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Gynaecology & Obstetrics Notes

Posted by Dr KAMAL DEEP on January 21, 2011

1. Feto maternal transfusion is demonstrated in the mother by: a) Coombs test b) Kleihauer count c) Electrophoretic methods, d) reticulocyte count

Fetal red cells in the maternal circulation can be identified by use of the acid elution principle first described by Kleihauer, Brown, and Betke, or any of several modifications. Fetal erythrocytes contain hemoglobin F, which is more resistant to acid elution than hemoglobin A. After exposure to acid, only fetal hemoglobin remains. Fetal red cells can then be identified by uptake of a special stain and quantified on a peripheral smear (Fig. 29–7). This test is very accurate unless the maternal red cells carry excess fetal hemoglobin as the result of a hemoglobinopathy.

During all pregnancies, very small volumes of blood cells escape from the fetal intravascular compartment across the placental barrier into the maternal intervillous space. This observation is important for several reasons. It is the cause of maternal red cell isoimmunization, as discussed in Isoimmunization.Choavaratana and colleagues (1997) performed serial Kleihauer–Betke tests in 2000 pregnant women and found that, although the incidence of fetal–maternal hemorrhage in each trimester was high, the volume transfused from fetus to mother was very small .

D-positive fetal red blood cells in D-negative maternal blood can be detected by the rosette test. Maternal red cells are mixed with anti-D antibodies, which coat any fetal (D-positive) cells present in the sample. Indicator red cells bearing the D-antigen are then added, and rosettes form around the fetal cells as the indicator cells attach to them by the antibodies. Rosettes indicate that fetal D-positive cells are present.

2.

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Broad ligament
The broad ligament is a sheet-like fold of peritoneum, oriented in the coronal plane that runs from the lateral pelvic wall to the uterus, and encloses the uterine tube in its superior margin (Fig. 5.50). The part of the broad ligament between the origin of the mesovarium and the uterine tube is the mesosalpinx.
The peritoneum of the mesovarium becomes firmly attached to the ovary as the surface epithelium of the ovary. The ovaries are positioned with their long axis in the vertical plane. The ovarian vessels, nerves, and lymphatics enter the superior pole of the ovary from a lateral position and are covered by another raised fold of peritoneum, which with the structures it contains forms the suspensory ligament of ovary (infundibulopelvic ligament).
The inferior pole of the ovary is attached to a fibromuscular band of tissue (the ligament of ovary), which courses medially in the margin of the mesovarium to the uterus and then continues anterolaterally as the round ligament of uterus (Fig. 5.50). The round ligament of uterus passes over the pelvic inlet to reach the deep inguinal ring and then courses through the inguinal canal to end in connective tissue related to the labium majus in the perineum. Both the ligament of ovary and the round ligament of uterus are remnants of the gubernaculum, which attached the gonad to the labioscrotal swellings in the embryo.

3.

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Between the perineal membrane and the membranous layer of superficial fascia is the superficial perineal pouch, and the principal structures in this pouch are the erectile tissues of the penis and clitoris and associated skeletal muscles

Structures in the superficial perineal pouch

The superficial perineal pouch contains:

  • erectile structures that join together to form the penis in men and the clitoris in women; and
  • skeletal muscles that are associated mainly with parts of the erectile structures attached to the the perineal membrane and adjacent bone

The superficial perineal pouch contains three pairs of muscles: the ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles

3.Lymph Nodes:-Lymphatic channels from superficial tissues of the penis  drain mainly into superficial inguinal nodes, as do lymphatic channels from the scrotum or labia majora.

The glans penis,clitoris, labia minora, and the terminal inferior end of the vagina drain into deep inguinal nodes

Lymphatics from the testes drain via channels that ascend in the spermatic cord, pass through the inguinal canal, and course up the posterior abdominal wall to connect directly with lateral aortic and preaortic nodesaround the aorta, at approximately vertebral levels L1 and L2.

