INTRODUCTION

History taking, Clinical examination and investigations are three main ways to diagnose change in
physiological and pathological condition. Pregnancy is a physiological condition where as diagnosis of
gynaecological problems are pathological.

There are several investigations which confirm pregnancy, screen high risk pregnancy and aids in
diagnosis of gynaecological problems

COMMON INVESTIGATIONS USED IN OBSTETRICS

During pregnancy profound changes occur in the body. Every aspect of the body shows marked
changes. In a healthy lady these changes are easily accommodated in her body without really dipping
into her reserves.

For those who start pregnancy with a physical or medical problems the body will put pressure on these
limited reserves. As a result there will be evidence of adverse effects on the body.

Common investigations in obstetrics include

 Tests for confirmation of pregnancy

 Test after confirmation of pregnancy
 Urine test
 Blood test
 Screening test
 Ultrasound scan
 Pap's smear

Tests for confirmation of pregnancy

Urine test to detect Pregnancy

How does urine test work?

Urine test examines the presence of human chorionic gonadotropin (hCG) hormone in the urine. This
hormone is also called as pregnancy hormone as they are present only in pregnant women.
hCG hormone is produced in the body when a fertilized egg implants in the uterus. The production of
hCG hormone occurs about 6 days after conception. The hCG amount increases drastically as the
pregnancy days pass by.
Instruction for performing the urine test for pregnancy is as follows:
 Take out the test strip from the package
 Take the urine in a wide mouth container ,take few drops of urine and put in the specified
space of the strip.
 Wait for the results as indicated in the instructions. –two prominent mark indicate positive
results ,one mark indicate negative result and no mark indicate invalid report
 How reliable is urine test?
Urine test and blood test are the only two ways of detecting pregnancy.
 Urine test have some advantages over the blood test for pregnancy.
 The primary benefit of doing the urine test is that it can be done in complete privacy at home.
 Secondly, the method of performing urine test is absolutely easy and gives immediate results as
compared to the blood test.
 To get the correct results, do the test with first urine in the morning.
 This test must be performed one or two day after the missed period. If you get a negative result,
try once again after one to two weeks.
 However, researchers believe that the urine test can give 97% accuracy. Hence, the urine test
may not give accurate results every time.
 Even after getting negative results for pregnancy through urine test, it is advised to perform a
blood test to confirm the results. Blood test for pregnancy is more accurate as compared to the
urine test for pregnancy

Blood Pregnancy Test:

This test can only confirm whether or not the pregnancy hormone, hCG, is present and, therefore,
whether a woman is pregnant or not. The qualitative hCG blood test tends to be about as accurate as a
home urine test

Blood Test Results:

It gives 98 to 99 percent accuracy rate. These tests can be conducted seven days after ovulation
As with urine pregnancy tests, it is possible to end up with false results (both negative and positive)
from a blood pregnancy test.

 False negative results (test is negative, but client are actually pregnant) usually occur if the test
was performed too early. This is because there may not be enough hCG in the blood to detect a
pregnancy.

 False positive results (test is positive, but client is not pregnant) may appear if she takes
medication that contains hCG.

Routine tests after pregnancy is confirmed

URINE TEST (URINE ANALYSIS)

The urine comprises the end products of body’s metabolism, which is filtered out in the kidneys and
excreted through the ‘water works’ to the outside.
Hence if there is any damage to any or both of the kidneys, these end products would accumulate in the
body causing undesirable effects. Urine comprises of the end products of body’s metabolism, which is
filtered out in the kidneys and excreted out as urine. If there is any damage to one or both of the kidneys,
the end products would accumulate in the body causing undesirable effects. E.coli infection is
commonly seen in urine.
Tests those are done

i) physical, ii) Biochemical, iii) Microscopical, iv) Bacteriological, v)immunological, vi)Hormonal

Proper collection of urine sample for test is important. A small precaution will prevent contamination of
urine sample-

Instruction to client regarding collection of sample

 Urine is collected in a wide mouth container

 To first wash perineal area with clean water before collecting the sample.
 For physical biochemical and microscopical tests client is instructed to give first morning
sample .

For bacteriological tests-

 Instruction given to pass a little urine in the toilet and then pass urine in the collecting jar i.e
collect a midstream specimen.

Tests on urine sample:-

 hCG hormone to confirm pregnancy.

 Protein – by heat and acetic acid test or distick test
 Sugar- by Benedict reagent or dipstick
 Bacteria
 Pus cells
 pH of urine

Physical examination of urine.

Color Normal: Pale to dark yellow

Abnormal: Urine with no color - long-term kidney disease or uncontrolled diabetes. Dark yellow
urine can be caused by dehydration. Red urine can be caused by blood in the urine.

Clarity Normal: Clear

Abnormal: Cloudy urine can be caused by pus (white blood cells), blood (red blood cells), sperm,
bacteria, yeast, crystals, mucus, or a parasite infection, such as trichomoniasis.

