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Essential
Gynaecological Care
A guide for the trainee
Second Ed ition
Deepal S. Weerasekera
MS(O&G), FRCOG(GtBr), FRCS(Ed), FSLCOG
Professor of Obstetrics and Gynaecology
Sir John Kotelawala Defence University, Sri Lanka
Coµyright DeepJI s. Wecrasekera
r-irst published - 2015

2"d Edition - 2021
Printed by
Ananda Press
277, Hokandara Road,
Thalawathugoda, Sri Lanka
E-mail: anandapress65@gmail.com
ISBN 978-624-97573-0-1
Contents
Page No.
Preface
History taking and examination 1
Disorders of sex development 11
Infertility 16
Miscarriages 28
Gestational trophoblastic disease 32
Ectopic pregnancies 36
Amenorrhoea 42
Poly cystic ovarian syndrome 46
Dysmenorrhoea 50
Abnormal uterine bleeding 53
Genital tract infections 65
Pelvic inflammatory disease 72
Endometriosis 77
Ade nomyosis 84
Fibromyomata of uterus 86
Endometrial hyperplasia 95
Endometrial carcinoma 99
Benign and malignant ovarian tumours 104
Pre-malignant lesions of the genital tract 113
Colposcopy 123
Vulval malignanci s 126
Carcinoma o1 th cervix 129
Urinan incontinence in women 138
P Ivie organ prolapse 147
Menopause and HRT 156
Contracepti on
163
Acute abdomen
173
Hysterectomy
176
Laparoscopy in gynaecology
185
Pa lliative care in gynaecology
192
Index
194
History taking and examination
Introduction
You must ask all the relevant questions and yet still leave sufficient
time to organize your presentation and examine the patient. This means
that your history taking has to be slick and efficient.
Method
1. Take history in the same order each time to minimize errors of
omission.
2. Use simple, uncomplicated English.
3. DO NOT use any technical language (eg. vagina, cervix and uterus
are technical, anatomical terms).
4. Follow through each answer to its logical conclusion, be curious

eg. If the patient tells you that she has had a previous D & C find
out why was this done, did it affect her symptoms, did she
have any complications with the anaesthetic or the operation.
5. Ask questions in the same sequences as you will present them

to the examiner (see history presentation note).
6. If the history is complex explain to the patient exactly what is

it that you are trying to achieve.
7. Do not become cross with the patient or criticize the answers.
If you are having difficulty it is YOUR fault.
Typical questions
This is an example of a sequence of questioning that you might use
although of course there will be other questions depending upon the
answers given and in some cases some of the questions may be
inappropriate.
1. Introduce yourself, explain the tim e limitation and what you

are trying to achieve.

2. What is your full nnnw?
3. How old arc you?
4. Arc you m.:i 1ricd or do you have a stable relation~hip or do you
live on your own 7
s. How long have you been married/ How long you have been
together if not married?
6. Have you been married before?
7. How old were you when your periods first started?
8. When did your periods start to give you trouble?
9. When your periods were normal how long did they last for?
10. When your periods were normal how long was there between
the first day of one period and the first day of the next.
11. When they were normal were your periods heavy? In other
words did you pass any clots or have any flooding?
12. What type of sanitary protection do you use?
13. How many tampons/towels did you use for the whole period
when your periods were normal?
14. What is happening to your periods now?
15. What was the first day of your last menstrual period?
16. Was your last period any different from your previous periods?
17. Do you have any bleeding in between your periods.
18. Do you have any discharge?
19. Do you have any bleeding after intercourse?
20. Is there any associated pruritus?
There is so~e times an anxiety in listing a sexual history. The secret is

to ask s~ra1ghtforwa_rd questions in a matter of fact way. The subject
~ay be introduced in younger women by an inquiry about their love
life. Eg
1. Do either of you or your husband use any form of birth control?
2 Essential Gynaecological Care

2. Do you have any difficulties in intercourse.
3. So your husband/boy friend has no difficulties with his erection

and he always ejaculat es.
4. So you have no pain or soreness with intercou rse and no

bl eeding.
5. How frequently do you have intercourse?
Examination
General examination
Examine the patient always from the right side.
General examination is the first thing to do in the examination. Alw ays

get the consent of the patient for the examination. If the patient has
not passed urine recently always get her to pass urine before you start
the examination. Carryout the examination from top to bottom so
that you will not miss important findings. Frontal baldness or loss of
hair is important in patients with suspected virilization. Features on
the face such as facial oedema, signs of hirsutism, acne, chloasma etc.
Check tongue and the eyes for pallor and icterus.
Swellings and thyroid enlargement in the neck. Check for cervical,
posterior auricular and supraclavicular lymphadenopathy.
Check the fingers for clubbing, nails and palms for pallor, axillary
lymphadenopathy.
Breast examination is mandatory in the gynaecological patient.

Examine the lower limbs for oedema, varicosities etc.
Before you proceed to abdominal and pelvic examination do the
examination of the systems. Don't forget to check pulse, BP,
respiration, and the chest for signs of effusions.
Abdominal examination
Abdominal examination i s done in the usual way of inspection,
palpation, purcussion and auscultation.

Inspection
Inspect wheth r the abdomen moves with respiration, any distention,
hair distributi on, st riae, dilat ed veins and surgical scars specially
laparocsopic scars.
Palpation
This is the most important part of the abdominal examination. If an
abdominal lump is felt, you need to check the following features
1. Site - ask the patient to raise the head or legs to contract the
anterior abdominal wall muscles. If the lump is intra-abdominal
it becomes less prominent and any lump in the abdominal wall
will become more prominent. Describe the region of the
abdomen - left and right hypochondrium, epigastric, left and
right lateral, umbilical, left and right inguinal and suprapubic
region.
2. Size - usually gynaecological lumps are described as the size of
a corresponding pregnant uterus. Or else you can measure the
lump and tell in centimeters.
3. Shape - whether the lump is oval, round or any other shape.
4. Surface - is the surface smooth or irregular.
5. Consistency - soft, firm or hard.
6. Margins - whether irregular or regular. Check whether you can
get below the lump. In pelvic lumps you cannot get below the
lump.
7. Mobility - whether the lump is fixed or mobile. If mobile in
which axis?
8. Tenderness - When eliciting tenderness always look at the
patients face. If tender do not cause any discomfort to the
patient. Look for signs of guarding and rebound tenderness.
Palpate for any liver and spleen enlargement and for ballotable
kidneys.
4 Es sential Gynaecological Care

Percussion
Start percu ssing from thl' c , 1111 , of lhe t.1bdomen <-md come t ow ards
the flanks. If th , , , is .rny rl ank dulln ess check for shif t ing dullness.
A band of resonance over the lump may bc> an indication of an attached
loop of bowel to the lump. Percussing down from the epigatric area
helps to determine the upper border of a pelvic lump.
Auscultation
Check for vascular bruit, bowel sounds. Vascular bruit are heard in
abdominal aortic aneurisms, solid lumps attached to the aorta and in
vascular lumps such as haemangiomas.
Pelvic examination
Always before the pelvic examination make sure that the patient has
emptied the bladder.
Pelvic examination essentially consists of inspection and palpation.
This is done with the patient in the dorsal position.
Inspect the vulva for any discharges, hair distirbution, gaping of the
vulva, swellings or cysts such as Bartholin's cysts, signs of genital
prolapse by asking the patient to strain, ask the patient to cough and
check for any stress incontinence.
If the patient is unmarried rest of the examination should not be done
unless special consent is obtained. If indicated proceed to a rectal
examination.
Inspection of the vagina and cervix is done by using a speculum. If

there are no signs of prolapse Cusco's speculum is used. Cusco's
speculum is introduced transversely with the two fingers of the other
hand separating the labia. Always use a lubricant on the speculum.
Now inspect the cervix (Never rotate the speculum inside the vagina
as this will cause lot of discomfort and trauma).
Os - open, patulous or closed . Any discharges. Nabothian follicles,

erosions or ectropian.
Now remove the speculum while observing the vaginal walls.

Do the bimanual examinalion by lnlroducine thf' indPx und the middle
fingers of the right hand gently inlo lhc vaglm.1 and firmly pressing the
suprapubic area with the palm of the left hund. Feel the consistency of
the cervi - firm or soft.
Bimanual examination. Nabothian follicle with a

patulous os.
Feel the size of the uterus, position - anteverted, axial or retroverted.

Mobility and for any adnexal lumps or tenderness. Place your fingers
in the lateral fornices to feel the adnexal lumps. If you feel any adnexal
lumps try to find out whether it is fixed or separate from the uterus.
In a patient with genital prolapse Sim's speculum is used with the
patient in the left lateral position with the upper leg flexed (Sims
position) to demonstrate an enterocoele.
Per rectal examination (PR examination)

Per rectal examination also becomes a part of the gynaecology
examination when indicated in situations such as
in unmarried girls to assess a pelvic lump.

confirmation of a rectocoele.
in p:1ticmts with ut ~, in and ovarian malignancies to check for the
in\ioh, em nt of t he reclt1I muc:osa.
- to assess the tone of th 1
~rnal sphincter in patients with
incontinence.
Recto-vaginal examination
This part of the exam ination is done to assess the rectovaginal septum
and the parametrium in conditions such as endometriosis and cervical
cancers. When carrying out a rectovaginal examination middle finger
of the right hand is inserted into the rectum and the index finger of
the same hand is inserted into the vagina. Normally rectal and vaginal
fingers can be easily approximated without any difficulty. If there is
involvement of the parametrium and recto-vaginal septum leading to
infiltration and thickening the two fingers will not be able to
approximate.
Presentation
1. One sentence summary including name, age, occupation, nature
of presenting problem.
2. Past obstetric history.
3. Past gynaecological history.
4. Past medical and surgical history.

5. Family history.
6. Personal history.
7. History of the present complaint.
8. Menstrual history (if not included in the present complaint).

