
Post-coital bleeding or Heavy menses
Purulent vaginal discharge when infected
On examination; usually reddish pink finger like
projection, glistening less than 1cm and they may be
friable

Thursday, July 13, 2023 Mlela 273

Differential diagnosis

Cervicitis
Cervical granuloma
Cervical cancer
Endometrial polyp
Cervical ectropion
Endometrial carcinoma
Pregnancy related bleeding

Thursday, July 13, 2023 Mlela 274

Investigations:

Most diagnosed during speculum examination

Histological examination after removal of the polyp
is a definitive investigation
Cervical smear for cytology
Cervical swab for microbiology incase of infections
Full blood count for anaemia and infenctions

Thursday, July 13, 2023 Mlela 275

Treatment

Polypectomy; grasp the base of the polyp with

forceps and twist off the polyp and send for histology
If the patient is anaemic provide ferrous sulphate
200mg twice a day plus folate 5mg once a day for a
month then re-asses
If there is infections treat with antibiotics according
to type

Thursday, July 13, 2023 Mlela 276

Complication

Anemia
Infections

Thursday, July 13, 2023 Mlela 277

Key points

Endometrial and cervical polyp are common benign

gyanecological lession
Both polyps have common clinical presentation i.e
abnormal uterine bleeding
Endometrial polyp is common in nullparous women
where as cervical polyps in multiparous women
Definitive diagnosis for both polyps is by
histopathalogy

Thursday, July 13, 2023 Mlela 278

Evaluation
A 50 years old woman para 5 presents at the health centre with
a complaints of intermenstrual bleeding for 4 months. On general
she has some pallor and speculum examination shows a small polypoid
reddish mass projecting from the cervical canal
What is the provisional diagnosis?
Mention the differential diagnoses
What investigations will you perform
How will you confirm the diagnosis
How will you treat this woman

Thursday, July 13, 2023 Mlela 279

 CERVICAL CARCINOMA
Session 12

Thursday, July 13, 2023 Mlela 280

Learning tasks
At the end of this session, students are expected to be
able to:
• Explain aetiology/risk factors of cervical carcinoma
• Outline epidemiology of cervical carcinoma
• Explain clinical features of cervical carcinoma
• Establish diagnosis/ provisional and differential diagnosis of cervical
carcinoma
• Provide pre-referral treatment of cervical carcinoma
• Provide follow-up services of cervical carcinoma
• Provide control and preventive measures of cervical carcinoma
Thursday, July 13, 2023 Mlela 281
Activity: Brainstorming

What is Cervical carcinoma?

Thursday, July 13, 2023 Mlela 282

Definition

Cervical carcinoma:
Cervical carcinoma is the malignant neoplasm of the
cervix.
Almost all cases of cervical carcinoma originate in
the transformation zone from the ectocervical or
endocervical mucosa

Thursday, July 13, 2023 Mlela 283

 Definition cont…

The cervix is divided into an ectocervix

which is lined by squamous epithelium
and endocervix which is lined by
columnar epithelium.
Almost all cases of cervical carcinoma
originate in the transformation zone
from the endocervical or ectocervical
mucosa

Thursday, July 13, 2023 Mlela 284

Epidemiology

Cervical cancer is the 3rd most common malignancy

in women worldwide.
More frequent in developing in comparison to
developed countries,
Cervical cancer is the 2nd most common cause of
cancer-related deaths in women in developing
countries
Most common cancer among females in Tanzania

Mlela 285

Thursday, July 13, 2023

Etiology

It is now recognized that cervical cancer is a long-term outcome

of persistent infection of the lower genital tract by high-risk HPV
types,
HPV is thus termed the “necessary” cause of cervical cancer.
HPV types 16 and18 account for 71% of cases
HPV types 31, 33, 45, 52 and 58 accounts for another 19% of
cases.

Thursday, July 13, 2023 Mlela 286

Risk Factors of Carcinoma of Cervix

 Risk Factors
 Sexually Transmitted Infections
o Human Papilloma Virus (HPV) Types 16, 18
o Herpes Simplex Virus (HSV)
 Early age at first sexual intercourse
 Multiple sexual partners (both male and/or female)
 Intercourse with uncircumcised male partner

Thursday, July 13, 2023 Mlela 287

Risk Factors of Carcinoma of Cervix cont..

Associated Factors
Cigarette smoking
High parity
Low socio-economic status
Affects ability to access health services, including
screening/vaccines for cervical cancer
Can contribute to multiple sexual partners, transactional sex
in exchange for money or other goods
Thursday, July 13, 2023 Mlela 288
Risk Factors of Carcinoma of Cervix cont..

Low immune system

May result from HIV infection, diabetes mellitus, prolonged
use of steroids, immunosuppression, organ transplant, etc.
Race: 2x in black as compared to whites.
Family history.
DES Exposure-enlarge transformation zone at the cervix.
COCs-Hormone contained promote proliferation of cell make it
vulnerable to mutation.
Thursday, July 13, 2023 Mlela 289
Activity: Brainstorming

What are clinical features of Cervical carcinoma?

Thursday, July 13, 2023 Mlela 290

Clinical features
History:
• Asymptomatic at early stage.
• Abnormal vaginal bleeding-post coital, spotting, intermenstrual
bleeding.
• Serosanguineous or yellowish discharge, at times foul smelling in
advanced or necrotic cancer.
• Pelvic pain: from locally advanced disease.
• Extension to pelvic wall may cause sciatic pain or back pain
associated with hydronephrosis

Thursday, July 13, 2023 Mlela 291

Clinical features cont…

History cont…
• Lumboscral back pain due to metastatic involvement of iliac and
Para-aortic lymph nodes that extend to lumbosacral nerve roots.
• Haematuria following bladder invasion by advance stage of
disease
• Pain during sex(dyspareunia)
• Pain during urination(dysuria).