Odor Normal: Slightly "nutty" odor

Abnormal: A sweet, fruity odor may be caused by uncontrolled diabetes. A urinary tract infection
(UTI) can cause a bad odor.

Specific gravity Normal: 1.005-1.030

 Abnormal: A very high specific gravity means very concentrated urine, which may be caused by not
drinking enough fluid, loss of too much fluid (excessive vomiting, sweating, or diarrhea),
or substances (such as sugar or protein) in the urine. Very low specific gravity means
dilute urine, which may be caused by drinking too much fluid, severe kidney disease, or
the use of diuretics.

pH Normal: 4.6-8.0

Abnormal: A high (alkaline) pH can be caused by severe vomiting, a kidney disease, some urinary
tract infections, and asthma. A low (acidic) pH may be caused by severe lung disease
(emphysema), uncontrolled diabetes, aspirin overdose, severe diarrhea, dehydration,
starvation, drinking too much alcohol, or drinking antifreeze (ethylene glycol).

Protein Normal: None

Abnormal: Protein in the urine may mean kidney damage, an infection, cancer, high blood pressure,
diabetes, systemic lupus erythematosus (SLE), or glomerulonephritis is present.
Protein in the urine may also mean that heart failure, leukemia, poison (lead or mercury
poisoning), or preeclampsia (if you are pregnant) is present.

Glucose Normal: None

Abnormal: Intravenous (IV) fluids can cause glucose to be in the urine. Too much glucose in the urine
may be caused by uncontrolled diabetes, an adrenal gland problem, liver damage, brain
injury, certain types of poisoning, and some types of kidney diseases. Healthy pregnant
women can have glucose in their urine, which is normal during pregnancy.

Ketones Normal: None

Abnormal: Ketones in the urine can mean uncontrolled diabetes, a very low-carbohydrate diet,
starvation or eating disorders , alcoholism, . Low levels of ketones are sometimes found in
the urine of healthy pregnant women.

Microscopic Normal: Very few or no red or white blood cells or casts are seen. No bacteria, yeast cells,
analysis parasites, or squamous cells are present. A few crystals are normally seen.

Nursing responsibility:

 Explanation of the procedure or need for the test

 Instruction to client regarding collection of sample I,e first morning sample or midstream
 Test of urine –pregnancy test/presence of protein/sugar
 Report results

THE ROUTINE BLOOD TESTS THAT ARE DONE DURING PREGNANCY ARE:-

 Hemoglobin content
  Complete Blood Count
 Blood Group and Rh factor
 VDRL Tests for syphillis (sexually transmitted disease)
 HIV Factor for AIDS
 Hepatitis B Screening.
 Blood sugar at 24-28 weeks

a) Hemoglobin content to check anemia (repeated in third trimester usually, done more often in some
cases e.g. anemia).

b) Complete blood count

c) Blood group and Rh factor- If mother is Rh negative then Rh antibody levels tested at 28 weeks of
pregnancy as she may be carrying an Rh positive baby

f) VDRL (syphilis) is a sexually transmitted infection and can be treated with antibiotics if found
positive. It can be a cause of abortion sometimes.

g) HIV is a virus that causes AIDS. If the test is positive the risk of passing the virus to the baby can be
reduced by treating the mother during pregnancy and delivering the baby by caesarian section.

h) Fasting Blood sugar- It is done routinely.

 If there is a family history of diabetes or if the female is overweight, there is a chance of

developing gestational diabetes. Hence a one step glucose challenge test should be done. 50g of
glucose is given orally and a sample is collected exactly after 1 hour.
 If the blood sugar level is more that130 mg/dL then a GTT (Glucose Tolerance Test) is advised.
 If the random blood sugar level is more that 200 mg/dL, do a GTT.
 Repeat blood sugar levels between 24-28 weeks of pregnancy.

i) Hepatitis B is a viral infection. If the mother is positive for this infection, then remember to immunize
(vaccinate) the baby at birth to protect the new born.

j) TSH (Thyroid stimulating hormone) - All pregnant women should be screened for Thyroid in the
beginning of pregnancy.

k) Platelets count- It can be done as platelets are important for blood clotting. It can be repeated in the
third trimester of pregnancy.

Nurse’s responsibility for tests of blood:

 Explanation of the needs for the tests

 Reassurance
 Specific Instruction like fasting or taking meal
 Preparation of articles
 Preparation of mother like skin preparation
 Collection of blood sample or assisting in blood sample
 Providing information regarding timing of getting report and providing information regarding
results
SPECIAL TESTS DURING PREGNANCY

Blood test for Rubella status- If rubella antibodies are present then the woman is immune and hence
safe. If the test is negative immunization vaccine cannot be given to the mother during pregnancy, it should
be given after the delivery.
Note: Ideally Rubella status should be done before pregnancy.

ULTRASOUND SCAN

Ultrasound was adapted to medical use in the early 1960's when it was first used in Obstetrics to locate
the position of the foetus and the placenta or afterbirth.

