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.