Thursday, July 13, 2023 Mlela 292

 Clinical features cont…

Physical examination:
 Vary with the extent/stage of the
disease
o Lesion on cervix (Exophytic
cervical mass)– easily bleeds on
touch and can be cauliflower-like
oSmall shallow ulcer or crater.
oBimanual examination: The cervix is
commonly enlarged, irregular and
firm (indurated barrel- shaped cervix)
Thursday, July 13, 2023 Mlela 293
 294
Mlela
Thursday, July 13, 2023
Staging (FIGO)

 Stage O: CIN 3 (Ca in situ)

 Stage Ia: microinvasive Ca < 3mm
Ib: invasive Ca confined to the cx
<4mm

Thursday, July 13, 2023 Mlela 295

 Stage IIa: extending upper ⅔ of vagina
IIb: extending to the parametrium but not to the pelvic
side wall

Thursday, July 13, 2023 Mlela 296

 Stage IIIa: involve the lower ⅓ of the vagina
IIIb: extending to the pelvic side wall
(obstructing the ureters)

Thursday, July 13, 2023 Mlela 297

 Stage IVa: involves the urinary bladder & rectum
IVb: extra pelvic extension
Thursday, July 13, 2023

Mlela 298
Differential diagnosis

Chronic cervicitis
Endometrial carcinoma
Endometrial hyperplasia
Cervical polyps

Thursday, July 13, 2023 Mlela 299

Investigations
Biopsy: for histology
Complete blood cell count: to rule out anemia, infections
Urinalysis: Haematuria.
HIV Test
Renal function test.
Liver function tests
CXR for possible pulmonary metastasis.
Abdominalpelvic Utrasund: metastasis in the liver, lymphnode or
hydronephrosis

Thursday, July 13, 2023 Mlela 300

Treatment

Pre-referral treatment: Largely supportive

• Correct anemia with hematenics ± BT
• Anaelgesics for pain management
• Oxygen if dyspnoeic

Thursday, July 13, 2023 Mlela 301

Treatment cont…

Specific treatment: Depends on clinical stage

• Surgery
• Radiotherapy
• Chemotherapy

Thursday, July 13, 2023 Mlela 302

Surgery

Standard surgical procedure is Wertheim’s hysterectomy which involves

removal of the uterus and paracervical tissues surrounding the cx & upper
vagina.

Pelvic LN (external iliac, internal iliac, common iliac, obturator &

presacral nodes) are carefully dissected

In the most extreme surgery, called a pelvic exenteration, all of the
organs of the pelvis, including the bladder and rectum, are removed.

Thursday, July 13, 2023 Mlela 303

Complications

Hemorrhage.
Frequent attacks of ureteric pain, due to pyelitis, pyelonephritis
and hydronephrosis.
Pyometra: specially with endocervical variety.
Vesicovaginal fistula.
Rectavaginal fistula (rare)

Thursday, July 13, 2023 Mlela 304

Follow up

35% of Patients with Invasive Cervical Cancer are estimated to

have persistent or recurrent disease. Most of these (85%) within
3 years of the initial treatment.

Evaluations include Pelvic Examinations, Careful Palpation of

nodal groups, Pap Smears, and Radiologic Imaging.

Thursday, July 13, 2023 Mlela 305

Prevention

Primary prevention:
• Vaccination against HPV:
Only works before HPV infection.
Targeted to girls and women of 9 to 26yrs of age
• Avoid risks e.g sex at early age
• Condom use
• Treatment of sexually transmitted infections (STIs)
• Do not smoke

Thursday, July 13, 2023 Mlela 306

Prevention cont…

Secondary prevention:
• Awareness: linkage between HPV and cervical cancer.
• Screening
Papanicolaus test (pap smear)
Visual inspection-Acetic Acid or Lugols Iodine (Schillers
test).
Colposcopy..

Thursday, July 13, 2023 Mlela 307

Prognosis (Expectations)

 Many factors influence the outcome of cervical cancer, the

most important of which are:
a) The type of cancer
b) The stage of the disease
c) The age and general physical condition of the woman

Thursday, July 13, 2023 Mlela 308

Key points

Cervical cancer is a malignant tumor of the cervix

It is the commonest malignancy among women in Tanzania.
HPV infection is termed as a “necessary factor” for
development of cervical cancer
Risk factors for cervical cancer includes sex at early age,
smoking, black race, high parity, e.t.c
Prevention involves vaccination against HPV, avoidance of
risks and screening

Thursday, July 13, 2023 Mlela 309

Review questions

1. What is Cervical carcinoma?

2. Outline the risk factors for cervical carcinoma.
3. What are the clinical presentation of Cervical
carcinoma?
4. Outline the management of Cervical carcinoma.

Thursday, July 13, 2023 Mlela 310

Assignment

Describe the clinical staging of cervical carcinoma

Thursday, July 13, 2023 Mlela 311

 OVARIAN CYST
Session 13

Thursday, July 13, 2023 Mlela 312

Learning tasks
At the end of this session, students are expected to be
able to:
Explain etiology/risk factors of ovarian cysts
Outline epidemiology of ovarian cysts
Explain clinical features of ovarian cysts
Establish diagnosis/ provisional and differential diagnosis of ovarian
cysts
Provide pre-referral treatment of ovarian cysts
Provide follow-up services of ovarian cysts
Provide control and preventive measures of ovarian cysts
Thursday, July 13, 2023 Mlela 313
Activity: Brainstorming

What is Ovarian Cysts?

Thursday, July 13, 2023 Mlela 314

Definition

Ovarian cyst:
Is a liquid or semiliquid-filled sac originating from the
ovary.
They are a source of anxiety among women due to
fear of malignancy
Most are benign

Thursday, July 13, 2023 Mlela 315

Types
Ovarian cyst can be classified as
Non-neoplastic (commonest)
Follicular cysts
Theca lutein cysts
Corpus luteum (Granulosa Lutein) cysts.
Polystic ovarian syndrome (PCOS)
Endometriomatous cysts
 Neoplastic
 Benign
 Malignant

Thursday, July 13, 2023 Mlela 316

 Epidemiology

Benign Functional cysts can occur at any age (infancy

to postmenopausal) but they are more common in
reproductive age
Risk for Malignant ovarian cysts (cystadenocarcinoma)
increases with age. They also more among women in
Western Europe and Northern America than in Africa,
South America and Asia

Thursday, July 13, 2023 Mlela 317

TYPES OF OVARIAN CYSTS

1. FUNCTIONAL CYSTS (Commonest)

Your ovaries normally grow cysts like structures called follicles
each month.
Follicles produce the hormones estrogen and progesterone
and release an egg when you ovulate.
If a normal monthly follicle keeps growing its known as
functional . There are two types of functional cysts.