Today, because of advances made in instruments, it is possible to learn important information about the

foetus and its surroundings

Purpose of test

The common reasons of asking for a Ultrasound are :-

1. Confirm an early pregnancy. .

2. Rule out ectopic pregnancy. This is usually necessary in early pregnancy.
3. Determine due date.
4. Determine foetal position.
5. Identify location of the placenta
6. Verify the diagnosis of twins/multiple pregnancy.
7. Evaluate foetal growth.
8. Determine the amount of amniotic fluid around the baby.
9. Assess fetal well-being.
10. Accompaniment to special procedures.

The test is normally performed in the doctor’s clinic or a hospital.In India the test is usually done by a
Doctor who is a specialist in Radiology or is also done by the Obstetrician.

Risks

There are no risks or precautions to be taken.A commonly asked question is if the procedure of
ultrasound harms the baby. Thus far, from all the information gathered and studied in human beings,
there has been no good data published that indicate that ultrasound used during obstetrical diagnosis has
any ill effect on the growth and development of the baby.

Type- --
  Trans Abdominal
 Transvaginal

Trans Abdominal

Procedure

 The test requires a full bladder to help define pelvic organs. Client should be instructed to drink
several glasses of water about 1 hour before the test and not to urinate until the test is finished.

 Positioning – Dorsal recumbent positon is maintained with knees slightly flexed .

 Oil or jelly is applied to abdomen to improve sound wave transmission.
 The doctor guides a transducer, which may feel cold on skin, over the area examined.
 Transducer sends an ultrasound beam, composed of very high-frequency sound wave, inaudible
to the human ear.
 Ultrasound waves travel at varying speeds, depending on the thickness of the material they travel
through.
 After passing through the tissue, reflected sound waves are converted into electrical impulses
and displayed on a video screen for interpretation or photographing for later interpretation.
 The time before results are reported to patient varies from a few minutes to a few days.

Trans-vaginal

 In certain cases, an internal ultrasound may be required, particularly in early pregnancy. This is
called ‘trans-vaginal sonography’ and can define pelvic structures and early pregnancy better,
 It is done by a probe placed inside the vagina (like an internal examination with a picture of
inner organs being taken).
 A full bladder is not required for this procedure.

The first trimester scan

 The first scan is done between 10-13 weeks to

 Confirm due date – CRL +42 days gives gestational age . BPD,FL,HC and AC
 Check for twins, and
 Anomalies like ectopic pregnancy and
 Nuchal translucency (NT) - a test which helps to assess baby’s risk of having Down
syndrome.

The last day have NT scan done is 13 weeks and 6 days pregnancy i.e. before 14 weeks. After
this it loses its significance

If NT scan is abnormal, may have to undergo other screening tests like CVS (Chorionic Villus
Sampling) or amniocentesis to confirm if the baby is actually affected with Down syndrome.

The NT scan needs special training and high resolution ultrasound equipment to perform it
correctly. Software enables the doctor to evaluate the baby’s risk. It’s not yet available yet
everywhere.
Second trimester scan

 The second scan should be done between 18-20 weeks.

 Fetal growth- Normal fetal weight should be between 10 th 90 th percentile.(<10th percentile-
SGA,>90th percentile-LGA)
 It is done to detect the physical abnormalities in fetus.
 This is also called level II scan and has to be done with patience so that no physical fetal
anomaly is missed.

Third trimester scan

The third scan is done around 36 weeks to determine

 fetal maturity,
 placental maturity and
 any anomaly if missed in the past.

PAPANICOLAOU TEST•

 Pap test-Screening test for cancer

 First described by Papanicolaou and Traut in 1943
 Routinely done after confirmation of pregnancy and gynaecological examination in females,esp
above 35 years
 Yearly screening for 3 years followed by 5 yearly test

• Uses—1.screening for cancer 2.identification of local viral infections like herpes and condyloma
accuminata 3.Cytohormonal study

Pap smear-screening of cancer

PROCEDURE

 Should be obtained prior to vaginal examination

 Patient placed in dorsal position with labia separated
 Cusco’s self retaining speculum inserted without lubricants
 Cervix exposed, squamocolumnar junction scraped with concave end of Ayre’s spatula by
rotating all around
 Thin smear is prepared on a glass slide and fixed by equal amounts of 95% alcohol and ether•
After 30 min,slide air dried and stained with papanicolaou or Short stain

BLOOD TEST FOR ALPHA FETO- PROTEIN (AFP)

This test can be done on mother’s blood (MSAFP or Maternal Serum AFP) around the 14th – 16th week
of pregnancy.

It is a screening test i.e. an abnormal result is found in certain conditions.

High levels make the doctor suspect

 defects in the development of spinal cord or brain (neural tube defects) in the baby.
 Gastrointestinal tract or in kidneys (congenital nephrosis)

Low levels may be seen in

 Genetic defects such as Down syndrome.

An abnormal result needs to be verified by additional tests, which will be advised by your doctor.
MSAFP is not done for all pregnancies. The doctor usually will suggest it to you if it is necessary.