Lymphatics from most pelvic viscera drain mainly into lymph nodes distributed along the internal iliac and external iliac arteries and their associated branches (Fig. 5.67), which drain into nodes associated with the common iliac arteries and then into nodes associated with the lateral surfaces of the abdominal aorta. In turn, these lateral aortic nodes drain into the lumbar trunks, which continue to the origin of the thoracic duct at approximately vertebral level T12.

Lymphatics of vulva transverse the labia from medial to lateral side. The lymphatic drainage of the labia proceeds to the upper vulva and mons, then to the inguinal and femoral nodes with both superficial and deep lymph nodes.

The last deep femoral node is called the Cloquet’s node; spread beyond this node affects the lymph nodes of the pelvis. The tumor may also invade adjacent organs such as the vagina, urethra, and rectumand spread via their lymphatic.

Vessels from the lower part of the uterine body pass mostly to the external iliac nodes, with those from the cervix. From the upper part of the body, the fundus and the uterine tubes, vessels accompany those of the ovaries to the lateral aortic and pre-aortic nodes. A few pass to the external iliac nodes. The region surrounding the isthmic part of the uterine tube is drained along the round ligament to the superficial inguinal nodes.

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4.Pelvic Floor

The muscles that span the pelvic floor are collectively known as the pelvic diaphragm(Fig. 38-8). This diaphragm consists of the levator ani and coccygeus muscles along with their superior and inferior investing layers of fasciae. Inferior to the pelvic diaphragm, the perineal membrane and perineal body also contribute to the pelvic floor.

Perineal body —The perineal body is an ill-defined but important connective tissue structure into which muscles of the pelvic floor and the perineum attach. It is positioned in the midline along the posterior border of the perineal membrane, to which it attaches. The posterior end of the urogenital hiatus in the levator ani muscles is also connected to it.

The deep transverse perineal muscles intersect at the perineal body; in women, the sphincter urethrovaginalis also attaches to the perineal body. Other muscles that connect to the perineal body include the external anal sphincter, the superficial transverse perineal muscles and the bulbospongiosus muscles of the perineum.

Urogenital Diaphragm/Triangular Ligament:-The perineal membrane is related above to a thin space called the deep perineal pouch (deep perineal space) which contains a layer of skeletal muscle and various neurovascular elements. The deep perineal pouch is open above and is not separated from more superior structures by a distinct layer of fascia. The parts of perineal membrane and structures in the deep perineal pouch, enclosed by the urogenital hiatus above, therefore contribute to the pelvic floor and support elements of the urogenital system in the pelvic cavity, even though the perineal membrane and deep perineal pouch are usually considered parts of the perineum.

5.Benign ovarian teratomas are usually cystic structures that on histologic examination contain elements from all three germ cell layers. The word teratoma was first advanced by Virchow and translated literally means “monstrous growth.” Teratomas of the ovary may be benign or malignant. Although dermoid is a misnomer, it is the most common term used to describe the benign cystic tumor, composed of mature cells, whereas the malignant variety is composed of immature cells (immature teratoma). Dermoid is a descriptive term in that it emphasizes the preponderance of ectodermal tissue with some mesodermal and rare endodermal derivatives. Malignant teratomas that are immature are usually solid with some cystic areas and histologically contain immature or embryonic-appearing tissueBenign teratomas may undergo malignant transformation. This occurs in approximately 1% to 2% of dermoids, usually in women over age 40.

6.because of their relative prevalence, dermoids are the tumor most frequently reported in a series of women with adnexal torsion. However, the relative risk of adnexal torsion is higher with parovarian cysts, solid benign tumors, and serous cysts of the ovary. The right ovary has a greater tendency to twist (3 to 2) than does the left ovary. Torsion of a malignant ovarian tumor is comparatively rare.Adnexal torsion occurs most commonly during the reproductive years, with the average patient being in her mid-20s.Pregnancy appears to predispose women to adnexal torsion, with approximately one in five women being pregnant when the condition is diagnosed. Most susceptible are ovaries that are enlarged secondary to ovulation induction during early pregnancy.