9. Contraception and sexual history.
10. Urinary history.
11. Two sentence summary including plan of management.
History laking and examination 7

Writing summaries
The summary at the beginning of a presentation is designed to set the
scene for examiners.
A typical gynaecological summary would be

"This is Mrs Gunawathie who is 45 years old clerk whose principle
problem is heavy, frequent periods". At the end of the presentation
include more details and information about the planned management.
In summary this is Mrs Gunawathie a 45 year old bank clerk who suffers
from heavy frequent periods. Pelvic examination has demonstrated
that she has a sixteen week size fibroid uterus and it is planned to
perform a total abdominal hysterectomy with conservation of both
ovaries tomorrow.
The problem list

The problem list is a way of demonstrating to the examiner that you
understand which features of a particular case are important risk factors
and to demonstrate your ability to put these in order of importance.
The problem list is only used when there is more than one problem. In
gynaecological case presentations it is not usually necessary to use a
problem list and the one or two problems can be enumerated in the
opening summary.
Differential diagnosis of a lump in the abdomen

1. Full bladder - always ensure that the patient has emptied the
bladder before the gynaecological examination. But in patients
with chronic retention of urine the bladder will remain full.
midline suprapubic swelling
margins well defined
soft in consistency
smooth surface
disappears after catheterization

2. Pregnancy - in a woman of reproductive age always be mindful of
pregnancy. History of amenorrhoea wil l not be present all the time.
midline suprapubic swelling
soft in consistency
fetal parts may be palpable
on vaginal examination cervix will feel soft
ultrasonography will confirm the diagnosis
3. Benign ovarian tumours - menstrua l history is usually normal.

Serous cysts, mucinous cysts, dermoids, endometr iomas are
common.
appear as su prapubic swellings extending to an iliac fossa
cystic or firm in consistency depending on the nature of the
cyst
well defined margins
- freely mobile
on bimanual examination, the uterus will feel separate from
the lump
4. Fibroids - could be asymptomatic or cause rnenorrhagia.

Commonly arise in the suprapubic area but can grow to other
areas of the abdomen, specially the pedunculated fibroids.
Firm in consistency
Smooth surface
Mobile from side to side (transverse axis)
Regular well defined margins
On vaginal examination the cervix feels firm and continuous
with the lump
5. Tubo-ovarian abscess - these could be sub-acute or chronic. Patients

complain of dysmenorrhea, lower abdominal pain, vaginal
discharge, fever and dyspareunia.
Lump appears in left or right iliac fossa and t ender to palpation.
Ill defined margins
History taking and examination

9
Irregular surface
Not mobile
On vaginal examination tender fornices
6. Ovarian
· carcinoma
· - advanced ovarian carcinomas can present as
.
an abdominal lump. Usually the patients will have dyspeptic
symptoms, abdominal puffiness and distension due to commonly
associated ascites.
Irregular in shape
Firm in consistency
Ill defined margins
Fixed and immobile
Accompanied ascites
Ultrasonography will show solid and cystic areas
7. Adenomyosis - the typical history is dysmenorrhoea and

menorrhagia.
Suprapubic lump
Oval in shape
Firm consistency
Regular magins
- Transversely mobile
Smooth surface
On vaginal examination cervix is firm and continuous with the

lump
8. Non gynaecological lumps - appendicular mass in the right iliac

fossa, inflammatory masses in the left iliac fossa due to diverticular
disease, loaded caecum or sigmoid due to chronic constipation
and bowel malignancies in caecum and descending colon can
present as abdominal lumps.
0
Disorders of sex development
The female reproductive system consists of the ovaries, tubes, uterus,

vagina and the external genitalia. Apart from the ovaries and the
external genitalia rest of the structures develop from the Mullerian
ducts (paramesonephric system). In the male reproductive system
develops from the Wolfian ducts (mesonephric system). Leydig cells
in the testis produce testosterone, which causes development of the
male reproductive organs, and the Sertoli cells in the testis produce
antimullerianhormone, which inhibits the development of mullerian
system. In the female Mullerian ducts meet in the midline and form
the fallopian tubes, uterus and the upper part of the vagina. The
urogenital sinus forms the lower part of the vagina.
During adolescence, sexual development and maturation occurs. In a

girl usually this occurs around the age of 8 or 9 years. During this period
hypothalamus starts secreting gonadotrophin releasing hormones
(GnRH), which in turn stimulates the pituitary to secrete gonado-
trophins. Gonadotrophins act on the ovaries to produce folliculo-
genesis. As a result, there will be an increase in the oestrogen levels
and this brings about the physical changes in the body. These are
1. Breast development
2. Pubic and axillary hair growth
3. Growth spurt
4. Onset of menstruation (menarche)

Usually menarche occurs around the ages of 12 or 13 and the
cycles in the first 3 to 4 years are irregular and anovulatory.
Precocious puberty
Onset of puberty before the age of 8 years is regarded as precocious
puberty. Hormone producing tumours should be considered in these
girls.

Central precocious puberty (CPP) is caused due to excess release of
GnRH, which subsequently increases the secretion of sex hormones,
luteinizing hormone (LH) and follicle stimulating hormone (FSH) by
gonadotrophin cells in the pituitary. Currently GnRH analogues are
considered as the drug of choice for the treatment of CPP. This
treatment causes reversible suppression of reproductive axis and also
adult height is preserved in treated children.
Delayed puberty
If secondary sexual characteristics do not occur by the age of 14 years
delayed puberty should be considered. This can be of two types.
1. Hypogonadotrophic hypogonadism - This is due to a central
defect and can be constitutional. Other causes are anorexia
nervosa, excessive exercise, chronic illnesses such as diabetes
and renal failure. Rare causes are pituitary tumours and
Kallmann's syndrome.
2. Hypergonadotrophic hypogonadism - In this condition primary

ovarian dysfunction occurs despite high levels of pituitary
gonadotrophin secretion. Turner's syndrome (XO) and XX
gonadal dysgenesis can cause this.
Chromosomal abnormalities
Turner syndrome
Results from a complete or partial absence of one X chromosome.

(45 XO) They have clinical features of short stature, webbing of the
neck, and a wide carrying angle. It is common to find coarctation of the
aorta, inflammatory bowel disease, conduction deafness and renal
anomalies in these patients. They have very streaky ovaries and do
n~t produce oestrogens. They present with delayed puberty and
primary amenorrhoea.
Testicular feminization syndrome
In this co~dition the karyotype is 46 XV. Phenotype is a well-developed

woman with normal breasts and minimal pubic hair. Undescended testis
12
Essential Gynaecological Care
can be eithe1 in th abdomi11t.1I cuvity or in the inguinal canal. These
testes need to be I emoved sur3lcc1lly becuuse of the risk of malignant
change.
Klinefelters syndrome
The karyotype is 47 XXV. The t ypi ca l picture is a tall, eunuchoid
individual with poor development of t he genitalia. The testis may be
either undescended or felt very sma ll.
XV gonadal dysgenesis
In this sit uat ion in spite of having XV chromosome pattern gonads do
not develop into testis. Therefore in the absence of anti mullerian
hormone (AM H) mullerian structures do not regress and t he vagina,
uterus and fallopian tubes develop. As a result the patient is pheno-
typical ly f emale with a XV chromosomic pattern. Patients present
usually w ith delayed puberty and amenorrhoea. The dysgenet ic gonads
have a high risk of malignancy and therefore needs removal, which
can be d one laparoscopically. These patients can be sta rted on
oestrogen and progesterone containing contraceptive pills t o induce
puberty and maintain withdrawal bleeding.
Androgen insensitivity syndrome

In complete androgen insensitivity syndrome (CAIS} virilizat ion of the
external genitalia does not occur. Their chromosomal pattern is XV.
These women w ill not have a vagina, uterus and f allopi an tubes
because AMH secreted by the testes will inhibit the development of
these structures. Since external genitalia do not undergo virilization
they appea r as female and the child is usually brought up as a female.
Presentation is usually at puberty with amenorrhoea and delayed
puberty and the testis are usually in t he inguinal canal and can be
associated with inguinal hernia. The management w ill be removal of
gonads and long-term hormone replacement therapy. Once t he patient
is about to get sexually active a neo vagina will have to be created. In
patients with partial androgen insensitivi ty th e chil d i s u sually
diagnosed at birth as ambiguous genitalia.

Congenital adrenal hyperplasia
This is usually due to a deficiency in 21-hydroxylase hormone, which
converts progesterone to deoxycorticosterone. This will lead to a
reduction in the levels of cortisol. As a result the negative feedback of
cortisol is removed resulting in over stimulation of the adrenal glands
leading to adrenal hyperplasia. This in turn leads to excessive pro-
duction of androgens and testosterone leading to virilization of the
external genitalia. The clitoris is enlarged and the labia fuses and appear
as a scrotum. In some patients the ability to produce aldosterone is
also affected and they are classified as the salt-losing type. These
children with CAH needs to be diagnosed as early as possible and
initiated on life long steroid replacement with hydrocortisone and
fludrocortisone for salt losers.
5-Alpha-reductase deficiency
These patients have a XY karyotype and normally functioning
testis, which produce both testosterone and AMH. However due to
the deficiency of 5-alpha-reductase the testosterone cannot be
converted to dihydrotestosterone in the peripheral tissue. Therefore
virilization does not take place. Presentation is usually with ambiguous
genitalia at birth. The testosterone levels are extremely high at
puberty.
lmperforate hymen
This is a condition where the hymen persists as a membrane and the
patients present with abdominal pain and primary amenorrhoea.
Secondary sexual development is completely normal. Abdominal
examination reveals a suprapubic lump, which is the haematometra
and distended vagina (haematocolpos) with menstrual blood. Vulval
examination will reveal a budging membrane at the entrance to the
vagina. The management is by making a cruciate shaped incision in the
membrane and let the blood come out on its own over the next few
days.