This blood test is done when there is a suspicion of a Neural Tube Defect in the unborn baby-

 Spina bifida,
 anencephaly.

TRIPLE MARKER TEST

This specialized test may be recommended if doctor is worried that the baby may not have developed
normally.

 It tests a pregnant woman’s blood around 14 – 16 weeks for AFP (as above) hCG (human
chronic gonadotrophin), and unconjugated estriol (uE3)

 A computerized program will give your risk, taking into account variables like your age, medical
history and other factors.
 This new test is not yet available everywhere but is being done by some centers. If abnormal
detailed testing may be recommended by doctor
 This test is more accurate and is beginning to replace the standard AFP test mentioned above.
 This test is able to detect about 60 % of the babies with Down syndrome and 80-90% of the babies
with neural tube defects.
 AFP is a marker for neural tube defects (spina bifida, anencephaly). Beta hCG, uE3 are markers for
Down syndrome and trisomy-18.

QUAD SCREEN TEST- In addition to AFP, hCG, estriol it checks the level of the hormone inhibin A as
well. It is a marker for Down syndrome.

PENTA SCREEN- It looks for the above four substances as well as Invasive Trophoblast Antigen (ITA).
ITA is a hyperglycosylated form of hCG produced by cytotrophoblast. Its level increases in Down syndrome.

Sensitivity of Triple screen for Down’s syndrome is 72%

Sensitivity of Quad screen for Down’s syndrome is 79%
Sensitivity of Penta screen for Down’s syndrome is 83%

Doctor will discuss each test before it is done, if refused it will not be done. It is advisable to go for screening test if
you are above 34 years of age.
INVASIVE TESTS DURING PREGNANCY ARE SOMETIMES NECESSARY-

If the screening test is positive, invasive screening tests have to be done to confirm the anomalies
(abnormalities). Invasive tests detect chromosomal disorders in the fetus.
The tests are:

 Amniocentesis- This is a procedure where under the guidance of an ultrasound a needle is passed
into the uterine cavity and some amniotic fluid is sucked out.
 Chorionic villus sampling (CVS)- this procedure involves inserting a needle into the uterus
cavity into the placenta to suck out a very small bit of tissue.
 Cordocentesis- In this procedure a needle is put through the uterine cavity into the vein in the
umbilical cord of the baby and fetal blood sample is obtained.

AMNIOCENTESIS (also referred to as amniotic fluid test or AFT) is a medical procedure used in
prenatal diagnosis of chromosomal abnormalities and fetal infections, in which a small amount of amniotic fluid,
which contains fetal tissues, is sampled from the amnion or amniotic sac surrounding a developing fetus, and the
fetal DNA is examined for genetic abnormalities.

Developed by Richard Dedrick, this process can be used for prenatal sex discernment and hence this procedure
has legal restrictions in some countries

Procedure

 Preparation of skin with antiseptic solution

 Local anesthetic is given to the mother in order to relieve the pain felt during the insertion of the
needle used to withdraw the fluid.

 After the local is in effect, a needle is usually inserted through the mother's abdominal wall, then
through the wall of the uterus, and finally into the amniotic sac.

 With the aid of ultrasound-guidance, a physician punctures the sac in an area away from the
fetus and extracts approximately 20 ml of amniotic fluid.

Examination of sample:

If used for prenatal genetic diagnosis, fetal cells are separated from the extracted sample. The cells are
grown in a culture medium, then fixed and stained. Under a microscope the chromosomes are examined
for abnormalities. The most common abnormalities detected are Down syndrome (trisomy 21), Edwards
syndrome (trisomy 18), and Turner syndrome (monosomy X). In regard to the fetus, the puncture heals
and the amniotic sac replenishes the liquid over the next 24–48 hours.[3][4]
Indications and results

Genetic diagnosis

Early in pregnancy, amniocentesis used for diagnosis of chromosomal and other fetal problems such as:

 Down syndrome (trisomy 21)

 Trisomy 13
 Trisomy 18
 Fragile X
 Rare, inherited metabolic disorders
 Neural tube defects (anencephaly and spina bifida) by alpha-fetoprotein levels.[5]

Lung maturity

Amniocentesis can predict fetal lung maturity, which is inversely correlated to the risk of infant
respiratory distress syndrome.

 In pregnancies of greater than 30 weeks, the fetal lung maturity may be tested by sampling the
amount of surfactant in the amniotic fluid.

 Several tests are available that correlate with the production of surfactant. These include the
lecithin-sphingomyelin ratio ("L/S ratio"), the presence of phosphatidylglycerol (PG), and more
recently, the surfactant/albumin (S/A) ratio.

 For the L/S ratio, if the result is less than 2:1, the fetal lungs may be surfactant deficient.

 The presence of PG usually indicates fetal lung maturity.

