Gynecological

Disorders in
pregnancy

PRESENTED BY
MS. ANNU PANCHAL
ASSISTANT PROFESSOR
 There is an increased cervical secretions and
vaginal transudate during pregnancy due to
increased vascularity and hyperestrogenic state.
The discharge is thick, mucoid in nature and non-
irritating.
Except improvement in personal hygiene, no
treatment is required.
 Trichomonas vaginalis is a parasitic
protozoan that infects the urogenital tract
of both women and men. It is the most
common sexually transmitted infection (STI)
 The infection is not increased during
pregnancy. The clinical features remain the
same as in non-pregnant state.
 Treatment consists of prescribing
metronidazole (Flagyl) 200 mg thrice
daily for 7 days. Metronidazole should be
avoided in the first trimester. The husband
should be treated simultaneously
 Vaginitis due to Candida albicans is relatively
more common than Trichomonas vaginalis. Its
growth is favored by the high acidic pH of
vaginal secretions and frequent presence of
sugar in the urine during pregnancy. It is more
prevalent in diabetic pregnancy.
 Treatment is by use of miconazole vaginal
cream, one applicator full, high up in the vagina
at bedtime for 7 nights.
 During pregnancy, there is increased
vascularity and as a result any pre-existent
polyp bleeds, confusing the diagnosis with
threatened abortion in early months and
constitutes extra placental cause of APH in
later months. The diagnosis is confirmed by
speculum examination.
 The polyp should be removed as in the
non-pregnant state and should be sent for
histological examination.
 INCIDENCE: The incidence of invasive
carcinoma of the cervix is about 1 in 2,500
pregnancies.
 Asymptomatic cases — Cytologic
screening of all pregnant mothers is a
routine during antenatal checkup in the
organized sector.
 Symptomatic cases — In cases of
bleeding during pregnancy either in the
early months simulating threatened
abortion or in the later months constituting
APH, the cervix should be inspected through
a speculum at the earliest opportunity. If
suspicion arises, a biopsy from the site of
lesion confirms the diagnosis.
 EFFECTS OF PREGNANCY ON CARCINOMA
CERVIX: The malignant process remains
unaffected. There may be a rapid spread
following vaginal delivery and induced
abortion.
 EFFECTS OF CARCINOMA ON
PREGNANCY:
There is increased incidence of (1)
abortion,
(2) premature labor, (3) secondary cervical
dystocia, (4) injury to the cervix and
lower segment leading to traumatic PPH,
 (5) lochiometra and pyometra, and (6)
uterine sepsis.
 Radical hysterectomy (with the fetus in
uterus), pelvic lymphadenectomy and
aortic node sampling are done. Oophoropexy
at the time of hysterectomy may be done.