Other abnormalities of the Mullerian system
Developmenta l abnorma lities of the Mullerian system can lead to
various abnormalities of the vagina and the uterus. Some of the
congenital abnormalities that can arise are duplication of the uterus,
biconuate uterus, septate uterus and even double vagina. Mullerian
agenesis can cause absent uterus and upper vagina (Rokitansky
syndrome). These patients will have a very short blindly ending vagina
with functioning normal ovaries. Mclndoe's operation and William's
vulvo-vaginoplasty are the two co mmonly performed surgi cal
procedures in vaginal agenesis. The principle of the technique is to
create a space between the bladder and the rectum and to skin graft it
to prevent it from shrinking. After the creation of the neovagina the
woman should engage in regular sexual intercourse to make it a well
functioning vagina.
Note: Primary amenorrhoea is when a girl fails to menstruate by

16 years of age.
Secondary amenorrhoea is absence of menstruation for more than 6
months in a normal female of reproductive age that is not due to
pregnancy, lactation or menopause.

Infertility
Infertility generally affects about one in seven couples. The de~inition

of infertility varies considerably in relation to the leng~h of time of
regular unprotected intercourse. However individual circumstances
will differ and couples should generally be seen whenever they think
there is a problem. By definition infertility is inability to conceive after
two years of unprotected intercourse. It can be primary where the
woman has not been pregnant before or secondary in a woman who
has been pregnant before.
The initial management of a couple with subfertility

l. Both partners should be involved in the management of their
infertility.
2. A complete history and examination should be done.
3. Ensure that regular unprotected coitus takes place at least 2 to
3 times per week and that they are not having any coital
difficulties, such as vaginismus and premature ejaculation.
4. Look for features in the history suggestive of ovulation such as
regular cycles, dysmenorrhoea, mid cycle ovulatory pain, mid
cycle wetting etc.
5. A careful pelvic examination to assess the size of the uterus
and for any adnexal lumps or tenderness.
6. Examine the male partner for undescended testis, varicoceles etc.
7. The female partner should be offered rubella vaccination if
not vaccinated before.
8. Male partner should be advised to stop smoking and alcohol.
9. Overweight women should be advised on weight reduction.
10. Women should be prescribed folic acid as a supplement while
they are trying to conceive.
Investigations
Initial investigations should be to do a seminal fluid analysis on the

male and check for ovulation in the female.
The male should have one or two seminal fluid analysis performed.

Following advice should be given before collection of a sample.
• Ejaculate by masturbation and abstain ror three days before
giving the sample.
• Do not use condoms for collection of the sample.
• Collect the sample to a dry container.
• Mark the container clearly with the name, date and time of
collection.
• Deliver to the lab as quickly as possi ble.
WHO values to consider semen analysis as normal.
• Volume - 2-5 ml.
• Liquefaction time - 20-30 minutes.
• Concentration - more than 15 million /ml.
• Total sperms - more than 30 million per ejaculate.
• Motility - more than 50% progressive motility.
• Morphology - more than 4% normal forms.
Investigations to check for ovulation

• Day 21 serum progesterone
• Day 12 transvaginal ultrasound scan-this should show a mature
follicle of 18-22 mm
Mature follicle of 20 mm on day 12.
Infertility 17
Confirmation of the ovu lation can be done by repeating the
tranwaginal scan on day 14 or by urinary LH strips.
• Day 22 endometrial biopsy to look for secretory changes in the
endometrium. This is hardly performed for the purpose of
checking for ovulation in modern day gynaecology.
Evaluation of the endometrium

By day 12-14 endometrium should be ready for the implantation to
occur. This can be checked using transvaginal ultrasound scan. By day
12 the endometria l thickness should be 8 or more mms and the
trilaminar appearance should be present.
Endometrium showing the trilaminar appearance.
Investigations for tubal patency, evaluation of the uterine cavity and

pelvis
In a couple with normal ovulation and normal seminal fluid analysis if

the delay continues tubal patency tests should be considered.
1. Hysterocontrastsynography (HyCoSy) - through a fin e catheter
placed in the uteri ne cav ity sterile so no-opaque contrast
medium is injected with a transvaginal probe in place. Contrast

media can be seen distending the uterine cavity and spilling
into the Pouch of Douglas if thP tubes are pat~nt. This is a simple
test that can be done In the clinic room without anaesthesia.
2. Hystero-sa lphingography - This is usually done in the X-ray

room with fluoroscopic screening. The woman is sedated with
intravenous pethidine. A Leech-Wilkinson catheter is screwed
into the cervix and under fluoroscopic screening a radio-opaque
dye is injected. Always emergency tray should be ready as
anaphylaxis can occur to the radio-opaque dye. This test is
usually done in the first half of the cycle. The presence of any
pelvic inflammatory disease is a contraindication for a HSG.
This gives information about any cervical incompetence,
congenital abnormalities or submucus fibroids of the uterine
cavity, dilatations (hydrosalphinges) or any blocks in the tubes.
HyCoSy. Hysterosalphingography
3. Laparoscopy, hysteroscopy and dye insufflation - This is the

procedure of choice when an eva luation of the pelvis is also
required . In laparoscopy it is possible to visua lize the uterus,
tubes, ovaries and rest of the pelvis in addition to checking the
tubal patency. Hysteroscopy is performed at the same time to
evaluate the uterine cavity. Congenital anomalies of the cavity,
submucus fibroids, endometrial polyps, intrauterine adhesions
(Asherman sy ndrome) can be diagnosed by hysteroscopy.
Infertility 19
Dye insufflation is performed by placing a fine catheter in the
uterine cavity and injecting methylene blue dye. Dye can be
seen filling and spilling from the fimbrial ends of the tubes by
the laparoscopic camera. Also conditions such as pelvic
inflammatory disease and endometriosis can be easily
diagnosed by laparoscopy.
Normal uterine cavity. Septate cavity.
Intrauterine adhesions. Endometrial polyp.

Cervix with double os. Single uterine cavity.
Tubal adhesions. After releasing the tube.
Extensive adhesions due Adhesiolysis and tubal

to PIO. patency restored.
Infertility 21
Double uterus - left side. Double uterus - right side.
Management of subfertility
Management depends on the cause in most of the cases.
Subfertility due to anovulatory cycles

Commonest cause of anovulatory subfertility is Poly Cystic Ovarian
Syndrome (PCOS) and this accounts for almost 70-80% Qf anovulatory
infertility. Classical clinical features of this disease are oligo -
menorrhoea, obesity, hirsutism and infertility. Diagnosis of PCOS is
based on the presence of two out of following three criteria.
• Amenorrhoea/oligomenorrhoea
• Clinical or biochemical signs of hyperandrogenism
• Ultrasound appearance of the ovaries
In this condition multiple follicles develop, but possibly due to thick

ovarian capsule they do not rupture. As a result there is unopposed
oestrogen activity on the endometrium causing irregular uterine
bleeding with periods of amenorrhoea. On transvaginal ultra-
sonography the ovaries appear enlarged with numerous small antral
follicles on the periphery, which is described as the 'cartwheel
appearance'. Usually more than 10 follicles of diameters varying from
2-8 mm are seen. Majority of women with PCOS also develop insulin
resistance and as a result a compensatory hyperinsulinemia state
develops.
22
Essential Gynsecologlcsl care
Appearance of the ovary in Laparoscopic ovarian drilling.
PCOS.
In these patients LH/FSH ratio is abnormally high (2:1 or more) and

also their serum androgen levels are elevated. PCOS patients with
infertility are initially treated with ovulation induction therapy such
as clomiphene citrate 50-150 mgs daily from day 2 to day 6 of the cycle.
Metformin is also commonly used in the management of infertile
patients with PCOS, but there is no clear evidence to support its use.
Metformin is commonly used in PCOS patients with hyperinsuli -
naemia. Monitoring of the ovulation is done by doing a transvaginal
scan on day 12. If the ovulation is satisfactory (a dominant follicle of
18-22 mm in size is seen) ovulation triggering is done by giving hCG or
rLH intramuscularly. The couple is then advised to have timed
intercourse or intra uterine insemination (IUI). IUI can be done either
as a single procedure 36 hours after the hCG triggering or as a double
procedure 24 and 48 hours later. Letrazole and tamoxifen are the other
medications that can be used if clomiphene is not successful. If
anovulation persists in spite of this treatment ovulation induction can
be attempted with gonadotropins or laparoscopic ovarian drilling can
be performed. Ovarian Hyperstim ulation Syndrome (OHSS) and
multiple pregnancies are risk factors in treatment with gonadotropins.
In majority of patients mono-ovulation occurs following laparoscopic
ovarian drilling and therefore the risk of OHSS and multiple pregnancies
can be avoided . Long-term effects of PCOS include development of
hypertension, hypercholesterolemia, increased risk of cardiovascular
disease and endometrial hyperplasia and carcinoma.
In fertility 23
If the woman is having hyperprolactinemia they present with
galactorrhoea and amenorrhoea . Treatment with bromocri ptine is
usually successfu l in these patients. If the cause of the hyperpro-
lactinaemia is a macroadenoma of the pituitary neurosurgical opinion
should be taken regarding surgical removal of the adenoma. A CT or
MRI of the pituitary fossa has to be performed to diagnose this. In
microadenomas the treatment is bromocriptine. Bromocriptine is
effective in regulating menses, restoring ovu lation, suppressing
galactorrhoea and achieving pregnancy. Cabergoline is another drug
that can be used instead of bromocriptine.
In women with irregular periods due to thyroid abnormalities these

should be corrected with appropriate replacement therapy.
In patients with blocked tubes tubal patency should be established.

