Diagnostic Procedures in Gynecology

Mrs. Tessy Joseph

Lecturer
BCF
BLOOD ROUTINE
• Hemoglobin estimation-Excessive bleeding
• Total and differential count- PID
• ESR - PID
• Platelet count, BT ,CT—Pubertal menorrhagia
• Serology-VDRL, australia antigen, HIV
URINALYSIS
1. Urine routine and microscopy

• Chemical estimation of protein and sugar • Pus cells, casts

2. Culture and drug sensitivity

• Indications— Pus cells >5 --UTI ,Cystocele

3.Urine pregnancy test– for diagnosis of pregnancy

Methods of urine collection

1. Midstream collection

2. Catheter collection – not ambulant or having chronic retension

3. Suprapubic bladder puncture- asked not to void, fine needle inserted through abdominal
wall just above symphysis pubis into the bladder. 5-10 ml urine collected
URETHRAL DISCHARGE
Method of collection
• Urethra squeezed 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

1.Normal discharge-normal vaginal cells with doderlein bacilli

2.Trichomonas vaginalis—vaginal discharge+ NS- motile organisms of varying shape

3. Vaginal candidasis

• Vaginal discharge + equal amount of 10% KOH • Typical hyphae, budding spores or mycelia detected
EXFOLIATIVE CYTOLOGY- PAPANICOLAOU TEST

• Pap test-Screening test for cancer

• First described by Papanicolaou and Traut in 1943

• Routine gynaecological examination in females,esp above 35 years

• Yearly screening for 30 years followed by 2-3 yearly test

• Uses— 1.screening for cancer

2.identification of local viral infections like herpes and condyloma accuminata

3.Cytohormonal study
ABNORMAL CELLS

1)Mild dyskaryosis— • superficial/intermediate squamous cells • Angular borders, transcluscent

cytoplasm • Nucleus < half of total area of cytoplasm • Binucleation is common • CIN-I

2)Moderate dyskaryosis— • Intermediate/parabasal/superficial squamous cell type • More

disproportionate nuclear enlargement and hyperchromasia • Nucleus-1/2-2/3 of total cytoplasm area
• CIN II

3)SEVERE DYSKARYOSIS • Cells- basal type round/oval/polygonal/elongated singly/in clumps • Nucleus-

almost fills the cell • CIN III • Fibre cells- severly dyskaryotic elongated cell • Tadpole cell- severely
dyskaryotic cell with an elongated tail of cytoplasm

4.Carcinoma in situ – cells are parabasal type with increased nuclear cytoplasmic ratio

5.Invasive carcinoma • Cells-single/clusters • Tadpole cells are large • Irregular nuclei • Nucleus-
chromatin irregular, sometimes multiple
PAPANICOLAOU CLASSIFICATION-GRADING

Group I. Normal cells

Group II. Slightly abnormal-inflammatory change
Group III. Cells suspicious of malignancy-biopsy indicated
Group IV. Few Distinctly abnormal, possibly malignant cells
Group V. Malignant cells seen-numerous
CYTOHORMONAL EVALUATION

• Exfoliative cytology

• Non invasive study of epithelium for hormonal status

• Principle-vaginal epithelium highly sensitive to oestrogen and progesterone. oestrogen—superficial

cell maturation, progesterone—intermediate cell maturation

• Procedure—scrapings taken from lateral wall of upper third of vagina

 Examination of cervical mucus
1. Bacteriological study

2. Hormonal status
•Estrogen- mucous copious, clear and thin
•Progesterone- scanty, thick and tenacious
•Fern test- under microscopic exam- characteristic pattern of fern formation
•Spinnbarkeit- elasticity

3. infertility tests
Post coital test
INFERENCE

• Normal smear-parabasal, intermediate and superficial cells

• Oestrogen predominant smear-large eosinophilic cells with pyknotic nuclei and clear back
ground

• Progesterone predominant smear- predominantly basophilic cells with vesicular nuclei and
dirty background

• Pregnancy- intremediate and navicular cells

• Post-menopausal smear- parabasal and basal cells

 UTERINE ASPIRATION CYTOLOGY

• Screening test for endometrial cancer- Endometrial sampling

• Sample obtained by endometrial pipelle/uterine aspiration syringe or brush

• 90% accuracy with no false positive findings

• Hormonal studies also done

• Indications

• Dysfunctional uterine bleeding

• Abnormal bleeding following hormonal replacement therapy

• Abnormal menopausal bleeding

A. ENDOMETRIAL BIOPSY
• Most reliable method to study endometrium
• Endometrial tissue obtained by curettage under general anesthesia and subjected for histopathology

Indications
• Suspected cases of Endometritis, endometrial cancer
• Infertility
• Abnormal menstrual bleeding
• Diagnosis of corpus luteal phase defect
B.CERVICAL BIOPSY

• Confirmatory diagnosis of cervical pathology

• Done at OP or indoor

• if pathology detectable, wider tissue excision as in cone biopsy – IP procedure

 COLPOSCOPY

• Colposcope-binocular microscope for the examination of cervix and vagina

- using an optical instrument to visualize pelvic structures through an incision in the pouch of douglas.