Thursday, July 13, 2023 Mlela 318

Types of functional cyst

i. Follicular cysts.
Around the midpoint of your menstrual cycle, an egg bursts out
of its follicle and travels down the fallopian tube.
A follicular cyst begins when the follicle doesn’t rupture or
release its egg but continues to grow. (Results from failure in
ovulation)
May be due to excessive FSH stimulation or lack of the normal
LH surge at midcycle just before ovulation.
Normally 3-8cm in diameter
Thursday, July 13, 2023 Mlela 319
Types of functional cyst

ii. Corpus luteum cyst.

When a follicle release its egg , its begins producing estrogen
and progesterone for conception. This follicle is now called the
corpus luteum.
Sometimes, fluid accumulates inside the follicle ,causing the
corpus luteum to grow into cyst. (Results from failure of
dissolution of corpus luteum)
Normally 3-11cm in diameter.

Thursday, July 13, 2023 Mlela 320

Types of functional cyst
iii. Theca-lutein ovarian cysts
Results from luteinization and hypertrophy of the theca interna cell layer in
response to excessive hCG
Commonly seen in
Gestational trophoblastic disease (GTDs)
Multiple gestation
Exogeneous ovarian stimulation
Usually resolve spontaneously as the hCG level falls.
Usually bilateral
Can result in massive ovarian enlargement,
These cysts are predisposed to torsion, hemorrhage, and rupture.

Thursday, July 13, 2023 Mlela 321

Thursday, July 13, 2023 Mlela 322
Types of functional cyst
2. Endometriomatous (Chocolate cysts)
Results from ectopic endometrial tissue in the ovary
May grow to 6-8cm
Contain thick, brown blood debris

3. Polycystic ovarian syndrome(PCOS)

Results from persistent anovulation.
K.k by polycystic ovaries, secondary ammenorrhoea or oligomenorrhea and
infertility.
The cysts ranges 2-5 mm in diameter

Thursday, July 13, 2023 Mlela 323

Rotterdam criteria for diagnosis of PCOS

1. Menstrual irregularities. Most patients with PCOS have menstrual

irregularities that begin during adolescence.
–Oligomenorrhea: less than nine menses per year
–Amenorrhea: no menses for 6 months or three or more skipped
cycles
Difficulty in conceiving is present in many women with PCOS

Thursday, July 13, 2023 Mlela 324

2. Hyperandrogenism. Patients may either show signs of clinical
hyperandrogenism or have biochemical hyperandrogenism:
–Clinical hyperandrogenism: e.g hirsutism, acne, or male pattern
hair loss.
–Biochemical hyperandrogenism: Up to 90% of women with
PCOS have elevated serum androgen concentration. However, the
androgen levels may be normal.

Thursday, July 13, 2023 Mlela 325

3. Polycystic ovaries. A diagnosis of polycystic appearing ovaries
can be made using pelvic ultrasound.
–PCOS by ultrasound criteria is defined as 12 or more antral
follicles between 2 and 9 mm in size and peripheral in location in at
least one ovary
–Transvaginal ultrasound is more sensitive, but may not be
appropriate to perform in a young female.

Thursday, July 13, 2023 Mlela 326

Thursday, July 13, 2023 Mlela 327
Types of ovarian cysts

Neoplastic ovarian cysts

Arise via the inappropriate overgrowth of cells within the ovary
May be malignant or benign.

Thursday, July 13, 2023 Mlela 328

Risk factors

Infertility treatment
Tamoxifen
Pregnancy
Hypothyroidism
Maternal gonadotropins
Cigarette smoking
Tubal ligation

Thursday, July 13, 2023 Mlela 329

Activity: Brainstorming

What are clinical features of ovarian cyst?

Thursday, July 13, 2023 Mlela 330

Clinical features

History
Most patients with ovarian cysts are asymptomatic,
Lower abdominal Pain or discomfort. May result from
Nerve compression
Torsion (twisting)
Rupture
Dull pelvic pain.
Dyspareunia

Thursday, July 13, 2023 Mlela 331

Clinical features cont…
History cont…
Menstrual irregularities: prolonged intermenstrual interval followed
by menorrhagia
Precocious puberty and early onset of menarche in children
Dysmenorrhea (endometriomas)
Abdominal fullness and bloating
Pressure symptoms: constipation, tenesmus, increased urinary
frequency
GI symptoms e.g indigestion, heartburn, early satiety

Thursday, July 13, 2023 Mlela 332

Clinical features cont…

Physical examination
PA:
Palpable cystic mass
± abdominal tenderness
Signs of peritonism (if ruptured)
Pelvic:
Adnexal cystic mass
Unilateral displacement of cervix and uterus
Thursday, July 13, 2023 Mlela 333
Differential diagnosis

Hydronephrosis Ovarian torsion

Hydrosalpinx Renal calculi
Paraovarian cyst Ovarian cancer
Pedunculated leiomyoma PID
Pelvic kidney Appendicitis
Tubo-ovarian abscess Full bladder.
Ectopic pregnancy

Thursday, July 13, 2023 Mlela 334

Investigations

FBP:
Hb in case of haemorrhage
WBCs: ↑ in torsion, infections
Cancer antigen 125 (CA 125): to rule out malignancy
Ultrasound
CT scan
MRI
Other investigations to rule out differential diagnoses

Thursday, July 13, 2023 Mlela 335

Treatment
Small (< 5cm) and asymptomatic cysts:- Symptomatic
management
Reassurance
Follow up
Symptomatic management
Analgesics if in pain
Surgery: Indicated when
Complications e.g hemmorrhage, torsion, rupture
Persistent large cyst
Complex cysts

