Lecture 6Mr. Othman Ta’ani

Gynaecological NursingNUR 352

Definition

Abnormal bleeding from the uterus in the absence of organic disease of the genital tract.

OR

Abnormal bleeding from the uterus unassociated with tumors, inflammation or pregnancy.

The term may be applied to any abnormal pattern of uterine bleeding but it is commonly applied to bleeding which is excessive in amount, duration or frequency.

Occurs during the reproductive years (between menarche and menopause).

Bleeding patterns

Excessive or heavy menstrual loss (menorrhagia)

Irregular bleeding (metrorrhagia)

Frequent bleeding with shortened cycle (polymenorrhoea).

Prolonged bleeding

Classification

Primary:

No detectable disease in genital tract. No intrauterine contraceptive device (IUCD) present. No prior administration of sex steroids or other hormones. Due to dysfunction arising within the genital tract or reproductive system.

Classification

Secondary: No detectable disease of the genital tract but a

known disorder outside the genital tract e.g. leukaemia,thrombocytopenia.

Iatrogenic: Abnormal bleeding is associated with IUCD, depot

medrxyprogesterone acetate (depo-provera) or estrogen administration.

Classification According to Etiology and Common Symptoms Disorders with Normal Ovulation

Ovulatory oligomenorrhoea:

- Proliferative phase is prolonged

- Secretive phase is normal

- Common in adolescents

- May be a normal feature of menarche

- May be a forerunner of polycystic ovarian disease

* From Up to Date: “The Normal Menstrual Cycle” 2008

Classification According to Etiology and Common Symptoms Disorders with Normal Ovulation

Ovulatory polymenorrhoea:

- Proliferative phase is shortened especially in adolescence

- Shortened secretive phase may also occur especially

in older women

- Due to premature degeneration of the corpus luteum

Dysfunctional uterine bleeding with corpus luteum abnormality

Failure in the development of corpus luteum

Decreased secretion of progesterone

Occurs mainly in the adult reproductive years

Shortening of the menstrual cycle and polymenorrhoea.

Prolonged activity of the corpus luteum, results in prolonged and excessive menstruation

Anovulatory Dysfunctional uterine bleeding

Failure of ovulation is the most common abnormality

May result in apparently normal periods e.g. regular cycles but with excessive loss

Irregular menstruation with periods of amenorrhea followed by excessive loss

Clinical presentation

There is no specific pattern of bleeding. May be abnormal in: 1- amount. 2- duration. 3- frequency and its relation to menstruation.

The incidence of pathological disease and prognosis varies with age. Therefore, it consider under 3 age groups:

under 20 years (adolescent DUB) 20-40 years over 40 years

Clinical diagnosis

Hx, abdominal, pelvic examination

Hematological

Endocrine: progesterone on the 21st day of the cycle (will indicate whether ovulation has occurred or if there is corpus luteum insufficiency).

Others: hysteroscopy, laparoscopy

Management

Exclude organic disease

Individualize treatment according to age, parity, severity, nature of the underlying defect and likelihood of organic disease

Explanation of the situation

If in doubt, keep record of loss for about 2-3months

Management

Under 20 years- Dilatation & curettage only if bleeding persists, hormone therapy,

antifbrinolytic therapy. Never hysterectomy. 20-40years- Always D&C- Next line of action after D&C ( hormone therapy, antifbrinolytic

therapy)- Seldom hysterectomy

Over 40 years- D&C mandatory- Hormone therapy and antifbrinolytic therapy only after D&C in the

absence of organic disease- Hysterectomy first resort if bleeding persists.

Hormone Therapy

Estrogens in cases of severe .

Progestogens: administered orally.

Medical Therapy

Antifibrinolytic agents.

Epsilon Aminocaproic acid

Tranexamic acid.

Prostaglandin synthetase inhibitors.

mefenamic acid.

flufenamic acid.

Surgical Treatment

Surgery

D&C

Hysterectomy

Radiotherapy. For those who are unfit for surgery and over 40 years. Produces amenorrhea in 99% of cases.

Lecture 7Mr. Othman Ta’ani

Gynaecological NursingNUR 352

Definition

Pregnant has not occurred after at least 1 year of engaging in unprotected coitus.

Sterility:

Is a lessened ability to conceive.

About 14% of couples in USA are infertile

TYPES OF INFERTILITY

1- PRIMARY : When there is no previous conceptions 20%

2- SECONDARY : When there has been a previous viable pregnancy but the couple is unable to conceive at present 80%

MALE INFERTILITY FACTORS

1- Disturbance in spermatogenesis

2- Obstruction in the seminiferous tubules, ducts or vessels preventing movements of spermatozoa.

3- Qualitative or Quantitative changes in the seminal fluid preventing sperm motility.

4- Problems in ejaculation or deposition preventing spermatozoa from being placed close enough to woman's cervix.

Causes are as follows in a general scale

Female factor 30% Male factor 30% Female and male 30% Idiopathic 10%

The causes will vary from this general scale according to the locality.

In Adequate Sperm Count

The sperm count is the number of sperm in a single ejaculation or in a milliliter of sperm.

Minimum sperm count considered normal is 20 million per milliliter of seminal fluid or 50 million per ejaculation.

At least 50% of sperm should be motile and 30% of sperm should be normal in shape and form

FACTORS AFFECTING SPERM

1- Body Temperature.

2- Congenital Abnormalities e.g (undescended testes).

3- Varicocele ( varicosity of the spermatic vein).

4- Trauma to the testes.

5- Drug use

6- Environmental Factors e.g X-Ray

FEMALE INFERTILITY FACTORS

1- Anovulation: ( absence of ovulation) Most Common cause of infertility in women.

2- Tubal transport problems

3- Uterine Problems : e.g Tumors , Uterine malformations

4- Cervical Problems: Normal Cervical mucus is thin & watery that help sperm to penetrate the

cervix when become this mucus too thick difficulty to allow sperm to penetrate to cervix.

Cervix Stenosis. D&C several times.

5- Vaginal Problems: Infection PH of vaginal secretion

become acidotic destroying the motility of spermatozoa

genetic factors – vaginal obstruction

DIAGNOSIS OF INFERTILITY

Semen analysis Ovulation Monitoring 1- By Recording Basal Body Temperature for at least 1 month every day each morning before getting out of bed. 2- Assessing the upsurge of LH that occurs before ovulation by urine sample using kit.

Tubal Patency : Ultrasound X-Ray imaging

MANAGEMENT OF INFERTILITY

Correction of underlying problem: Sperm count & motility. Presence of infection. Hormone Therapy. Surgery: e.g Fibroid Tumor

Myomectomy

Artificial Insemination: Instillation of sperm into the female reproductive tract to aid

conception This technique can be done in case of : 1- In adequate amount of sperm count 2- Woman has vaginal or cervical factors

In Vitro Fertilization ( IVF ): This technique used in Blocked or Damaged fallopian tubes. Oligospermia or Sperm count

MANAGEMENT OF INFERTILITY

Slide 30

Social and Psychological Implications Related to Infertility

Psychological reactions Guilt Isolation Depression Stress on the relationship

Cultural and religious considerations

NURSING MANAGEMENT

The Major focus of nursing care are:

1- Providing support for couple as they undergo diagnosis and their chosen treatment.

2- Therapeutic communication skills.