Tubal surgery is performed in these patients depending on the
condition of the tubes. In patients with endometriosis and pelvic
inflammatory disease peritubal adhesions can cause impaired tubal
motility and even tubal obstruction. Division of adhesion s
(adhesiolysis} which can be done either by laparoscopy or open surgery
may help these patients to restore tubal motility and tubal patency.
Tubal sterilization reversal can be done by reanastomosis of the
previously resected two ends of the tubes . When a patient gets
pregnant after tubal surgery ectopic pregnancy should be excluded as
early as possible since the risk is very high.
In c?~ples with oligospermia (low sperm counts) and poor sperm

motility (asthenospermia) intra uterine insemination with prepared
conce~trated sperm samples is the method of choice of treatment
For ollgospermic men various drugs such as clomiphene citrate
testosterone, has been tried without much success.
In c~upl~s wit~ hostile cervical mucus (negative post coital test) intra
~t:;~:~ '::~nmina~ion _with husband's sperms can be done. In this
sperms are d! a f~ne i~tra uterine insemination catheter, wa shed
Th f posited in the uterine cavity beyond the endocerVlll·
ere ore sperms do not com · s
Density gradient method and ~ into contact with cervical mucut~
prepare the sperms. swim up method are used commonlY
24 care
Essential Gynaecological
Washed
Sperm
Principle of JUI.
JUI catheter.
Procedure of doing an IUI

• Patient should be in the lithotomy position.
• Vulva and vagina is cleaned with normal saline.
• Aseptic precautions are taken and the patient is covered with
clean sterile towels.
• A Cusco's speculum is inserted to visualize the cervi x.
• The washed sperm sample should be identified and drawn into
the IUI catheter.
Infertili ty 25
. theter through the
• Gently introduce the tip of the IUI ca .
endocervical canal into the uterine cavity.
. th uterine cavity.
• Release the washed sperms into e
d the speculum.
• Slowly withdraw the IUI catheter an ..
. . he dorsal pos1t1on for
• Patient should be asked to remain in t
20-30 minutes.
. . 'I' lation induction with
In patients with unex pl aine d rnfert 1 ity ovu f onceiving If
. . . . the chances o c ·
clomiphene citrat e is t ried to improve I t·on w·1th
. d at e supe r ovu a 1
the response to clomiph ene 1s not a equ .
. /LH) be tried This treatment
human chorionic gonadotrophrns (FSH can · f h . k f
·t · because o t e ns o
has to be given under ve ry close moni orrng
• OHSS the ovaries can become
ovarian hyperst imulat1on syndrome. 1n . .
great ly enlarged with large ovarian cysts associated ~ 1th a~cites _and
also hydrothorax. The patient will develop abdominal di ste~tion,
vomiting and reduced urine output. This is due to extravasat1on of
fluid from the intravascular to extravascular compartment. Careful fluid
management of the patient is extremely important in these patients.
IVF and ICSI

Th is is recommended when all other treatment methods fail. Super
ovulation is done by using gonadotrophins and the ova are aspirated
using ultrasound guidance. This procedure can be done either under
general anaesthesia or under sedation of the mother. Aspirated fluid
from the follicles contain ova. This follicular fluid is immediately t rans-
ferred to the embryologist who will recover the ova. In IVF prepared
sperms are deposited on to the ovum expecting natural fertilization
In intra cytoplasmic sperm injection (ICSI) sperm DNA is injected into
the ovum. In both methods embryo is developed in culture media anc
incubated in the laboratory. The fertilized embryos are the n
transferred in to the uterine cavity for implantation usually on day 3 o
day 5. Embryo transfer is done under ultrasound guidance using an
embryo transfer catheter. No anaesthesia is necessary for embryo
transfers.
26 Essential Gynaecological ca
!VF - sperms are deposited. /CS/ - sperm is injected.
Day 3 embryo 6-8 cells. Embryo transfer under USS

guidance.
Infertility 27
Miscarriages
Miscarriage is spontaneous terminati on or threat at termination of

pregnancy before t he 28'" week of pregna ncy. In developed ~ountrie~
t his is taken as 24 weeks. Most of the misca rriages take place rn t he 1s
trimester. Al l pregnancies have a ri sk of about 10-20% to end in a
miscarriage. This risk decreases to 3% once the fet al hea rt is demons-
trated. With the advanci ng maternal age the risk of misca rriage also
th
increases. Majority of miscarriages occur before the 12 w eek. More
than 70% of miscarriages in the 1st trimester are due to chromosomal
an euploidies.
Threatened miscarriage - Patient presents with vaginal bleeding in a
viable pregnancy. On transvagi nal ult rasou nd examination f etal
heartbeat can be demonst rated if the period of gestation is more than
6 weeks. The management consists of rest and progest erone treatment.
Progesterone can be given orally, vagi nal or rectal suppositories or by
intramuscular injections.
Inevitable miscarriage - Although t he fetus is viable the progression
of the miscarriage is unstoppable. The os is open and t he f etal contents
are bulging.
Incomplete miscarriage - Patient usually present with more intense
pain and bleeding. On exam ination os is open and some pa rts of
concept ion is already out. Ultrasound scan shows retained prod ucts of
conception within the uterine cavity.
Septic miscarriage-When retained products get infected this is t ermed

as_ a se~tic miscarriage. Th is usually occurs in criminal o r induced
miscarriages.
Co~plete ~is~arri~ge - All the products get expelled from the uterine
cavity. Patients pain and bleeding subsides.
Missed mi~carriage - The fetus has already died in utero. Patient

presents with brownish vaginal discharge.
Blighted ovum - Only the t .
t issue inside t he gestationg::c~t1onal sac is formed . There are no feta
28 Essential Gynaecological care

Management of a patient with miscarriage Patients with
miscarriages can have prof us bleeding. During the Initial management
pulse. BP and temper atur l' should be recorded. A full blood count,
blood group and cross matching should be done If the bleeding Is heavy
In patients with heavy bleeding even blood transfu sion may be
necessary. Ultrasonography is mandatory in deciding the definitive
management of the patient. In a patient with heavy bleeding and
suspected of an incomplete miscarriage a speculum examination
should be done and if retained products are visible at the os t his can
be removed using a sponge forceps. This alone can relieve the patient
of the pain and reduce bleeding. Further management can be either
surgical or medical.
Surgical- Evacuat ion of retained products of conception is done in the

operating theatre under general anaesthesia. Suction curette is
commonly used. The risk of this procedure is uterine perforation. Use
of ultrasonography to visualize the curette can minimize this.
Medical management - Medical management has become more

popular during the recent years. The main pharmacological agents used
include prostaglandins (misoprostol, gemeprost) used alone or in
combination with the anti-progesterone mifepristone. Misoprostol is
given either sublingually or vaginally. Mifepristone is a progesterone
antagonist and is very effective in medical management of a mis-
carriage. This can be combined with misoprostol. If the patient is septic
intravenous broad-spectrum antibiotics should be administered.
2nd trimester miscarriages

Second trimester miscarriages contribute to less than 4% of all
miscarriages. An important cause of second trimester miscarriage is
cervical incompetence. Usually miscarriages due to cervical
incompetence are painless. The patient aborts with the entire sac. In
subsequent pregnancies the duration of the pregnancy becomes
shorter before it miscarries. Iatrogenic causes such as cervical biopsies,
dilatation and curettage, cervical tears during previous deliveries can
lead to cervica l incompetence. In a patient suspected of cervica l
Miscarriages 29
incornpetence t1 ansvaginal monitoring of the cervical length should
be done vi.:, y closely. If the cervix shows signs of opening up and
shortening, ce, vical ce1 clage should be considered . There are two types
of ervical titches
1. MacDonald's stitch - The stitch is put from the vagina at the
highest accessible level of the cervix.
2. Shirodkars stitch - Needs dissection suprapubically and the
stitch is applied at the level of the internal os.
Cervical Cerclage Procedure
The su ure being plac~d Cervic I canal narrowed

around the open cervix after tying the string
Recurrent miscarriages
When three or more consecutive miscarriages occur in one woma n
this is termed as recurrent miscarriage. Immunological causes such as
systemic lupus erythematosis, chromosomal abnormalities, uterine
cavity deformities, luteal phase defect and unexplained causes ca n
cause this.

Following investigations are done in a prJtient with recurrent
miscarriages
Peripheral blood karyotyping in both partners
Karyotyplng of all fetal products
Pelvic ultrasound scan to assess the uterine cavity
- Screening for antiphospholipid antibodies {lupus anticoagulant
and anticard iolipin anti bodies)
Principles of management
If t he immunological tests are positive treatment with low dose aspirin
and low molecular weight heparin has been shown to be beneficial.
In women with recurrent miscarriages due to a uterine septum,

submucus fibroids and arcuate uterus can undergo corrective
hysteroscopic surgery.
Couples with abnormalities with the karyotyping can be referred to a
clinical geneticist.
In women with luteal phase defect administration of progesterone
may be beneficial.
Couples with otherwise unexplained recurrent miscarriages should
be counseled regarding the potential for successful pregnancy without
treatment.
M/1c1rr/1gea 31
Gestational trophoblastic disease
WHO Classification
GTD
Premalignant Diseases
• Complete Hydatidiform Mole (CM)
• Partial Hydatidiform Mole (PM)
Malignant Diseases (Gestational Troph obl astic Neoplasia)
Non metastatic
• Invasive Mole
• Placental site trophoblastic tumour (PSTT)
• Epitheloid tumour
Metastatic
• Gestational Choriocarcinoma
A simple vesicular mole is known as a hydatidiform mole. In this

condition the trophoblast shows marked proliferation and the embryo
dies at an early stage and is not seen. The chorionic villi undergo
hydropic degeneration and shows gross oedema. Hydatidiform mole
can be subdivided into complete mole and partial mole. In complete
mole the karyotype is 46xx or 46xy. In partial mole it is 69xxy or 69xyy
due to an extra haploid set of paternal origin. In partial mole part of
the embryo is formed and the rest of the trophoblast undergo molar
changes.
Invasive mole - in this condition chorionic villi become more active

and deeply invades the maternal tissue.
Choriocarcinoma - in this condition chorionic villi undergo malignant

change.
Patients with molar pregnancies present with a history of bleeding in

early pregnancy and typically they may even say that vesicles have

been passed. Hyperemesis gravidarum and hyperthyroidi sm can be
associated. Pre-eclampsia is observed in about 25% of patients.
Hyperthyroidism occurs in about 5% of patients.
On examination the uterine fundus palpates more than the period of

amenorrhoea. Ultrasound scan shows the typical "snow storm"
appearance. Bilateral theca-luteal cysts are usually present in majority
of patients. These cysts develop due to high hCG levels and undergo
spontaneous regression after evacuation of the mole. Increased use
of ultrasound in early pregnancy has led to diagnosis of molar
pregnancies when the patient is still asymptomatic.
Snow storm appearance in a vesicular mole.
In evacuating a mole an oxytocin drip (20 units in 500 ml of saline)

should be started and once the uterine contractions are established
the patient is taken to the operating theatre and suction evacuation of
the mole is performed. After evacuation the patient should be
followed-up with regular serum beta hCG levels. The patient should
be seen weekly until the serum beta-hCG levels become normal. Also
the patients should be examined for vaginal nodules, regression of
the size of the uterus and disappearance of theca-luteal cysts.