Thursday, July 13, 2023 Mlela 336

Complications

Torsion
Rupture: trauma, coitus
Hemorrhage
Malignant progression

Thursday, July 13, 2023 Mlela 337

Follow up

Indicated during expectant management of cysts. It

involves:
Serial ultrasound
Serum CA125

Thursday, July 13, 2023 Mlela 338

Prevention

Oral Contraceptives Pills (OCPs) may protect

against functional ovarian cysts
Prophylactic Oophorectomy for those at risk of
developing malignancy

Thursday, July 13, 2023 Mlela 339

Key points
Ovarian cysts are liquid-filled sacs resulting from ovaries
Most of ovarian cysts are benign and are most common in
reproductive age
Risk factors includes Infertility treatment, Tamoxifen, Pregnancy,
Hypothyroidism, cigarette smoking and tubal ligation
Most women with ovarian cyst will be asymptomatic. Common
symptoms includes pelvic pain, lower abdominal pain, bloating,
dyspareunia and pressure symptoms
Most small and asymptomatic cysts are managed expectantly
Surgery is indicated in persistent cysts or in case of
complications

Thursday, July 13, 2023 Mlela 340

Review questions

1. What is Ovarian cyst?

2. Outline causes of ovarian cysts
3. What are the clinical presentation of ovarian cysts?
4. Outline the management of ovarian cyst

Thursday, July 13, 2023 Mlela 341

 OVARIAN CANCER
Session 14

Thursday, July 13, 2023 Mlela 342

Learning tasks
At the end of this session, students are expected to be
able to:
Outline epidemiology of ovarian cancer
Explain aetiology/risk factors of ovarian cancer
Explain clinical features of ovarian cancer
Establish diagnosis/ provisional and differential diagnosis
of ovarian cancer
Provide pre-referral treatment of ovarian cancer
Provide control and preventive measures of ovarian cancer

Thursday, July 13, 2023 Mlela 343

Activity 1: Brainstorming

What is Ovarian cancer?

Thursday, July 13, 2023 Mlela 344

Definition

Ovarian cancer:
 Malignant lesion of the ovaries including primary
lession arising from the normal structures of the
ovaries and secondary lession from cancer arising
from elsewhere ( breast, stomach, colon)

Thursday, July 13, 2023 Mlela 345

Epidemiology

Is one of the commonest cause of cancer death, 5th leading cause of death
Has higher mortality rate than all gynaecological malignancies
60% of patients presents when the disease is advanced because it is to
diagnose in early stage
The life time risk of developing ovarian cancer is 1.3 to 1.6%
Epithelial cancer are the commonest and account for about 90%
Germ cell tumor are common in young age
Most patients have no risk factors

Thursday, July 13, 2023 Mlela 346

Classification

Categorized according to site of origin

Epithelial (90%)
most common is serous cystadenocarcinoma
mucinous
endometroid
brenners
clear cells

Thursday, July 13, 2023 Mlela 347

Classification...

Sex cord stromal

Granulosa cell tumor
Thecoma
Arrhenoblastoma
Androblastoma
Fibroma
Leydigtheca cell tumor

Thursday, July 13, 2023 Mlela 348

Classification...

Germ cell cancer

Teratoma demoid cyst and immature cyst teratoma
Choriocarcinoma
Yolk sac
dysgeminoma
endodermal sinus tumor

Metastatic from breast ,GIT , endometrium and colon

Thursday, July 13, 2023 Mlela 349
Thursday, July 13, 2023 Mlela 350
Risk factors

Most patient with ovarian cancer have no risk factors.

The following are some of the risks:
White race
Advanced Age >50
Nulliparous/low parity
Early menarche

Thursday, July 13, 2023 Mlela 351

Risk factors...

Late menopause
Family history/genetic
Prolonged intervals of uninterrupted ovulation -
Prolonged use of ovulation inducing drugs
History of breast cancer, colorectal cancer and
endometrial cancer
Use of coffee, tobacco, alcohol and dietary fat has
been implicated
Thursday, July 13, 2023 Mlela 352
Ovarian cancer spread

Direct extension within peritoneal cavity

Lymphatics

Haematogenous

Thursday, July 13, 2023 Mlela 353

Activity 2: Brainstorming

What are clinical features Ovarian cancer?

Thursday, July 13, 2023 Mlela 354

Clinical features

History:
Asymptomatic in early stage. Due to anatomical
location, most patients present with advanced disease
and Symptoms/signs are often nonspecific
Irregular menses
Mass effects of the bladder or rectum such as urinary
frequency or constipation
Lower abdominal or pelvic fullness - usually a late
manifestation caused by the tumor or ascites

Thursday, July 13, 2023 Mlela 355

Clinical features...

Features of dyspepsia such as flatulence

Dyspareunia
Abdominal distention is often the presenting chief
complain (caused by ascites)
Weight loss
Loss of appetite with a sense of bloating after
meals.

Thursday, July 13, 2023 Mlela 356

Clinical features...
Physical Exam:
Pelvic masses are suggestive.
Feel — solid or heterogeneous.
Mobility — mobile or restricted.
Tenderness — usually present.
Surfaces — irregular.
Margins — well-defined but the lower pole is usually not reached.
Percussion — usually dull over the tumor; may be resonant due to
overlying intestinal adhesions.
If ascites and upper abdominal masses are present, ovarian cancer is most
likely

Thursday, July 13, 2023 Mlela 357

 Features of malignancy

Age more than 50 and child hood Ascites

Rapid growth Fixed tumors

Pain Weight loss

Solid tumor and bilateral Tumor markers CA125

Fever Metastatic features

Thursday, July 13, 2023 Mlela 358

Staging of malignant tumours (FIGO)

Stage I : Growth limited to the ovaries

IA: One ovary involved
IB: Both ovaries involved
IC: One /both ovaries involved with
(i) Surface involvement
(ii) Malignant fluid in the peritonium (ascites)
(iii) Capsule rupture

Thursday, July 13, 2023 Mlela 359

Cont…..