 For the S/A ratio, the result is given as mg of surfactant per gm of protein. An S/A ratio <35
indicates immature lungs, between 35-55 is indeterminate, and >55 indicates mature surfactant
production (correlates with an L/S ratio of 2.2 or greater).

Other

Amniocentesis can also be used to detect problems such as:

 Infection, in which amniocentesis can detect a decreased glucose level, a Gram stain showing bacteria or
an abnormal differential count of white blood cells.[6]
 Rh incompatibility
 Decompression of polyhydramnios

An emerging indication for amniocentesis is in the management of preterm rupture of membranes where
measurement of certain amniotic fluid inflammatory markers may be helpful. If amniotic fluid IL-6, a
marker of inflammation, is elevated, the fetus is at high risk and delivery should be considered.[7]

Risks and drawbacks

Amniocentesis is performed between the 15th and 20th week of pregnancy; performing this test earlier
may result in fetal injury. The term "early amniocentesis" is sometimes used to describe use of the
process between weeks 11 and 13.

Complications of amniocentesis include

 preterm labor and delivery,

 respiratory distress,

 postural deformities,

 chorioamnionitis,

 fetal trauma and

 alloimmunisation of the mother (rhesus disease).

Nurses responsibility for invasive screening tests

 Explanation of the procedure

 In Rh negative mother immunization with Anti D immunoglobulin as per advice

 Obtaining consent

 Reassurance

 positioning of the mother in dorsal recumbent position

 Arranging articles for skin preparation

 Preparation of skin with antiseptic lotion

 After care

 Observation of complications and checking of FHR at 15 min interval

TESTS FOR BABY'S HEALTH IN-UTERUS

These are usually recommended in advanced pregnancy (after 32 weeks) and are to be done if doctor
advices it.

NON STRESS TEST

 This is a test to assess the well being of baby.

  It is a non- invasive test and carries no risk of the procedure.
 The duration of the test is approximately 20 minutes.
In this test , movements of the baby are monitored along with the heart rate with each movement.
 The baby needs to be awake during this test.
With the movement of the baby, there is a corresponding increase in the heart rate.
 The NST is done in a high risk pregnancy and is usually done after the 36 th week and repeated
weekly.

BIOPHYSICAL PROFILE

In late pregnancy, to assess the baby’s health in utero, the gynecologist studies the foetus to know the
movements, posture and one, and assesses the placenta and amniotic fluid. The overall result tells how
well the baby is doing. If the result is not good, further tests or some intervention may be needed. Some
intervention may be needed. This is usually done if there is some problem complicating the pregnancy,
such as hypertension, diabetes, IUGR, etc.

DOPPLER

This is a special addition to the routine ultrasound machine, which enables study of blood flow to the
baby and in the feto-placental circulation. It is done to assess feotal health in complicated pregnancies,
and may be used in deciding when to deliver the baby.

VITRO-ACOUSTIC STIMULATION TEST (VAST)

Here a vibrating and sound stimulation is given through the mother’s abdomen to the foetus and its
reaction in terms of increase in heart rate and movements is seen

CARDIOTOCOGRAPHY

Cardiotocography (CTG) is a technical means of recording (-graphy) the fetal heartbeat (cardio-) and
the uterine contractions (-toco-) during pregnancy, typically in the third trimester. The machine used to
perform the monitoring is called a cardiotocograph, more commonly known as an electronic fetal
monitor (EFM).

The invasive fetal monitoring was invented by Doctors Alan Bradfield, Orvan Hess and Edward Hon. A
refined (antepartal, non-invasive, beat-to-beat) version (cardiotocograph) was later developed for
Hewlett Packard by Dr. Konrad Hammacher.

 Simultaneous recordings are performed by two separate transducers,

 one for the measurement of the fetal heart rate and a second one for the uterine contractions.
  Each of the transducers may be either external or internal.

 External measurement means taping or strapping the two sensors to the abdominal wall.

 Internal measurement requires a certain degree of cervical dilatation.

Fetal heart rate Uterine contractions

The pressure-sensitive contraction

The heart (cardio) sensor is an ultrasonic sensor, transducer, called a tocodynamometer (toco)
similar to a Doppler fetal monitor, that has a flat area that is fixated to the skin by a
External continuously emits ultrasound and detects motion band around the belly. The pressure required
of the fetal heart by the characteristic of the to flatten a section of the wall correlates with
reflected sound. the internal pressure, thereby providing an
estimate of it.

Internal measurement of FHR involves attaching

This involves inserting a pressure catheter
a scalp electrode (or spiral electrode) to the fetal
into the uterine cavity. Internal measurement
head to adequately measure the electric activity
is more precise, and might be preferable
Internal of the fetal heart. This measures the R-R interval
when a complicated childbirth is expected.
on a fetal electrocardiogram. "STAN", which
Internal measurement is required to calculate
includes analysis of the ST segment, is available
Montevideo units.
on some equipment.