Reid colposcopic index

Based on 4 features of the lesion. Scored from 0 to 2

1. Margin

2. Color

3. Vascular pattern

4. Lugol solution staining effect

 CULDOCENTESIS
• Transvaginal aspiration of peritoneal fluid from the pouch of douglas

• Diagnostic procedure- pelvic abcess, ectopic pregnancy, in hemoperitoneum

PROCEDURE

• Patient-lithotomy position

•vagina clean with betadine

• a posterior vaginal speculum inserted

• Aspiration syringe inserted into the pouch and aspirated

• if unclotted blood- intraperitoneal bleeding
• No bleeding- withdrawn the needle
IMAGING TECHNIQUES
1. X-RAY
• Plain x ray chest and intravenous urogram- pelvic malignancy especially 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
2.ULTRASONOGRAPHY

• Simple, noninvasive, painless, safe procedure

• Pelvis and lower abdomen scanned longitudinally and transversely

A. Transabdominal sonography(TAS)

• Done with transducer operating at 2.5-3.5Mhz

• Bladder full

• Large masses examination –ovarian tumour/fibroid

B. Transvaginal sonography (TVS)

• Probe placed close to the targeted 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

1) folliculometry-measurement of ovarian follicle diameter

2) measurement of endometrial thickness
3) evidence of ovulation-internal echoes and free fluid in pouch of douglas
4) timing of ovulation-helps in ovulation induction, Artificial insemination, Ovum retrieval
5) sonographic guided oocyte retrtieval
• detect ectopic pregnancy-tubal ring in adnexa with empty uterine cavity
• Evaluation of pelvic mass- uterine fibroid, ovarian mass
• Oncology-to assess vascularity of tumour and confirm malignancy
• Endometrial study in DUB
• Diagnose uterine pathology- fibroids, adenomyosis
• Location of misplaced IUD
Uterine Artery Embolization

•Treatment procedure of uterine myomas.

• for visualization and occlusion of vasculature by embolization – stops blood flow - necrosis of
fibroids
•Catheter placed in femoral artery and through uterine artery
•Complications - Pain, Infections, nausea, vomiting, fever and ovarian failure
•Contraindications- pregnancy, pelvic infections, suspected pelvic malignancy, renal impairment
3) Computed Tomography
•Whole abdomen and pelvis visualised in one sitting after taking 600-800ml of a dilute contrast medium 1
hour prior to procedure
•contrast medium can be given orally, IV, rectally
• Patient scanned in supine position
• Accurate in assessing local tumour invasion and enables accurate localisation in biopsy
• Diagnose pelvic vein thrombophlebitis, intraabdominal abcess and other extra genital abnormalities
• Useful in evaluating pituitary tumors

• IntraperitoneaI implants and lymphnodes < 1 cm—not detected

• Contraindicated in pregnancy
4) 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 differentiate post-treatment fibrosis or
tumour
5)Positron Emission Tomography(PET)

• To differentiate normal tissue from cancerous one based on the uptake of 18F-FLURO-
2DEOXYGLUCOSE
- Also used for post surgical monitoring of patients with endometrial cancer or ovarian cancer
DIAGNOSTIC ENDOSCOPY
1. Laparoscopy
• To visualize peritoneal cavity with a fibroptic endoscope through the abdominal wall

• Diagnose uterine, tubal, ovarian, generalised diseases affecting pelvic organs- endometriosis, PID, genital
TB

• uterine perforation

• Infertility workup

• a/c pelvic lesions-ectopic pregnancy, salpingitis

 
2)Hysteroscopy
• Visualise endometrial cavity with fibroptic telescope
-- uterine distension is achieved by carbon dioxide, normal saline or glycine
--Instrument pass trans cervically

• Diagnostic uses
1. Unresponsive irregular uterine bleeding
2. Congenital uterine septum
3. Missing threads of IUD
4. Intrauterine adhesions
5. Endometrial polyps/ malignant growth
3)Salpingoscopy and falloposcopy
• Visualise of fallopian tube
• Permits selection of patients for IVF rather than tubal surgery

4)Culdoscopy
 • Visualise pelvic structures via an incision in pouch of Douglas
5)Cystoscopy
• To evaluate cervical cancer prior to staging
• Investigate urinary symptoms- haematuria,incontinence and fistulae

6) Proctoscopy and sigmoidoscopy

• To evaluate rectal invovement in genital malignancy
Pre operative management of patient undergo gynecological surgeries

•History collection
•Physical examination
•Investigations - • Complete blood count • Urinalysis • FBS,PPBS • BT,CT • Blood group and Rh factor
• RFT • LFT • Serology- VDRL • Serum electrolytes-Na,K,Cl,HCO3 • Chest radiograph
• ECG • IVP

•Informed consent
•Patient should be on NPO
•Empty the bowel 24 hrs before surgery.
•Skin preparation
•Antibiotics prophylaxis
•Preoperative drugs
•Compressive stockings or elastic bandage 30 min before surgery
•Catheterization
Post operative management of patient
undergo gynecological surgeries
•Vital signs- BP and pulse half hourly for 2 hrs and then 4 hourly for 24 hrs
•Fluid and electrolytes
•Pain management
•Care of bladder
•Early Ambulation
•Prophylaxis for thromboembolism- heparin 5000 units every 12 hrs for 5 days
•I/O chart
•Assess bleeding and other complications
•Deep breathing exercises
•Wound care- dressing
•Advice on discharge- avoid heavy lifts, avoid coughing/ constipation, gradually
resume work after 2-3 weeks, take iron and vitamin supplements, avoid sexual
contact for 4-6 weeks, follow up after 6 weeks