Thereafter the patient is seen two weekly for another 3 months and
monthly for anothe1 9 months. /\s a contraceptive method patients
are advised to use a ba11 le1 method. Orn I contrnceptiv(l pills should be
avoided until the serum beta hCG levels return to normal, and the
progesterone preparations should be avoided as they cause irregular
bleeding, and IUD also is best avoided.
More than 80% of moles are benign. Outcome after treatment is very
good. Pregnancy after evacuation shoul d be avoided for at least 12
months.
Almost 10-15% of moles develop into invasive moles. This condition is

also known as persist ent trophoblastic disease. The molar tissue invades
deep into the myomet rial tissue. This can sometim es lead to uterine
perforation and intraperitoneal bleeding.
Placental site tumours are very rare and can follow any type of
pregnancy. It is composed of only cytotrophoblast cells. Syncytial cells,
which produce hCG, are absent. Therefore the serum beta hCG levels
are very low. Diagnosis is by curettage and histological examination.
After evacuation of a vesicular mole the patient has to be followed-up
with seru m beta hCG levels. If this level is rising, curettage of the
cavity is done for histological confirmation of the condition. Chemo-
therapy is the essential treatment. Methotrexate is used either alone
or in combination with actinomycin D and other cytotoxic age nts.
Hysterectomy is not recommended routinely but should be considered
in resistant disease and if there is severe haemorrhage.
Invasive mole
In invasive mole villus formation is preserved but the trophoblast cells

invade the myometrium and blood vessels. These penetrating villi
can cause severe haemorrhage. The invasion is usually local and it has
no metastatic potential. Invasive mole is less malignant t han
choriocarcinoma. Management is with methotrexate follow ing
evacuation. Hysterectomy has to be considered in patients with no
fertility wishes and in uncontrollable bleeding after evacuation.
Diagnosis is made by the histological examination of the hysterectomY
specimen.

Choriocarcinoma
2-3% of molar pregnancies ca n progress into choriocarcinoma.
Choriocarcinoma can also occur fallowing t1 pregmmcy or miscarriage
rarely. Choriocarcinomatous tic_,~ue Is very fri,1ble irnd invades the wall
of the uterus.
Usually the patients present with continued irregular bleeding

following evacuation of a mole or a miscarriage. Sometimes chorio-
carcinoma can present with vaginal metastasis. The commonest site is
introitus and suburethral in position. It will appear as a bluish nodule.
In choriocarcinoma both ovaries enlarge with theca-lutein cysts formed
as a result of high levels of chorionic gonadotropins from tumour cells.
Blood born secondary spread can occur to lungs, brain, liver, and bones
out of which lungs are the commonest. "Cannon ball" lesions on chest
X ray is typical of choriocarcinoma.
The mainstay of treatment of chorio_carcinoma is chemotherapy.

Chemotherapy consists of methotrexate in combination with other
agents. Routine hysterectomy is not indicated in choriocarcinoma but
becomes necessary in resistant disease or in severe haemorrhage.
Vaginal metastatic deposits. Cannon ball lesions.

ctopi pr gnanci
B • definition ltopi pr 'gn.mcy Is il prcgmrncy occurring outside the

ut rin cavity. H '\te, otopic pregnancy is simultanPous developmf'nt
oft\ o pr gnancies one inside and the other outside the uterine CdVtty
Corr,mon sites of ectopic pregnancies are fa ll opian tubes, ovaries dnd
peritoneal cavity. In the fallopian tubes 80% of ectopics occur in the
ampulla and about 15% in the isthmus and fimbrial end and the rest in
other sites.
~ ctopic Pregnancy I
80% Ampull
Ov
Cervix I
Sites of ectopic pregnancy.
Risk factors for ectopic pregnancies are

1. Pelvic inflammatory disease
2. Previous ectopic pregnancy
3. Previous tubal surgery
4. Pregnancies following treatment for subfertility
5. Pregnancies despite having an IUCD in-situ
,rl
36 Essential Gynaecological
In early stages patients present with lowP.r abdomln<1I discomfort ancl
blood stained discha, ge in P,11 ly JHCftn,mc.y, /\ period of amenorrhoea
is not always seen. On t'><nmin,lllon putlc>nts will have lower abdominal
tenderness. Bimanua l examlnt1tlon wi ll rc>V(1 r1I tenderness in the
fornices and cervical excitation pain. lrans vaginal ultrasonograph/ 1s
very useful in making the diagnosis. Uterine cavity will be empty and
an ectopic sac may be located in t he adnexae. Presence of blood in the
Pouch of Douglas can be easily noted on trans vaginal sonography.
Ectopic pregnancy seen in a TVUSS.
Usually by transvaginal ultrasonography an intrauterin e gestat ion sac

should be identified by 4-5 weeks of the pregnancy. The corresponding
serum beta hCG level should be around 1500 mlU/ml by this st age. If
there is no intrauterine pregnancy sac immediate serum beta hCG
should be done. If there is a discrepancy between beta hCG levels and
ultrasound appearance an ectopic pregnancy has to be excluded. In a
normal pregnancy serum beta hCG levels should double every 48 hours.
In patients with ectopic pregnancies this rise is suboptimal. If this is
positive the suspicion of an ectopic pregnancy will be very high. In a
clinically stable patient serum beta hCG levels could be repeated after
48 hours. If this shows a significant increase and still the uterine cavity
is empty on vaginal ultrasonography a laparoscopy should be
performed to exclude an ectopic. The histological changes that take
place in t he decidua in an ectopic pregnancy are termed as "Arias-
Stella" reaction.
Rarely an ectopic could rupture and patient may present as an acute

emergency. Abdomen will be tense and tender depending on the
amount of blood in the peritoneal cavity. Patient also may complain of
shoulder tip pain. In such a patient an immediate wide bore cannula
should be inserted and blood should be sent for urgent cross matching.
Patient should be prepared for emergency laparotomy. In a patient
who presents with acute abdominal pain the other conditions which
needs to be considered in the differential diagnosis are
• Gynaecological conditions such as acute pelvic inflammatory

disease, tuba ovarian abscess
• Haemorrhage or torsion of an ovarian cyst
• Gastrointestinal causes such as appendicitis, bowel obstruction
or diverticulitis
• Genitourinary such as cystitis or pyelonephritis
• Musculoskeletal such as abdominal wall haematomas
Surgical management - If the patient is haemodynamically stable

surgical management is almost always laparoscopic. If the tube is
already ruptured a salpingectomy is done. In a patient with an
unruptured tube the surgical method will depend on the state of the
contralateral tube. If the other tube is normal procedure of choice will
be to perform a salpingectomy. If the other tube is absent or diseased
then a salphingostomy should be done. In this procedure the tube is
incised and products of conception are removed through the incision
conserving the tube. Recurrence of an ectopic is high after
salphingostomy.

Medical management In unrupturecl ectoplt s rn edlc;t1I management
can be considered in following situations
1. Patients with one fallopian tube

2. Cornual pregnancy
3. Persistent trop hoblastic disease

4. Patients w ho refuse surgery
For t he patient to be managed medically follow ing criteria should be

fulfi lled
1. M i nimal symptoms
2. Adnexa l mass of less than 4 ems in diameter.
3. Serum hCG concentration less than 3000 iu/I
Medical management is done using methotrexate. This inhibits DNA

synthesis in trophoblastic cells. This is given by intramuscular injection
in a dose based on patients body surface area {50mg/m 2) . If medical
management is done the patient should be followed up with serial
beta hCG levels and vaginal ultrasonography. The hCG should be
measured on day 4, 7 and 11 and weekly thereafter until it becomes
undetectable. The level should fall by 15% between day 4 and 7.
Contraindications for medical therapy are
1. Chronic liver, renal or haematological disorders
2. Immunodeficiency
3. Infections
4. Breast feeding
Patients should be advised to avoid getting pregnant for 3 months

following methotrexate treatment.
Unrup tured right ectopic. Slow leaking ectopic.
Laparoscopic excision. After laparoscopic excision.
Ectopic f etus inside a tubal mole.

__,,,,,,.
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"Allt".
Luba teg en stund, hennes strålande ögon sökte hans, men det
var för mörkt, hon kunde icke skönja något.
"Svär att du är obefläckad — — — inför människor", sade hon,