Stage II: Spread to adjacent structures

IIA: Spread to uterus of fallopian tubes
IIB: Spread to pelvic peritonium
IIC: Confined to pelvis with malignant ascites

Thursday, July 13, 2023 Mlela 360

Cont…..

Stage III: Spread to upper abdomen

IIIA: Microscopic spread to upper abdomen
IIIB: Ca nodules of <2cm in the abdomen
IIIC: Ca nodules of >2cm/+ve pelvic /paraortic nodes

Stage IV: Distant spread beyond abdomen, liver, lungs etc.

Thursday, July 13, 2023 Mlela 361

Spread of ovarian ca occurs mainly by:-

(a)Transcelomic (through the peritoneal cavity)

(b)Lymphatic
(c)Direct
(d)Haematogenous

Thursday, July 13, 2023 Mlela 362

Differential diagnosis

Ovarian cysts:
Tubo-ovarian masses
Hydrosalpinx
Uterine tumours
Bladder tumours
Pregnancy
Pelvic or horseshoe kidney

Thursday, July 13, 2023 Mlela 363

Activity 3: Brainstorming

How would you establish the diagnosis and

differentials of ovarian cancer

Thursday, July 13, 2023 Mlela 364

Diagnosis

Clinically

Ancillary (accessory/secondary) aids.- investigations

Operative findings.

Histological confirmation

Thursday, July 13, 2023 Mlela 365

Investigations
The diagnosis is established clinically and confirmed by histopathological analysis
Abdominal/ pelvic ultrasound
Biopsy for histopathological analysis to exclude malignancies (Typically primary
surgery is performed rather than a biopsy if suspicion is high for tumour).

Other supportive investigations are:

Full Blood Picture
Chest X-ray

Thursday, July 13, 2023 Mlela 366

Investigations...

Renal and Liver function tests

Tumour markers if available, CA-125, AFP, hCG, Lactate
dehydrogenase, inhibin
Computed Tomography (CT) scan
MRI is helpful to determine the nature of ovarian neoplasm and
also for the retroperitoneal lymph nodes and detection of
metastasis

Thursday, July 13, 2023 Mlela 367

Treatment

Refer patient to the hospital for appropriate management

Treatment modalities will depend on the diagnosis and its
complications (extent of the disease spread, symptoms and
patient’s fitness)
The treatment options include
Surgery,
Chemotherapy and
Radiation therapy.

Thursday, July 13, 2023 Mlela 368

Complications

Torsion

Rupture

Intestinal obstructions

Pelvic adhesion

Thursday, July 13, 2023 Mlela 369

Preventions

No screening tools like cancer of the cervix

Thursday, July 13, 2023 Mlela 370

Key points
Ovarian cancer is the commonest cause of cancer death, and has
higher mortality rate than all gynaecological malignancies

Epithelial tumors are the commonest and most have no risk factor

Due to anatomical location, most patients present with advanced

disease and Symptoms/signs are often nonspecific

There is no screening tool for ovarian cancer.

Thursday, July 13, 2023 Mlela 371

Evaluation

1. What are the commonest ovarian cancer?

2. what are the features of malignancy to a patient

with ovarian tumor?

3. How will yo establish the diagnosis of ovarian

tumor?

Thursday, July 13, 2023 Mlela 372

 CHORIOCARCINOMA
Session 15

Thursday, July 13, 2023 Mlela 373

Learning tasks
At the end of this session, students are expected to be
able to:
• Explain aetiology/risk factors of Choricarcinoma
• Outline epidemiology of Choricarcinoma
• Explain clinical features of Choricarcinoma
• Establish diagnosis/ provisional and differential diagnosis of
Choricarcinoma
• Provide pre-referral treatment of Choricarcinoma
• Provide follow-up services of Choricarcinoma
• Provide control and preventive measures of Choricarcinoma
Thursday, July 13, 2023 Mlela 374
Activity: Brainstorming

What is Choricarcinoma?

Thursday, July 13, 2023 Mlela 375

Definition
Choriocarcinoma:
Is a highly malignant tumor arising from the chorionic
epithelium.
Is a malignant and rapidly growing tumor which arises
from fetal tissue.
It is not a tumor of the uterus which is secondarily
involved.
Characterized by abnormal trophoblastic hyperplasia
and anaplasia , absence of chorionic villi

Thursday, July 13, 2023 Mlela 376

Epidemiology

About 3–5% of all patients with molar pregnancies

develop choriocarcinoma.
Of all patients with choriocarcinoma, 50% develop
following a hydatidiform mole, 30% follows a
miscarriage or an ectopic pregnancy and 20%
follows apparently normal pregnancy.

Mlela 377

Thursday, July 13, 2023

Risk factors

• Increased maternal age. It is 5-15 times higher in

women 40 years and older than in younger women
• Molar pregnancy: 3-5% of molar pregnancies will
complicate into choriocarcinoma

Thursday, July 13, 2023 Mlela 378

Activity: Brainstorming

What are clinical features of Choriocarcinoma?

Thursday, July 13, 2023 Mlela 379

 Clinical features

History: History cont…

• Recent Hx of molar, ectopic or normal • Symptoms indicating metastasis
pregnancy Lung: cough, shortness of
• Persistent ill health breath, hemoptysis
• Abnormal vaginal bleeding Liver: jaundice, epigastric pain
Brain: headache, vomiting,
• Continued amenorrhea
convulsions, confusion, coma
Vagina: irregular bleeding

Thursday, July 13, 2023 Mlela 380

Clinical features cont…

Physical examination:
• Pallor
• Uterine subinvolution
• Purplish red nodule in the lower-third of the anterior vaginal wall
• Unilateral or bilateral enlarged ovaries

Thursday, July 13, 2023 Mlela 381

FIGO STAGE FOR CHORIOCARCINOMA

Stage I – choriocarcinoma involves the affectation of the

uterus only. The malignant cells are limited inside the womb.
Stage II – involves spread up to the genital tract structures
(adnexa, vagina , broad ligament
Stage III – choriocarcinoma involves the spread to the lungs.
The metastases are hematogenous in nature, which means it
has spread through the blood circulation.
Stage IV – involves metastases of cancer cells to other parts
of the body through hematogenous and lymphatic routes i.e.
liver and brain metastasis
Thursday, July 13, 2023 Mlela 382
DDX