7.Ovarian Abnormalities in pregnancy

The best treatment of an asymptomatic ovarian cyst in the first trimester
a) Immediate laparotomy b) Laporatomy in second trimester…ANS
c) Laparotomy after delivery d) Leave it alone till it becomes symptomatic

D-nothing should be left alone.They should be observed serially with imaging techniques, and resection is performed if they grow, begin to look suspicious, or become symptomatic

Any type of ovarian mass may complicate pregnancy

Management

Early in pregnancy, ovarian enlargement less than 6 cm in diameter usually is the consequence of corpus luteum formation. With the advent of high-resolution sonography, Thornton and Wells (1987) proposed a conservative approach to management based on ultrasonic characteristics. They recommend resection of all cysts suspected of rupture or torsion, those capable of obstructing labor, and measuring more than 10 cm in diameter because of the increased risk of cancer in large cysts. Cysts 5 cm or less could be left alone, and indeed, most undergo spontaneous resolution

Recommendations

It seems reasonable to remove all ovarian masses over 10 cm because of the substantive risk of malignancy. Tumors from 6 to 10 cm should be carefully evaluated for the possibility of neoplastic disease by ultrasound, MRI, or both. If evaluation suggests a neoplasm, then resection is indicated. If the corpus luteum is removed before 10 weeks, then 17-OH-progesterone, 250 mg intramuscularly, is given weekly until 10 weeks. Cystic masses that are thought to be benign or are less than 6 cm are observed serially with imaging techniques, and resection is performed if they grow, begin to look suspicious, or become symptomatic. In general, we have performed elective surgery at 16 to 20 weeks. Most masses that will regress will have done so by that time.

8.OCP—-Decreased risk of endometrial and ovarian cancer

INCREASES—liver, cervix, and breast cancer

Tamoxifen is an antagonist of the estrogen receptor in breast tissue via its active metabolite, hydroxytamoxifen. In other tissues such as the endometrium, it behaves as an agonist(increases endometrial ca risk but decreases breast cancer risk), hence tamoxifen may be characterized as a mixed agonist/antagonist.

OESTROGEN UNOPPOSED INCREASES RISK OF breast and endometrial cancer

9.Women with TOA most commonly present with lower abdominal pain and with unilateral or bilateral adnexal masses. Fever and leukocytosis may be absent. Abscess rupture causes severe pain with chills, fever, and progressive peritonitis. If large volumes of pus are released into the peritoneal cavity, infection may spread upward along the colonic gutters to form subphrenic abscesses that cause shoulder pain. Sonography is typically diagnostic.

25-year old married infertile woman having regular menstruation, fever. lower abdominal pain and dysmenorrhoea presents herself at the OPD. On examination, there are bilateral soft tender masses of 3″ diameter in both fornices and uterus is of normal size. The most likely diagnosis is,
a) Cystic ovaries b) Tubo-ovarian masses
c) Ectopic pregnancy d) Tuberculous salpingitis

10.The size of ovum is : a) 0.133 mm, b) 0.144 mm, c) 0.2 mm, d) None of the above

The mature ovum  measures 120-130 u/0.133 mm

11.The second maturation division of the human ovum occurs at the time of: a) fertilisation b) implantation c) ovulation d) puberty.

12.Relaxin

This protein hormone has structural features that are similar to insulin and insulin-like growth factors I and II. Its major biological action is remodeling of the connective tissue of the reproductive tract, thus allowing accommodation of pregnancy and successful parturition (Weiss and colleagues, 1993). Relaxin is secreted by the corpus luteum, decidua, and placenta in a pattern similar to that of chorionic gonadotropin (hCG). It is also secreted by the heart, and increased levels have been found in association with heart failure (Fisher and co-workers, 2002).

The role of relaxin during human pregnancy is not completely defined, however, it is known to have effects on the biochemical structure of the cervix (Bell and colleagues, 1993). The hormone also affects myometrial contractility, which may be implicated in preterm birth. Increases in peripheral joint laxity during human pregnancy do not correlate with serum relaxin levels (Marnach and co-workers, 2003; Schauberger and colleagues, 1996

13.Females with diabetes, hypertension or taking diet rich in fat are at higher risk. This is called Corpus cancer syndrome which consist of obesity, hypertension and diabetes.

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