"svär, så att jag får falla ned och dyrka dig!"
Pastorn kysste henne. Eder väkslades och togos. Skymningen

väkste, månen steg upp och lyste in i rummet. En bred, hvitblå stråle
silade sig in mellan rullgardinerna, strödde sitt sken på byrån med
dess porslinsprydnader, föll som ett regn af matt silfver på mattan,
och målade Lubas nu uppbäddade säng skimrande hvit som ett
altare.
De talade ej mer om dessa allvarliga saker. Pastorn hade sakta

fört samtalet på en angenämare stråt. Han var musikalisk och hade
kommit in i en vekare stämning, talade om sin ungdoms favoritvisor,
och gnolade de vackraste.
Luba var hänryckt. I öfversvinnlig dyrkan såg hon upp till honom
där han nu satt bredvid henne — — en oändlig tacksamhetskänsla
fyllde hennes själ.
"Ja", hviskade hon, — "Gud har skapat oss för hvarann".
Pastorn sjöng "Kristallen den fina" och tryckte henne i sina armar
vid refrängen "Du ädla ros och förgyllande skrin".
Hon lutade sig bakåt i sin stol, knäppte sina händer och önskade
att tiden måtte stanna… att intet måtte bli annorlunda — — att hon
finge dö just nu.
Nej — nej — hon ville vidare. Vidare. Lefva mer. Lefva mycket.
Lefva, bara lefva — med honom. Hon hade ju lidit nog, gjort bot, —
— lifvet hade ju gifvit henne bara lidande. Nu var hennes dag!
Nu skulle hennes tur komma.
Lefva, lefva!
Månen sken allt klarare, gjöt sin glans öfver dem och förskönade
dem, gaf dem ett skimmer af poesi och skänkte denna stund en
stämning af äkta lycka som ingen af dem kännt förut.
Och de trodde sig kunna börja ett lif tillsammans, ett lif i sällhet.
Det ringde ånyo och syster Lina kom hem.
Lämmenen hade aldrig ätit med mer aptit än i kväll. Linas lilla supé
var förträfflig — och ingen kunde göra en så bra skinkomelett som
hon. Den skulle Luba lära — — naturligtvis.
17.
LUBA GIFT.
Ännu in i April var där kvar en mängd is på skuggställena. Inne i

staden kunde man möjligen använda hjuldon men ute på landet
åktes för det mesta med släde.
Det unga paret skulle ut och åka för första gången. Pastorskan
Lämmenen kunde icke begagna sig af vagn eller droska, det skulle
skakat alldeles för mycket, så ojemna som gatorna ännu voro, men
doktorn hade gifvit lof att hon skulle få försöka den friska luften,
åkande i släde.
Sakta hade man förberedt detta, först fick hon några minuter stå
vid ett öppet fönster, sedan kom hon ut på trappan och tilläts att en
stund, sittande i en stol, inandas den ännu vinterklädda vårens första
milda fläktar.
Straks efter bröllopet blef hon svagare, — man fruktade ett återfall.
Hon hade kanske öfveransträngt sig en smula vid flyttningen till det
nya hemmet… dit hon hade transporterats i bärstol eller kanske
hade glädjen tagit på henne för mycket! Alltjemt öfverretad och
eksentrisk gladde henne allt detta nya i så hög grad att hon ofta, just
efter det hon skrattat af förtjusning brast ut i gråt, och snyftade tills
hon somnade.
Förvånad och orolig öfver dessa alldeles icke helgonlika små

humörer, aflägsnade sig Lämmenen, med hufvudet fullt af farhågor,
han förstod intet af allt detta.
Han hade trott sig blifva gift med den heliga Caecilia sjelf, med en
kristen martyr i samma stil som dem hans gamla kyrkohistoria
berättat om, och han fann en människa, därtill en rätt komplicerad
natur i hvilken tillika med hälsan en mängd nycker uppvaknade, en
massa nya fordringar, en hop känslor, tycken, ja passioner som han
icke alls kunde manövrera med, och helst ville gå ur vägen för, så
länge som möjligt.
När han på tal om sitt föregående lif anförtrodde sin unga hustru
ett och annat af det han ej velat förtro bruden, blef hon orolig, — grät
och förhäfde sig öfver världens ondska — — — vid några och trettio
år hade hon ännu en adertonårings hela osanna föreställningar om
lifvet.
Luba var mycket ömtålig på denna punkt, hon hade så gärna velat
vara den enda riktiga, och pastors berättelser lugnade henne endast
till hälften.
En annan gång på tal om det förflutna kom pastorn i förbigående

att tala om en tjenstekvinna, en halffånig skräddaredotter som hängt
sig på honom med sin dyrkan… en besvärlig person som han dock
ej haft hjärta att stöta bort utan antagit i sin tjenst. Det var en
stackars naturmänniska som hade svårt att skilja själasörjaren från
sjelfva gudaväsendet. Pastorn tyckte synd om henne, Gud vet hvad
det blifvit af henne nu… Hon hade varit par är i hans hus.
Luba våndades då hon hörde denna berättelse. Det var ju intet

ondt, ingalunda nej! historien var ju alldeles oskyldig, men — — —
det var ändå något dervid som pinade henne…
Visst var han ju likafullt hennes idealmänniska, visst var han

hennes apostel, hennes lekamliggjorda Kristusbild, men — — — der
var något som gnagde, något med hans förtid som hon icke tyckte
om.
Det hade gått ur hennes minne, hurudan hon sjelf varit, och hon
ville absolut att han skulle vara det han inför henne gjort sig till, än
mer sådan hennes fantasi skapat honom, den upphöjde, den kristligt
renhjertade, den fullkomlige, den oberörde.
Hon ville blott älska det fullkomliga, och hon fordrade att kunna tro
på honom som på ett öfvermänskligt väsen.
Hennes farhågor förstod han dock snart att jaga på flykten.
Han drog fram hela sin rika arsenal af bibelspråk, originela

liknelser, bizarra theologiska bilder, och med deras tillhjelp lyckades
han öfvertyga henne att allt var som det borde och som hon ville ha
det.
Men mer än af allt annat öfvertygades hon af hans kyssar och

omfamningar. Först när hon nästan försvann i hans stora armar blef
hon lugn och njöt af sitt lif så intensivt som blott den förstår att njuta
som länge lidit.
Hon lefde i ständigt väkslando stämningar, glädje och oro följde

ofta tätt på hvarann, omotiveradt gret eller skrattade hon, svag som
en flägt tordes hon ej sysselsätta sig med något arbete — — —
dagarne kommo och gingo utan att det uppstod någon allvarligare
förändring.
Ju längre det led desto mer flegmatisk och hvardagsaktig blef

mannen. Det var som om hans riktiga natur först nu, då han
ingenting mer hade att bråka för, kommit fram. Och han såg med
oförställd förvåning på sin hustru hvars lynne skiftade i lika många
olika brytningar som det var timmar på dagen.
Nu skulle hon alltså ut, och det var visst sista dagen man kunde
åka med släde. Ehuru vintern varat längre än eljes i mannaminne,
skrapade medarne redan hårdt i och det fastän kusken försigtigt
körde på de sista resterna af vinterns drifvor.
Luften var härlig, ifrån hafvet spelade en frisk, ljum bris, och när de
nådde Brunnsparken kastade Luba tillbaka floret som betäckt
hennes ansigte för att se sig omkring. Hon hade glömt hur det såg
ut, alltsammans. Detta var således bärg, riktiga bärg, skönare, högre
större, än hon mindes från fordom.
Och så såg då vägen ut — — stenar, buskar, träd! allting så

vackert, så fritt, så annorlunda än gatan därhemma.
Rundtomkring dem, inne i parken stodo granar och tallar gröna;

hvitstammiga björkar vajade sina fina löflösa grenar sakta för
luftningen — — undrande betraktade hon allt, med vidtuppspärrade
ögon, medan munnen begärligt sög in den starka, saltmängda luften.
Och fåglarne! Att så små väsen kunde föra ett sådant lif! De pepo,
flögo af och an, kvittrade och hoppade, hon hade nästan glömt att
det fanns annat än damgrå sparfvar och grannens kanariefogel som
hon bara hörde men aldrig såg, ibland när hon hade fönstret uppe
för att vädra en smula.
De mossiga tufvorna med en fläck snö här och där förtjusade

henne, hon kunde aldrig tro att de voro så starkt gröna… och att
naturen härute var så vacker…
Naturn, ja naturn. Detta var då naturn! Guds sköna härliga natur!
Hänryckt betraktade hon allt. Hon kunde ej tala, hon sög luftens
kraft, men det öfverväldigade henne så hon nästan icke kunde bära
det allt på engång. För ett ögonblick måste hon sluta ögonen och
hämta sig.
Lämmenen satt och tänkte på sin predikan. Den gjorde honom
stort hufvudbry, han hade nu under det år han varit i Helsingfors sagt
näranog allt hvad han hade att säga — — — hade uttömt sitt
närvarande förråd af god modelltheologisk material och visste ej
hvad nytt han skulle skaffa sig.
Släden körde förbi badhuset vid Ulrikasborg. Där var hafvet, vidt
och oändligt. Mellan staden och Sveaborg låg ännu isen bitvis,
endast här och där arbetade sig vattnet fram i breda rännor. Gråblått
och daskigt i färgen, poröst och svagt såg det återstående istäcket
ut, men borta, på andra sidan fästningen syntes det öppna blå. Och
en mängd hvita segel lågo vid båken — foro framåt eller tillbaka,
belysta af solen, och glimrande som svanar.
Luba öppnade åter ögonen, och fattade i en enda blick denna

syns hela stora och underbara skönhet.
Hon tog sin mans hand, tryckte den darrande och frågade med
bäfvande stämma hvad han tyckte om allt detta.
Han svarade henne distraherad, med en fras, han satt lite lågt,
slädan var för trång för hans kraftiga ben…
Luba satte sig bättre upp i slädan, löste på sina hattband, drog
djupare andedrag och kisade med ögonen för att kunna se än längre
ut mot horizonten.
De grepo henne starkt, dessa öfverväldigade och nya intryck.
Hon kunde ej mer. Det var för mycket, alltför mycket. Det
mörknade för hennes ögon, och hon sjönk tillbaka med hufvudet;
tyst, medvetslös, som om hon slocknat föll hon i en af dessa
svimningar som förr kommo så ofta.
Skrämd och orolig körde nu Lämmenen hem igen, sände bud efter
läkaren och rörde upp himmel och jord.
Men det var ingenting, alldeles ingenting. Doktorn hviskade något i

kyrkoherdens öra, unga frun skulle vara försigtig — — det var allt.
Man telegraferade efter Lina, Anna kunde ej mer få behålla henne,

det var ju också otroligt dumt att man låtit henne resa bort på andra
brölloppsdagen, i tro att hon ej mer skulle behöfvas…
Detta var en kris. Tiden gick och hon blef bättre.
Doktorn var förvånad öfver Lubas härefter allt mer tiltagande hälsa
och en dag sade han att man hade de största förhoppningar att hon
efter ännu en vigtig kris skulle bli alldeles frisk.
Kyrkoherden strålade då han såg hur hon tog sig, han egnade sin
hustru de ömmaste omsorger och Luba sjelf blef efter den första
förskräckelsen som en annan människa.
Kunde det vara möjligt — — — ännu ett undervärk, ett det största
och mest oväntade!
Det som hon förr funnit så prosaiskt, så obehagligt och