Endometrial carcinoma
Cervical carcinoma

Thursday, July 13, 2023 Mlela 383

Investigations

Serum hCG
Biopsy: Not normally done due to hemorrhage
Complete blood cell count: to rule out anemia, infections
Renal function test.
Liver function tests
Chest X-Ray for possible pulmonary metastasis.
Abdominal-pelvic Ultrasound: Uterus, metastasis in the liver
CT scan, MRI

Thursday, July 13, 2023 Mlela 384

 Treatment

Pre-referral treatment: Largely Specific treatment: Depends on

supportive clinical stage
Correct anemia with hematenics ± Surgery: hysterectomy
BT Chemotherapy:
Analgesics for pain management Radiation therapy.
Oxygen if dyspnoeic

Thursday, July 13, 2023 Mlela 385

Follow up after treatment

Quantitative serum hCG levels should be obtained monthly for

6 months, every two months for remainder of the first year, every
3 months during the second year
Contraception should be maintained for at least 1 year after the
completion of chemotherapy. Condom is the choice.

Thursday, July 13, 2023 Mlela 386

Prevention
Prophylactic chemotherapy in ‘at risk’ women following evacuation of
molar pregnancy
Age of patient > 35 years.
Initial levels of serum hCG > 100,000 IU/mL.
hCG level fails to become normal by 7–9 weeks time or there
is re-elevation.
Histologically diagnosed as infiltrative mole.
Evidence of metastases irrespective of the level of hCG.
Previous history of a molar pregnancy.
Woman who is unreliable for follow up.

Thursday, July 13, 2023 Mlela 387

Prevention

Meticulous follow up following evacuation of hydatidiform mole is

essential for at least 6 months to detect early evidence of
trophoblastic reactivation.
Selective hysterectomy in hydatidiform mole over 35 years. There
is 4 fold reduction in the risks of choriocarcinoma.
Diagnostic uterine curettage in unexplained abnormal bleeding, 8
weeks following term delivery or abortion.

Thursday, July 13, 2023 Mlela 388

PROGNOSIS

Choriocarcinoma is highly treatable when metastases are

not yet present.
-Women may also regain their optimal reproductive function
Good prognosis will depend on
- Metastasis are confined to the lungs or pelvis
- serum hCG levels are < 40,000mlu/ml.
-Treatment is started within 4 months of apparent onset of symptoms.

Thursday, July 13, 2023 Mlela 389

Poor prognosis of choriocarcinoma is associated with the
 metastases to brain and liver
Reoccurrence of cancer, despite treatment in the past
High hCG level reaching >40,000 mIU per ml
Occurrence of pregnancy symptoms of more than 4 months before
therapy initiation
Development of choriocarcinoma after delivery or normal pregnancy

Thursday, July 13, 2023 Mlela 390

Key points
Choriocarcinoma is a malignant tumor arising from chorionic
epithelium
It commonly follows a molar pregnancy but can also occur after
an abortion, ectopic or normal pregnancy.
It commonly presents with abnormal vaginal bleeding, persistent
ammenorrhea and symptoms of metastasis
It is highly responsive to chemotherapy and therefore early
diagnosis and referral is important in management

Thursday, July 13, 2023 Mlela 391

Review questions

1. What is Choricarcinoma?
2. Outline the risk factors for Choricarcinoma.
3. What are the clinical presentation of Choricarcinoma?
4. Outline the management of Choricarcinoma.

Thursday, July 13, 2023 Mlela 392

 MULTIPLE PREGNANCY
Session 16

Thursday, July 13, 2023 Mlela 393

OBJECTIVES

Define multiple pregnancies, monozygotic and dizygotic

twinning
Describe the prevalence and types of multiple pregnancies
Describe clinical features and diagnosis of multiple pregnancies
Describe the complications of multiple pregnancies
Describe the management of multiple pregnancies

Thursday, July 13, 2023 Mlela 394

Definitions
Multiple pregnancy refers to presence of more than one foetuses
intrautero.
Different names for multiple pregnancy(births) are used according to
the number of foetuses (offsprings).
Most common multiple are two and three for Twin and triplets,
respectively.
Multiple pregnancy can either be monozygote or polyzygote.
Incidence:
According to Hellin’s formula:
Twins 1:89, triplets 1:89², quadruplets 1:89³ etc...

Thursday, July 13, 2023 Mlela 395

Dfn cont..

I) Monozygotic = (identical=Uniovular ) twins:

- developed from splitting of single zygote as from a single ovum
which was fertilised by a single sperm, has undergone division to
form two embryos.
- The twins are of the same sex. why??
- They have similar physical and mental characters as well as the
blood group but not finger prints.

Thursday, July 13, 2023 Mlela 396

Varieties of Monozygotic
Monozygotic twins arise from one fertilized ovum
a)Split within first 3 days  dichorionic-diamniotic
Aetiology
Division occurs before the inner cell mass (morula) is formed and
the outer layer of blastocyst is not yet committed to become chorion
i.e. within the first 72 hours after fertilization.

The frequency = 18 - 36% i.e 1/3 of monozygotic twins.

There may be two distinct or a single fused placenta

Thursday, July 13, 2023 Mlela 397

Dichorionic diamniotic..

Thursday, July 13, 2023 Mlela 398

b) Split between days 4 and 8  monochorionic-diamniotic
Division occurs between day 4 -8 day, after the inner cell mass
is formed and cells destined to become chorion have already
differentiated but those of the amnion have not.
account 2/3 of MZ
Two embryos will develop, each in separate amnionic sacs.
The two amnionic sacs are covered by a common chorion.

Thursday, July 13, 2023 Mlela 399

Monochorionic diamniotic

Thursday, July 13, 2023 Mlela 400

C) Monoamnionic, Monochorionic,
Monozygotic Twin Pregnancy
Division occurs when amnion has
already become established, around 8
– 13 days after fertilization. , Account
1%,
Division results in two embryos within
a common amnionic sac.