Interpretation of a CTG
 Uterine activity (contractions)

Normal- less than or equal to 5 contractions in 10 minutes, averaged over a 30-minute window
Tachysystole- more than 5 contractions in 10 minutes, averaged over a 30-minute window

 Baseline fetal heart rate (FHR)- the mean FHR rounded to increments of 5 beats per minute
(bpm) during a 10-minute window, excluding accelerations and decelerations
 Baseline FHR variability- Baseline FHR variability is defined as fluctuations in the baseline
FHR that are irregular in amplitude and frequency.
 Presence of accelerations- a visually apparent abrupt increase in FHR. greater than or equal to
15 bpm greater than or equal to 15 seconds from the onset to return
 Periodic or episodic decelerations- a visually apparent decrease in FHR from the baseline
 Changes or trends of FHR patterns over time.

Effect on management

 Cardiotocography reduces the rate of seizures in the newborn,

 There is no clear benefit in the prevention of cerebral palsy, perinatal death and other
complications of labour.

 The false-positive rate of cardiotocography for cerebral palsy is given as high as 99%, meaning
that only 1-2 of one hundred babies with non-reassuring patterns will develop cerebral palsy.

COMMON INVESTIGTIONS IN GYNAECOLOGY

Common investigations in gynaecology include-

 Blood values
 Urine examination
 Urethral, vaginal, cervical discharge biopsy
 Imaging techniques
 Endometrial sampling
 Culdocentesis
 Exfoliative cytology
 Endoscopy
 Colposcopy
 hormonal assays
BLOOD ROUTINE

• Hemoglobin estimation- done for excessive bleeding

• Total and differential count- For PID

• ESR, Platelet count, BT,CT—Pubertal menorrhagia

• Serology- VDRL, australia antigen, HIV

URINALYSIS

Urine routine and microscopy• Physical examination• Chemical estimation of protein and sugar

• Pus cells, casts

Culture and drug sensitivity

• Indications—Pus cells>5 UTI Cystocele Urinary complaints Fistula

Urine pregnancy test– for diagnosis of pregnancy

Methods of urine collection -1. Midstream collection2. Catheter collection3. Suprapubic bladder
puncture

URETHRAL DISCHARGE

Method of collection

• Urethra squeesed against symphysis pubis from behind forwards using sterile gloved fingers

.• Discharge through external urethral meatus collected with sterile swabs

• Swabs—microscopy and culture

VAGINAL DISCHARGE

Method of collection

• Patient not to have vaginal douche for 24hrs

• Cusco’s bivalve speculum introduced
• Discharge from posterior fornix on the blade of speculum or cervical canal taken with a
swab
• microscopic examination-Discharge mixed with normal saline• culture
Identification of organisms in the slide

 .Normal discharge-normal vaginal cells with doderlein bacilli

 Trichomonal vaginalis—hanging droppreparation shows motile flagellatedorganisms of varying
shape
 Gardnerella vaginosis (bacterial/nonspecific vaginitis)—clue cells, few inflammatory cells, free
floating clumps of gardnerella, scanty lactobacilli
 Vaginal candidasis

• Vaginal discharge + equal amount of 10% KOH• Caustic potash dissolves all cellular debris,leaving
behind more resistant yeast like organisms

• Typical hyphae, budding spores or mycelia detected

EXFOLIATIVE CYTOLOGY- PAPANICOLAOU TEST

• Pap test-Screening test for cancer

• Routine gynaecological examination in females, especialy above 35 years
• Yearly screening for 3 years followed by 5 yearly test
• uses and procedure- explained above

INTERPRETATIONS

Normal cells

 Basal cells- small, rounded basophilic with large nuclei

 Squamous cells from middle layer –transparent and basophilic with vesicular nuclei
 Cells from superficial layer-acidophilic with characterestic pyknotic nuclei4.Endometrial cells,
histiocytes, blood cells and bacteria

Abnormal cells

Mild dyskaryosis—

• superficial/intermediate squamous cells

• Angular borders,transcluscent cytoplasm• Nucleus < half of total area of cytoplasm
• Binucleation is common

Moderate dyskaryosis—

• Intermediate/parabasal/superficial squamous cell type

• More disproportionate nuclear enlaregement and hyperchromasia
• Nucleus-1/2-2/3 of total cytoplasm area• CIN II
Severe dyskaryosis

• Cells- basal type round/oval/polygonal/elongated singly/in clumps

• Nucleus- almost fills the cell thick, dense, narrow rim of cytoplasm irregular with coarse
chromatin pattern
• Fibre cells- severly dyskaryotic elongated cell
• Tadpole cell- severly dyskaryotic cell with an elongated tail of cytoplasm

Carcinoma in situ Invasive carcinoma

• Parabasal cells with • Cells-single/clusters increased nucleo-

• Tadpole cells cytoplasmic ratio
• Irregular nuclei
• Cytoplasm scanty
• Coarse clumping of
• Nucleus- chromatin irregular, sometimes multiple
• Chromatin pattern- granular