förnedrande, nu var det ju en lycka så stor och oförtjent som någon,
en gåfva af Gud, ett tecken på den största nåd, en obegriplig glädje.
Hon såg från den dagen på lifvet genom en rosenslöja. Det onda
var borta, alla sorgsna tankar veko, och lifvet var idel ljus.
Fanns det värkligen synd och sorg i lifvet? Jo — — naturligtvis,
men hon tänkte därpå som på något utanförstående, någonting som
ej hörde till hennes horizont utan till mörkret, fattigdomen och
fängelserna.
Och medan tiden led blef hon allt raskare och bättre.
Man var i tillfälle att hålla Midsommarkalaset i prestgården utan all

fruktan att det skulle skada den unga frun… hon hade ju sin syster
nu, och sjelf kunde hon gerna sitta i sin soffa och presidera, föra en
konversation och se etherisk ut, det var ju allt som behöfdes.
Gästerna betraktade med undran och vördnad den nya

kyrkoherdens märkvärdiga hustru. Luba Donner, den heliga
martyren, hon var nu där ibland andra människor, rörde sig emellan
dem, säg ut som andra, visserligen blek och ytterligt mager, men
intressant med sina mörka ögon och sitt själfulla väsen.
Ibland märkte en eller annan att hon ändå ej fullkomligt hämtat sig.
Hon kunde stundom öfverfallas af en underlig skakning, fick tårar i
ögonen och rodnade…
Det kunde komma på helt oväntadt, just när man minst anade det
och stämningen var som muntrast. Ja, det råkade hända tillochmed
när kyrkoherden var som gladast och vid sitt toddyglas sade en wits
eller sjöng en liten visstump.
Men det gick snart öfver igen. Lina kom med litet eaudecologne,
och mannen med en smekning.
Skyn försvann fort och himlen blef åter klar som förut.
18.
SLUTET.
Det var åter vinter. Julen hade gått och det nya året kom med köld
och is.
Nätterna voro långa, och först mot förmiddag ljusnade det. Men till
middag kom solen stundom fram en smula, lifvade upp och strålade
en stund.
Klockan tre steg aftonrodnaden på himlen och solen sjönk igen,

lemnande jorden i skymning och skärpt kyla. En mörk, snötung
förmiddag när kyrkoherden gått till sitt kansli och Lina ut i bodarne,
kom pigan in till sin fru och sade att det var en "människa" i köket
som alls icke förstod svenska, och som ville tala med kyrkoherden.
Luba ville icke gärna störas, hon satt sömning i sin gungstol och
sydde. Dagarne föreföllo henne litet tunga, hon hade svårt att röra
sig, och den stora krisen kunde inträffa när som helst.
Nu sof hon bort största delen af tiden… och tyckte att hon ständigt
ville sofva mer.
Endast med våld höll hon sig uppe. Doktorn ville det… det skulle
ju vara så förslappande att öfverlemna sig till den dåsighet och
sömnsjuka som betog henne. Och så satt hon i sin gungstol,
arbetade på ett litet ylleplagg, drömmande, nöjd med ögonblickets
frid, och njutande af sin tillvaros nya rikedom.
"Kan inte Lisett be henne komma igen senare", frågade Luba sin
svensktalande piga, "jag är så trött just nu".
"Nej, hon vill inte gå. Hon förstår inte ett ord af hvad jag säger, och
jag begriper inte ett muck af hennes prat. Hon kommer direkte från
bangården, och har sitt bylte och sin korg i köket, och i korgen
någonting till kyrkoherden, jag undrar om det inte är en knippa
ullgarn eller någon annan landsföring. Hvad tycker frun jag skall göra
med henne, hon sitter nu där och ser så förskräckligt dum ut, så"…
"Så tag henne in, hvarifrån är hon?"
"Vet inte, snälla frun, jag kan inte den otäcka finskan, det vet frun".
"Det är en skam, Lisett, att du är så okunnig. Sätt kaffepannan på,

och spring efter bullar. Hör, är hon snyggt klädd?"
"Ah jo, efter landsmanér, och hon har lädergaloscher på sig, så

nog kan hon komma in alltid?"
Luba satte sig bättre tillrätta i stolen, flyttade sig närmare sybordet,
och jemkade sin schal så att den fremmande icke kunde observera
hennes figur.
Bondkvinnan kom in, blef anvisad plats på stolen vid bordet, och
satte sig ned efter en glad och vänlig hälsning.
Det var en temligen ung kvinna, stor och akselbred, med grofva
former och ett märkvärdigt enfaldigt, men gladt och troskyldigt
uttryck i sitt ansigte.
Hon hade vacker färg ehuru en hop ljusa fräknar vanstälde hyn
just omkring näsan, oregelbundna anletsdrag, men en stor frisk mun,
och jemna tänder som hon alltid visade.
Där hon satt liknade hon en ting, välmående och hemtreflig
bondko, godlynt och from, en som icke skulle kommit sig före att
stångas, huru man än försökte reta henne.
"Hvem är ni", frågade Luba på finska och såg med ett trött
ögonkast på henne. "Och hvar är ni hemma?"
"Jag är Parkkala Calles dotter", svarade hon, "och heter Carolina.

Jag vill träffa pastorn, kommer han snart?"
"Hvad vill ni pastorn?" frågade Luba likgiltigt, "kan ni inte gå till

kansliet, här tar han inte så gärna emot, först kan ni ju dricka kaffe i
köket och så söka upp honom i kansliet… vet ni hvar det är?"
"Jag vill träffa honom ensam", sade kvinnan, "för si fröken, han är
min gamla bekanta och nu har jag kommit hit för att jag vet att han
vill hjelpa mig. Sen jag kom i olycka och far dog, går det inte uppe i
Parkkala längre, jag ämnar försöka min lycka i hufvudstaden nu".
Hon smålog förtröstansfullt och nickade vänligt till Luba.
"Han bor fint här", tillade hon, och tittade sig nyfiket omkring, "det
var annat när han var adjunkt och hade mig där hemma och det bara
fanns två rum, låga i tak och med trästolar, inga sådana som de här,
nej inte en".
"Är ni skräddarns dotter?" frågade Luba, nu med vidöppna ögon,

och en röst som darrade.
"Jo, är jag så", svarade hon, "det är just jag. Kan väl tro att han
talat om alltihop. Jag tyckte så mycket om honom, han var alltid så
snäll. Och när han ville något, så sade han så vackert. En kunde inte
stå emot, så god han såg ut. Och alla de andra karlarne var så
lättsinniga och menade bara ondt, men han, han var alltid lika, och
han menade ärligt. När nu Gud tog pojken, så tyckte jag, jag måste
hit straks och tala om det för pastorn, sä skulle också han bli glad,
att Gud tog 'en. Jag tänker söka mig tjenst här nu, ser fröken".
Med sitt fåniga, glada leende såg kvinnan på Luba. Men Luba
besvarade ej hennes blick, hon såg ned, — glödande brännde
hennes kinder, hon hade svårt att få luft.
"Hvems var ert barn", stammade ändtligen Luba, "var det hans?"
"Hvems annans", skrattade kvinnan, "inte tror jag det var någon
annans inte! Hvem är fröken, det skulle jag nu också vilja veta, efter
jag talat så mycket om mig? Kanske systern hans, hva'?"
Luba sväljde tårarne. Hon kände en underlig smärta i halsen, det

tog ondt som om hon höll på strypas.
Hon ville svara något, men det gick icke. Blodet strömmade till
hennes hjärta i onaturlig fart. Hon kände bara en sak, en brännande
blygsel, hon skämdes inför denna kvinna som hade tidigare rätt öfver
hennes man än hon sjelf, hon skämdes öfver att vara hustru,
skämdes att vara hans barns mor, skämdes så att hon kunnat sjunka
under jorden.
"Hvem är fröken?" upprepade bondkvinnan, denna gång med sin

allra vänligaste röst.
Luba kunde icke tala. Hon kunde icke säga att hon var hans
hustru. I detta ögonblick kände hon ej som var hon hustru, nej, utan
som något annat sämre.
Hon tyckte sig vara det eländigaste väsen på jorden. Och det var
som skulle jorden öppnat sig och med ens slukat all hennes glädje,
allt hennes hopp, hennes tro på lifvet.
Hon letade i denna skeppsbrottets stund efter sin kärlek, som efter
det räddande halmstrået. Men hon fann den icke, halmstrået fanns
ej… hon var nära att sjunka… tröstlös stirrade hon på den
fremmande med en blick full af förtviflan.
Tredje gången upprepade kvinnan det, med sin mest smekande

röst:
"Hvem är fröken, säg nu då?"
Lubas schal föll ned när hon försökte resa sig för att gå ut…
åsynen af kvinnan plågade henne.
Hon ville bort, bort från alltsammans. Hon hade ej mod att höra
mer, tanken på denna fremmande kvinna och barnet som Gud tagit,
äcklade henne, hon ville bort, den vidriga "naturmänniskan" kunde
hon ej se, inte en minut längre — bara bort.
Men hon förmådde oj. Golfvet sjönk för hennes ögon, och en svart
tomhet fanns i stället. Hon kunde ändå icke stanna, hon måste in i
det tomma, sjunka, försvinna, förintas. Hon tog ett steg, kände en
häftig smärta och förstod att hon fallit och fått en stöt, någonstädes
på sidan.
Så sjönk hon vidare, djupare i det svarta, tomma. Som stora,

tunga bolster låg det på hennes bröst, hon kunde ej andas, ej få luft.
En ångest, som höll hon på kväfvas, en kamp som till döden.
Bondkvinnan sprang ut i köket och tillkallade pigan… Frun låg
afsvimmad på golfvet, det lilla sybordet låg sönderslaget inunder
henne, hon var kanske döende, och ingen fanns som kunde hjelpa.
Som en yr höna sprang Lisett omkring, skrek och jemrade sig,

bondkvinnan gret och försökte förgäfves lyfta den sjuka, men det
gick icke.
Så ringde det och Lina kom hem. Hon såg och uppfattade
situationen i ett ögonblick. De buro nu alla tre på den sjuka, och fick
henne mödosamt släpad in i sängkammarn och lagd på sängen.
Lisett sprang efter läkare och sände ett bud till kyrkoherden, Lina
som icke ens fick tid att taga af sig öfverplaggen, baddade den
sjuka, löste upp hennes kläder, tog af skodonen och bäddade in
henne så godt hon kunde.
Efter svimningen följde konvulsionerna och när läkarn kom hade