Thursday, July 13, 2023 401

Mlela
d)CONJOINED TWIN PREGNANCY
Division is initiated after the
embryonic disk is formed,more than
12days
occur rarely 1:200,000 birth,
Survival rate 25%.>females to males
3:1

Thursday, July 13, 2023 Mlela 402

Cleavage is incomplete.
Thoraco-omphalopagus (28%)
Thoracopagus(18.5%)
Omphalopagus(10%)
Parasitic twin(10%)
Craniopagus(6%)
Ischiopagus
Pyopagus

Thursday, July 13, 2023 Mlela 403

(II) Polyzygotic
a) dizygotic = Binovular= non-identical-fraternal) twins
developed from two separate ova which may or may not come from the same ovary
and fertilised by two separate spermatozoa.
Superfecundation: Fertilization by separate act of coitus of two ova released in the
same menstrual cycle
Superfelation: DZ twin from ova released from different cycle
- The twins are of the same or different sex.
- The similarity between them is not more than that btn members of the same family.
- They have : - two placenta, -two chorions, - two amnions, - two umbilical cords.
Binovular twins are 4 times more common than the uniovular variety.

Thursday, July 13, 2023 Mlela 404

Thursday, July 13, 2023 Mlela 405
Terms used for the multiple pregnancies(birth):
No. OF FETUS (OFFSPRINGS) TERMS
2 TWINS
3 TRIPLETS
4 QUADRUPLETS
5 QUINTUPLETS
6 SEXTUPLETS
7 SEPTUPLETS
8 OCTUPLETS
9 NONUPLETS
10 DECAPLETS
11 UNDECAPLETS
12 DUODECAPLETS
Thursday, July 13, 2023 Mlela 406
Thursday, July 13, 2023 Mlela 407
Maternal physiological changes

Exageration of normal physiological adaptations

Increase in Blood volume, CO, GFR, RBF > Singleton
Hyperemesis gravidurum, backache, oedema, varicose vein,
hemorrhoids,striae gravidurum > Singleton

Thursday, July 13, 2023 Mlela 408

Diagnosis
(I) History:
1. Family history of multiple pregnancy (wife and/ or husband).
2. Recent intake of ovulatory drugs.
3. Increased foetal movement.
(II) Inspection:
More enlargement of the abdomen.
(III) Palpation:
Fundal level: higher than that corresponds to the period of amenorrhoea.
Fundal, umbilical and first pelvic grips: can detect multiple foetal poles.
At least, 3 poles should be palpated to diagnose twin pregnancy.
Foetal limbs: felt as multiple knobs.

Thursday, July 13, 2023 Mlela 409

Diagnosis cont,
(IV) Auscultation:
Foetal heart sounds: are heard with maximum intensity in 2 separate points
by 2 observers with a < difference of 10 b/m.
(V) Ultrasonography:
(1) Diagnosis of twins:
- If routine scanning of all pregnant women is carried out at 16 weeks
twins should rarely be missed.
(2) Detection of :
- Presentations and positions.
- Gestational age.
- Congenital anomalies.
- Polyhydramnios.
- Placental site. Mlela 410
Thursday, July 13, 2023
Diagnosis cont,

(VI) X-ray:
If ultrasound is not available it can detect foetal heads and
vertebral columns.
(VII) Vaginal examination during labour:
The presenting part is small if compared to the oversized
abdomen.

Thursday, July 13, 2023 Mlela 411

DIFFERENTIALS OF LARGE UTERUS FOR
GESTATIONAL AGE
Elevation of the uterus by a distended bladder
Inaccurate menstrual history (wrong dates)
Polyhydramnios
Hydatidiform mole
Uterine myomas
Closely attached adnexal mass
Macrosomia late in pregnancy/hydrocephaly.

Thursday, July 13, 2023 Mlela 412

Thursday, July 13, 2023 Mlela 413
Martenal Risks with twins
(A) During pregnancy:
1- Anaemia : because of the increased foetal demand for iron and folic acid.
2- Hyperemesis gravidarum.
3- Pregnancy induced hypertension. Pre-eclampsia – 5 times more likely in
twin pregnancy.
4- Polyhydramnios .
5- Abortion and preterm labour. Av.36/40 twins,32/40 triplets,30 quadruplets
6- Placenta praevia due to the presence of 2 placentae or one large placenta.
7- Pressure symptoms: dyspnoea, palpitation and oedema of the lower limbs.
8- Congenital anomalies: double its incidence in singleton pregnancy.
9- cord entanglement

Thursday, July 13, 2023 Mlela 414

Risk of pregnancy with twin cont..

(B) During labour:

(1) Complications of malpresentations:
- In 45% vertex-vertex.
- In 35% vertex-breech.
- In 10% both breech.
- In 10% one is transverse lie-cephalic or breech.
- Very rare that both twins lie transversely.

Thursday, July 13, 2023 Mlela 415

(2) PROM.
(3) Cord prolapse.
(4) Dysfunctional uterine action: of all types may occur due to
overdistension of the uterus and malpresentations.
5) Operative Delivery - Caesarean Section

Thursday, July 13, 2023 Mlela 416

Risks cont..

(5) Locked twins: occurs when the after- coming head of the first
breech foetus is locked with the head of the second cephalic
foetus. This is managed by:
a. Disimpaction: tried under GA by grasping the head of the
second twin, rotating and pushing it up. If failed do,
b. Sacrification of the first foetus: which is usually by decapitation,
the second twin can then be delivered followed by extraction of
the head of the first twin.

Thursday, July 13, 2023 Mlela 417

(6) Retained second twin.
(7) Postpartum haemorrhage due to:
a. atony results from overdistended uterus and prolonged labour,
b. large placental site,
c. placenta praevia or early separation of the placenta after
delivery of the first twin.

Thursday, July 13, 2023 Mlela 418

Foetal risks

Stillbirth and neonatal death: 10% perinatal death

Death of one fetus
Early in pregnancy, the risk to the co twin is small.
After 20weeks it may lead to neurological damage and death to
the other twin, the risk is 30%& 3.3% for monochorionic &
dichorionic twins.