 Koilocytosis• Nuclear abnormalities due to HPV infection

 Positive pap smear in genital herpes-giant cells with viral inclusion bodies• Silver pap test– pap
test+PCR– used for diagnosis of herpes

Reporting system• normal/abnormal• Abnormal-CIN/papilloma infection/invasive malignancy•

Doubtful/inconclusive smear-repeat smear

Papanicolaou classification-

Grading I. Normal cells

Grading II. Slightly abnormal-inflammatory change

Grading III. Cells suspicious of malignancy-biopsy indicated

Grading IV. Few Distinctly abnormal,possibly malignant cells

Grading V. Malignant cells seen-numerous

Limitations of pap smear

• Detect only 60-70% of cervical cancer and 70% of endomitrial cancer

• Reliability depends on slide preparation and skill of cytologist
• 10-15% false negative results• False positive results in presence of infections
• Difficulty if squamocolumnar junction-indrawn as in post menopausal women(10 day
course of oestrogen cream suggested)
• Postradiation cytology difficult- scarring and atrophy of vagina

ENDOMETRIAL BIOPSY

• Most reliable method to study endometrium

 • Endometrial tissue obtained by curretage and subjected for histopathologyIndications
• suspected cases of Endometritis,endometrial cancer
• Infertility
• Abnormal menstrual bleeding
• Diagnosis of corpus luteal phase defect

CERVICAL BIOPSY

• Confirmatory diagnosis of cervical pathology

• Done at OP if pathology detectable
• Wider tissue excision as in cone biopsy – IP procedure

COLPOSCOPY

• Colposcope-binocular microscope- 10-20 X

• Use-colposcope directed biopsy colposcopic examination of cervix and vagina

CULDOCENTESIS

• Transvaginal aspiration of peritoneal fluid from the pouch of douglas

• Diagnostic procedure- pelvic abcess ectopic pregnancy in haematocele detect malignancy in

ascitis with ovarian cyst

o Instruments- vulsellum forceps,posterior vaginal speculum,aspiration syringe

Procedure

• Patient-lithotomy position
• Posterior lip of cervix-downwards and forwards with vulsellum forceps
• Speculum-retracts posterior vaginal wall
• Area disinfected
• Aspiration syringe inserted into the pouch and aspirated
• Done best in OT under full asceptic precautions and to proceed laproscopy/laprotomy if
indicated

HORMONAL ASSAYS

•ELISA

• Hormones assayed- FSH, LH, Prolactine, ACTH,T3,T4,TSH,progesterone, oestradio

,testosterone, aldosterone, cortisol, hCG, dehydroepiandrosterone, andostenedione

• Uses- Diagnosis of menopause, PCOD, prolactinemia Monitoring treatment regimes in

ovulation induction and AST

IMAGING TECHNIQUES-

X-RAY
 • Plain x ray chest and intravenous urogram- pelvic malignancy esp cervical cancer,prior to
staging.
• Plain x ray pelvis- To locate misplaced IUCD Visualize bone/teeth in benign cystic
teratoma
• Hysterosalpingography-to test tube patency, Intracavity uterine mass and mullerian
anomalies of uterus
• Lymphangiography-to locate lymph nodes involved in pelvic malignancy

ULTRASONOGRAPHY

• Simple,non invasive,painless,safe procedure

• Pelvis and lower abdomen scanned longitudinally and transversely
• D3 ultrasound-3-D images of pelvic organsTransabdominal sonography(TAS)-
• Done with transducer operating at 2.5-3.5Mhz
• Bladder full
• Large masses examination –ovarian tumour/fibroid

Transvaginal sonography(TVS)

• Probe placed close to organ

• High frequency waves used-5-8MHz
• No need of full bladder
• Detailed evaluation of pelvic organs possible
• Better image resolution but poor tissue penetration
• Difficulty in narrow vagina Transvaginal colour doppler sonography
• Information regarding blood flow to, from or within the uterus or adnexa

Diagnostic USG in gynaecology

• Infertility workup
 folliculometry-measurement of ovarian follicle diameter
 measurement of endometrial thickness
 evidence of ovulation-internal echoes and free fluid in pouch of douglas
 timing of ovulation-helps in ovulation induction, ovum retrieval
 sonographic guided oocyte retrtieval
• Ectopic pregnancy-tubal ring in adnexa with empty uterine cavity• Evaluation of pelvic
mass

ONCOLOGY-to assess vascularity of tumour and confirm malignancy

• Endometrial study in DUB

• Diagnose uterine pathology-fibroids,adenomyosis
• Location of misplaced IUD• Falloposcopy-to study medial end of tube
• Diagnose endometriosis
• To study ovarian pathology-PCOD,ovarian cyst,tumour
• Congenital anomalies of uterus• Diagnose adnexal mass

COMPUTED TOMOGRAPHY
 • Supplements information from USG
• Whole abdomen and pelvis visualised in one sitting after taking 600-800ml of a dilute
contrast medium 1 hour prior to procedure• Patient scanned in supine position
• Accurate in accesing local tumour invasion and enables accurate localisation in biopsy
• Diagnose pelvic vein thrombophlebitis, intraabdominal abcess and other extra genital
abnormalities
• Metastatic implants and lymphnodes < 1 cm—not detected
• Contraindicated in pregnancy