Lina genomlefvat några af de svåraste ögonblick i sitt lif.
Barnmorskan hade icke funnits i sitt hem, kyrkoherden hade gått

till en sjuk långt borta, i Rödbärgen, doktorn var i Hospitalet men
påträffades snart och kom genast.
Emellertid, då han anlände var det svåra öfverståndet och Lina

som aldrig förr varit med om något sådant hade ensam fått hjelpa sin
syster. .
Hon hade varit nära att förtvifla öfver sin okunnighet om en af de

saker som i en kvinnas lif vore vigtigast att lära, — — den första
nödhjelp i ett fall som detta, men hennes vana vid sjuksängen och
hennes jemna kallblodighet och sjelfbehärrskning kommo henne till
hjelp — — och när Collin steg in i rummet stod Lina där med sin lilla
systerdotter i armarne efter att ha egnat modren den hjelp hon
kunnat.
Doktorn bragte reda och ordning i allt, fick Lisett att göra under
och använde bondkvinnan i köket till hvad hon kunde göra, så att
badvattnet och kläderna snart nog kommo in…
Den sjuka var nu befriad från smärtorna och låg i dvala, skött och
omhuldad på bästa vis.
Hon hade för en stund glömt allt och hvilade drömlös och utan
känsla.
Ändtligen kom barnmorskan, beskeftig och vigtig — — hon hade

svårt att låta bli visa sin förargelse öfver att hon försummat det
vigtigaste.
Hon började göra ursägter för doktorn, men han lugnade henne,
och försäkrade att allt var så bra det kunde… frun hade ju fallit, och
katastrofen hade därför något framskyndats…. fröken Lina hade
förresten gifvit frun en utmärkt hjelp, och sedan med honom
undangjort en hop svårt arbete, nu kunde fru Block se till barnet, ge
det en smula sockervatten, och så gå in till pastorskan.
Med en häpen blick tittade fru Block till Lina, och gick.
Doktorn följde denna blick och kom sig på en stund icke för att
flytta sina ögon ifrån henne, Linas gestalt och hela personlighet hade
ännu för honom ett stort behag.
Han smålog så godmodigt. "Kära Lina", sade han, "nu ha vi två

hjelpts åt som ett par goda kamrater, utan allt falskt pjunk eller
tvekan från din sida. Du ska’ ha tack Lina — — visserligen är du en
kvinna efter mitt tycke. Så god och så! — Ja, du är stor, Lina — — —
det är ordet".
"Smickra mig inte", log hon medan där smög henne en tår i ögat
som skymde blicken, "hvem som helst skulle ha gjort detsamma".
"Nej, ingen".
"Jo, hvem som helst. Sådana äro vi alla, när det är allvar. Det är
bara när vi tagas på det orätta sättet som vi visa oss så pjunkiga.
Men när man tar oss riktigt, kunna vi nog"…
"Oförbätterliga idealist", mumlade doktorn. "Om det bara fanns

flere af den sorten. Hör", tillade han hårdare, "hör Lina, tänker du
gifta dig?"
Lina såg upp.
"Jag, jag, hvad menar doktorn, fyratio år, jag?"
"Jaså, du är så gammal… det trodde jag inte. Du ser så ung ut.

Din kropp är så rank och stark, och du är graciös som en ung
kvinna".
"I mitt ansigte läser man mitt lifs historia, så mycken gråt, så
många onyttiga streck och märken efter tårar".
"Ja visst ja, det är rätt! Du är inte ung, Lina". Doktorn såg alitjemt
på henne, "det jag känner för dig ar också ingenting som har med
åldern att göra".
Och han steg tungt och långsamt upp från stolen och gick emot
kyrkoherden som i detsamma kom in.
Lämmenen var alldeles blek. Han flämtade ångestfullt och frågade

ifrigt doktorn efter Lubas hälsa. Han hade fått veta det först nu, i
detta ögonblick, af madamen han mötte i trappan.
Doktorn afgaf sin bulletin, — allt var så bra det kunde, både med
mor och barn.
Så gick lian, och lofvade att om par timmar återkomma.
Det blef nu Linas tur att berätta om allt. Om fallet, den sjukas korta
men svåra kamp, barnets födelse och minuterna som följde.
Han fick veta allt, utom orsaken, och ville genast in att se till Luba.
Nej, det fick han icke, hon skulle ej störas, doktorn hade förbjudit
det… också barnet sof.
Kyrkoherden rusade ut i köket, han skulle riktigt leksa upp Lisett,

att tänka sig att hon ej bättre kunde passa på, utan lät frun gå falla.
I köket var stor oro, det sprangs af och an, kitteln kokade, en
massa baljor, fat och ämbar stodo på golfvet, Lisett stod och sköljde,
med ärmarne högt uppvikna, hon såg knappt upp när kyrkoherden
steg in.
Förbluffad blef han stående.
På en stol, vid dörren, satt med sin korg på armen den fremmande
bondkvinnan, färdig påklädd, lugn uti allt detta bråk, stilla och
väntande som om hon satt i sin tredjeklass kupé medan tåget gick i
ilfart framåt med henne.
Hon steg makligt upp då hon såg Lämmenen och stirrade halft
slugt och halft enfaldigt på honom.
"Det är jag", sade hon, "inte kunde jag veta han var gift inte.
Hustrun därinne fick slag när hon fick höra hvem jag var, och ramla i
golfvet när jag talte om vår pojke som är död nu och begratven.
"Han behöfver inte se så arg ut, pigmännskorna förstå int' ett ord
af hvad jag säger. Ska' det förresten vara rätt, att vara Herrans
tjenare och gifta sig med en annan när man lofvat en".
Kyrkoherden tog henne omildt i akseln och visade henne vägen

ut…
Han följde efter, talade med henne under några minuter i

förstugan, och så gick hon med sin korg.
Man såg henne aldrig mer i prestgården.
Natten kom.
Kyrkoherden satt timtal med sin lilla dotter, han kunde ej se sig
mätt på detta lilla, späda väsen som lefde och andades, som
öppnade och slöt sina dunkla, underliga ögon och som var svept i
spetsar och hvita mjuka yllen likt en docka. Att detta var en
människa, och hans egen!
Han ville dock se Luba, och bad doktorn så länge att han slutligen
lofvade.
"Men försigtigt, ytterst försigtigt".
Lina underrättade sin svåger om att Luba gråtit hela natten — —

— också nu på morgonen var hon förtviflad. Visst en nervös
öfverretning, det var en olycka med detta fall.
Man öppnade ändtligen sängkammardörrn och kyrkoherden gick

in.
Luba slumrade. Hennes magra hand plockade sakta på täcket,

hennes läppar voro hårdt pressade mot hvarann.
Han gick närmare, satte sig sakta på stolen och tryckte en kyss på
hennes hand.
Luba spratt upp och vaknade. Hon såg på honom ett ögonblick.
"Gå ut", sade hon, "gå bort! Jag vill inte se dig! Gå till henne som
var din hustru förr än jag. Gå!!"
"Men Luba, Luba, hvad tänker du på, förifra dig inte, mitt hjärtas
älskade, förlåt mig, jag har ju intet så fasligt ondt gjort, men förlåt mig
ändå! Se på mig, Luba, Luba!"
Men hon vände sig häftigt om, satte sig sedan upp i sängen,
begynte att fäkta med armarne och ropa efter Lina.
Förskräckt drog Lämmenen sig tillbaka, och lät sin svägerska

komma in… barnmorskan skyndade till, man hade svårt att åter
lugna den sjuka, och först sedan dropparne hunnit värka blef hon
stilla.

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History taking and examination 1

Disorders of sex development 11

Gestational trophoblastic disease 32

Poly cystic ovarian syndrome 46

Abnormal uterine bleeding 53

Genital tract infections 65

Pelvic inflammatory disease 72

Benign and malignant ovarian tumours 104

Pre-malignant lesions of the genital tract 113

4. Follow through each answer to its logical conclusion, be curious

5. Ask questions in the same sequences as you will present them

6. If the history is complex explain to the patient exactly what is

1. Introduce yourself, explain the tim e limitation and what you

History taking and examination 1

There is so~e times an anxiety in listing a sexual history. The secret is

1. Do either of you or your husband use any form of birth control?

2 Essential Gynaecological Care

3. So your husband/boy friend has no difficulties with his erection

4. So you have no pain or soreness with intercou rse and no

General examination is the first thing to do in the examination. Alw ays

Breast examination is mandatory in the gynaecological patient.

History taking and examination 3

4 Es sential Gynaecological Care

Inspection of the vagina and cervix is done by using a speculum. If

Os - open, patulous or closed . Any discharges. Nabothian follicles,

Now remove the speculum while observing the vaginal walls.

History taking and examination 5

Bimanual examination. Nabothian follicle with a

Feel the size of the uterus, position - anteverted, axial or retroverted.

Per rectal examination (PR examination)

6 Essential Gynaecological Care

4. Past medical and surgical history.

7. History of the present complaint.

8. Menstrual history (if not included in the present complaint).

11. Two sentence summary including plan of management.

History laking and examination 7

A typical gynaecological summary would be

The problem list

Differential diagnosis of a lump in the abdomen

8 Essential Gynaecological Care

3. Benign ovarian tumours - menstrua l history is usually normal.

4. Fibroids - could be asymptomatic or cause rnenorrhagia.

5. Tubo-ovarian abscess - these could be sub-acute or chronic. Patients

History taking and examination

7. Adenomyosis - the typical history is dysmenorrhoea and

On vaginal examination cervix is firm and continuous with the