Thursday, July 13, 2023 Mlela 419

 Cont.

Congenital anomalies.
Twin Reversed Arterial Perfusion Sequence
(A cardiac monster),very rare 1/35000birth,
There is perfusion of deoxygenated blood to
the recipient twin resulting into rudimentary
development of upper body structure.
Occur in monochorionic monoamniotic twin

Thursday, July 13, 2023 Mlela 420

 Twin – Twin Transfusion Syndrome.TTTS

Common in monochorionic (4 – 35%), rare in

dichorionic 1.5%. Pathophysiology not well
understood. There is chronic net shifting of
blood from the donor to the recipient.
Donor twin, growth restricted, hypovolaemic
and oligohydromnious
Recipient become hypervolaemic, polyuric and
polyhydromnious
Treatment, serial amniocentesis and laser
ablation, indomethazine Rx
Cord accident
Intrauterine growth restriction
Birth asphyxia, 4 – 5 times > Singleton
Thursday, July 13, 2023 Mlela 421
Management options

Pre-pregnancy: counseling ART(IVF), pre-conceptional folate

supplementation
Antenatal: regular visits, US for chorionicity at 10 – 14 weeks,
Anomaly scan at 18 – 20 weeks, counseling for pre-term labour
and regular foetal surveillance for growth and well being

Thursday, July 13, 2023 Mlela 422

Labour and Delivery

Delivery in hospital preferably in tertiary unit

IV line, Hb, Blood group and Cross match
Optimal mode of delivery controversial
Triplets CS is recommended
Both twins vertex, vaginal delivery is recommended
1st twin vertex, 2nd twin non vertex, vaginal delivery is
recommended
1st twin non vertex delivery by CS

Thursday, July 13, 2023 Mlela 423

Thursday, July 13, 2023 Mlela 424
Management cont..

(A) During pregnancy:

1. Frequent antenatal visits: to detect early any complication
mentioned before and manage it.
2. Proper diet: with prophylactic supplementation of iron and folic
acid.
3. Adequate rest: to improve placental blood flow and avoid
preterm labour.

Thursday, July 13, 2023 Mlela 425

Management cont..
(B) During labour: Delivery should be in a hospital.
1st stage: is managed as usual unless there is an indication for c/s.
2nd stage:
(I) Delivery of the first twin:
- If it is vertex : proceed as normal usually there is no problem.
- If it is breech : c/s is safer for fear of locked twins, although vaginal
delivery may pass without this complication.
- Immediate clamping of the cord is essential after delivery of the 1st
twin to avoid bleeding from a uniovular 2nd twin.

Thursday, July 13, 2023 Mlela 426

Management
(II) Delivery of the second twin: It depends upon its presentation;
(1) Longitudinal lie ( vertex or breech) :
Amniotomy is done during uterine contraction which may be delayed up to 5
minutes . Should be delivered within 30 minutes after the first twin
If delay is more than 5 minute, start oxytocin drip.
Delivery of the second twin is usually easy due to dilatation of the maternal
passages by delivery of the first twin.
If there is foetal distress or cord prolapse, rapid delivery is indicated by ;
- breech extraction in breech presentation.
- Forceps delivery in engaged vertex presentation.
- Vacuum extraction or rarely internal podalic version and breech extraction
may be indicated in non-engaged head.
Thursday, July 13, 2023 Mlela 427
 Management

(2) Transverse or oblique lie:

a. External cephalic or podalic version
is done then do amniotomy and
deliver the foetus as cephalic or by
breech extraction respectively or ,
b. Internal podalic version and breech
extraction under general or epidural
anaesthesia.

Thursday, July 13, 2023 Mlela 428

Management
C/S is indicated in : 5. Conjoined twins.
1. The 1st baby is transverse lie. 6. Triplets or more .
2. Prolapsed pulsating cord or 7. Other indications of C/S as
foetal distress in the 1st stage. placenta praevia, contracted
3. Retained 2nd twin when it is; pelvis ....etc.
- transverse lie,
- Is big than the 1 twin(In terms of
st 3 rd stage of labour:

weight) Active management and

- membranes are ruptured, observation is indicated to guard
against postpartum haemorrhage
- uterus is retracted and cervix is
not fully dilated.
Thursday, July 13, 2023 Mlela 429
REMEMBER

Multiple pregnancies account for about 1.5% of all pregnancies.

Perinatal mortality in multiple pregnancies is about six times
higher than in singletons, primarily due to spontaneous preterm
births.
Both serious maternal and foetal complications and minor
discomforts are increased in multiple gestations

Thursday, July 13, 2023 Mlela 430

 POLYHYDRAMNIOS
Session 17

Thursday, July 13, 2023 Mlela 431

Thursday, July 13, 2023 Mlela 432
Mlela 433
Thursday, July 13, 2023 Mlela 434
Thursday, July 13, 2023 Mlela 435
Mlela 437
Thursday, July 13, 2023 Mlela 438
439
440
Mlela 441
 OLIGOHYDRAMNIOS
Session 18

Thursday, July 13, 2023 Mlela 442

444
References

D.C Dutta. Textbook of Gynecology. 6th edition

https://emedicine.medscape.com//article/279116
American College of Obstetricians and Gynecologists, 2004
Cunningham et al, Williams Obstetrics,23 ed ,2010
Obstetrics & Gynaecology, Beckmann.
Hacker & Moore’s Essentials of Obstetrics & Gynaecology.

Thursday, July 13, 2023 Mlela 445

References

Lurain JR.Gestational trophoblastic disease I: Epidemiology,

pathology, clinical presentation and diagnosis of gestational
trophoblastic disease, and management of hydatidiform mole.
Am J Obset Gynecol. 2010;203:531–539
Current diagnosis & treatment, Obstetrics & Gynaecology.
Gynaecology By Ten Teachers, 18th edition.
MoH (2021). Standard Treatment Guidelines and National
Essential Medicines List: Tanzania Mainland (6th Ed).

Thursday, July 13, 2023 Mlela 446

 ‘GRAZIE’
GRARIE
Thursday, July 13, 2023 Mlela 447