MAGNETIC RESONANCE IMAGING

• Well established cross sectional imaging modality

• High soft tissue contrast resolution without air/bone interference
• Limitations-cost,time,availability
• Indicated only when a sonar or CT fails to detect a lesion or to differntiate post-tratment
fibrosis or tumour5)Positron emission tomography(PET)
o To differentiate normal tissue from cancerous one based on the uptake of 18F-FLURO-
2DEOXYGLUCOSE

DIAGNOSTIC ENDOSCOPY-

• To visualize body cavityLapraroscopy-

• Diagnose uterine,tubal,ovarian,generalised diseases affecting pelvic organs-
endometriosis,PID,genital TB
• Staging of genital cancers
• Infertility workup
• a/c pelvic lesions-ectopic pregnancy,salphingitis etc

HYSTEROSCOPY

• Visualise endometrial cavity

• Diagnostic uses

o Unresponsive irregular uterine bleeding

 o Congenital uterine septum
o Missing threads of IUD
o Intrauterine adhesions
o Endometrial polyps/ malignant growth

SALPHINGOSCOPY AND FALLOPOSCOPY

• Visualise of fallopian tube

• Permits selection of patients for IVF rather than tubal surgery

CULDOSCOPY

• Visualise pelvic structures via an incision in pouch of Douglas

CYSTOSCOPY

• To evaluate cervical cancer prior to staging

• Investigate urinary symptoms- haematuria,incontinence and fistulae

PROCTOSCOPY AND SIGMOIDOSCOPY

• To evaluate rectal involvement in genital malignancy

INFERTILITY IN FEMALESTESTS FOR TUBAL PATENCY

• Hystero salpingography
• Laproscopic chromotubation
• Sonosalpingography
• Hysterofalloscopy
• Ampullary and fimbrial salpingography

TESTS FOR OVULATION

• Basal body temperature

• Examination of cervical mucus-fern test
• Ultrasound
• Hormonal assays-estrogen and progesterone

INFERTILITY IN MALES

• Semen analyisis
• Post-coital test-Sim’s test
• Sperm penetration test
• Semen-cervical mucus contact test
• Urine examination
• Patency of vas-vasogram
• Testicular biopsy
• Hormonal assays-FSH,LH,testosterone,prolactin• Chromosomal study
 • Immunological tests-ELISA, RIA
• Ultrasound scanning

PRE-OPERATIVE INVESTIGATIONS IN GYNAECOLOGY

o Complete blood count

o Urinalysis
o FBS,PPBS
o BT,CT
o Blood group and Rh factor
o RFT
o LFT
o Serology- VDRL
o Serum electrolytes-Na,K,Cl,HCO3
o Chest radiograph
o ECG
Nursing responsibilities in Gynaecological investigations

Nursing responsibilities in Surgical diagnostic Gynaecological investigations

 Explanation of the procedure
 Obtaining consent
 Preoperative management include NPM, clearance of bowel , antibiotic therapy fluid
management, immunization and reassurance
 Post operative management include- Stabilization of vitals ,pain management, fluid
management, prevention of infection, management of complications associated with anaesthesia
post opearative medications ,care of wound, Follow up
 Reassurance and Counselling

Conclusion:
Investigations has great diagnostic value and it is a guideline for further management also. But blind
reliance on investigation may give wrong results hence it must be correlated with clinical examination
and history of the client

REFERENCES:

1. Dutta D. C(2011),Text book of Obstetrics including Perinatology,7 th edition, New

central book agency(p) Ltd, 148-149.

2. Cooper M.A and Fraser D.M , Myles Text book forMidwives ,14th edition,Elsevier,

3. Dawn CS , Text book of Gynaecology 14 th edition, Dawn book stall ,Kolkata

4.www.amazon.com › ... › Medicine › Internal Medicine › Family Practice ,Practical Obstetrics
and Gynaecology Handbook: For the General Practitioner [Thiam ... as well as common
obstetrics and gynaecology (O&G) investigations

5. reference.sabinet.co.za/document/EJC79023,Knowledge of laboratory tests is critical to

clinical management. <BR>Preconception and antenatal screening is essential. <BR>Repr

6. pm.lsmuni.lt/data/studijoms/Obstetrics%20and%20gynaecology.pdf,May 22, 2006 – 5.31

Radiological investigations in obstetrics and gynaecology. (2 h). ...... The most common
benign breast disorders and their treatment

ASSIGNMENT ON
 COMMON INVESTIGATIONS IN
OBSTETRICS AND GYNAECOLOGY

Submitted to
Madam S.ROY
Govt College of Nursing, Burdwan

Submitted by
Anupama Jash
M. Sc Nursing 1st year
Govt College of Nursing, Burdwan