 Post operative
 irradiation following evaluation of prognostic
factors
 Radical hysterectomy, pelvic
lymphadenectomy after classical
cesarean delivery.
 Dissection may be easy, but bleeding is often
more in pregnancy.
 Second trimester: Management
decisions are more difficult.
 INCIDENCE: The incidence of fibroid in
pregnancy is about 1 in 1,000 and it depends
on population characteristics.
 It depends on their location. (1) May be
none; (2) Pressure symptoms due to
impaction —
 (a) bladder—retention of urine
 (b) rectum—constipation;
 (3) Abortion;
 (4) Malpresentation;
 (5) Non-engagement of the presenting
part;
(6) Preterm labor and prematurity;
 (7) Red degeneration;
 (8) Placental abruption.
 EFFECTS ON PUERPERIUM: (1) Subinvolution;
(2) Sepsis is common
 (3) Secondary PPH;
 (4) Inversion of uterus;
 (5) Lochiometra and pyometra.
 (1) Acute onset of focal pain over the tumor;
 (2) Malaise or even rise of temperature;
 (3) Dry or furred tongue;
 (4) Rapid pulse;
 (5) Constipation;
 (6) Tenderness and rigidity over the tumor;
 (7) Blood count shows leukocytosis.
 The diagnosis is confused with acute
appendicitis or twisted ovarian tumor. The
diagnosis is often made only on
laparotomy.
 Conservative treatment should be
followed. Patient is put to bed. Ampicillin
500 mg capsule thrice daily for 7 days is
given. Analgesic and sedative are frequently
given. The symptoms usually clear off
within 10 days
 INCIDENCE: The incidence of ovarian tumor with
pregnancy is about 1 in 2,000.
 On pregnancy: There is increased
chance of
 (1) impaction leading to retention of
urine,
 (2) mechanical distress in presence of large
tumor
 (3) malpresentation,
 (4) Non-engagement of the head at term.
 On labor: There is chance of
obstructed labor if the tumor is
impacted in the pelvis.
 Patient may remain asymptomatic or
presents with the symptoms of
 (a) retention of urine due to impaction of
the tumor
 (b) mechanical distress due to the large
cyst
 © Abdominal examination reveals
the cystic swelling felt separated from
the gravid uterus
 DURING PREGNANCY
 Uncomplicated — The best time of
elective operation is between 14th week
and 18th week, as the
 Complicated — The tumor should
be removed irrespective of the
period of gestation.
 (1) If the tumor is well above the
presenting part, a watchful expectancy
hoping for vaginal delivery is followed;
 (2) If the tumor is impacted in the pelvis
causing obstruction, cesarean section
should be done followed by removal of the
tumor in the same sitting.
 On occasion, the diagnosis is made
following delivery. The tumor should be
removed as early in puerperium as
possible. Following operation the specimen
is sent for histological examination.
 Retroverted uterus, either congenital or
acquired, is considered as a normal variant
of uterine position.
 Retroversion is either pre-existing or may be
due to pregnancy. The incidence is about 10%
during first trimester of pregnancy
 Changes in the uterus:
 (1) The cervix is pointed upwards and
forwards and is placed even on the upper
border of the symphysis pubis;
 (2) Rarely, the uterus continues to grow
at the expense of the anterior wall called
anterior sacculation while the thick
posterior wall lies in the sacral hollow
 Urethra:Marked elongation along with the
bladder base due to stretching of the
anterior vaginal wall by the cervix. There is
retention of urine.
 The causes of retention are:
 (1) Mechanical compression of the urethra by
the cervix;
 (2) Edema on the bladder neck;
 (3) The woman passes small amount of urine
with increased pressure (strain) even when
the bladder is full (paradoxical
incontinence).
 As a result of retention of urine, the bladder
gets distended and becomes an abdominal
organ reaching even upto the umbilicus. If the
retention is not relieved, the following may
happen:
 (1) The bladder walls become thickened due to
edema;
 (2) Severe cystitis, pyelonephritis with uremia
supervenes;
 (3) Intraperitoneal rupture may occur in grossly
neglected cases resulting in infective peritonitis;
 (4) Obstructive nephropathy in a severe
case may occur.
 (1) Miscarriage; (2) If pregnancy continues
with anterior sacculation, there is
increased chance of
 (a) Malpresentation
 (b) Non-engagement of the head,
 (c) Preterm delivery and prematurity, and
 (d) Rupture of the uterus during labor.
 Pregnancy is not uncommon in first-degree
uterine prolapse with cystocele and
rectocele. Pregnancy is, however, unlikely
when the cervix remains outside the introitus
and continuation of pregnancy in third
degree prolapse is an extremely rare event.

 The incidence of prolapse is about 1 in 250

pregnancies
 Vaginal discharge may be copious
 There is chance of incarceration
 On pregnancy: There is
an increasedchance of:
 (1) Miscarriage;
 (2) Discomfort due to
increased ailments;
 (3)Premature rupture of the
membranes
 (4) Chorioamnionitis.
There is an increased chance of:
(1) Early rupture of the membranes;
(2) Cervical dystocia;
(3)Prolonged labor due to non-
dilatation of cervix and
obstruction due to sagging
cystocele and rectocele;
(4) Operativeinterference.
During puerperium:
(2) Subinvolution;
(3) Uterine sepsis.
 If the cervix is outside the introitus —The
pessary is to be kept until 18th–20th week of
pregnancywhen the body of the uterus will
be sufficiently enlarged to sit on the brim of
the pelvis.
 The pelvic floor is too much lax — The patient is
to lie in bed with the foot end raised by about 20
 cm.
 If the cervix remains outside the
introitus even in the later months, it is
preferable to admit the patient at 36th
week.
 Th e patient should be in bed,
 Intravaginal plugging soaked with glycerine
and acrifl avine not only helps in reduction of
cervical edema but also facilitates its
dilatation.
 Prophylactic antibiotic,
 Manual stretching of the cervix or pushing
up the cystocele or rectocele past the
presenting part during uterine contractions
facilitates progressive descent of the head.
 If the head is high up and/or the
cervix remains edematous, thick or
undilated, cesarean section is a safe
 (1) The patient should lie flat on the bed;
 (2) If the mass remains outside, it should be
 covered with gauze soaked in glycerine and
acriflavine;
 (3) If subinvolution is evident, a ring pessary
may be put in until involution is completed;
(4) Prophylactic antibiotic is administered.
THANK
YOU
 FAVORABLE: In the majority, spontaneous
rectification occurs. As the uterus grows, the
fundus rises spontaneously from the pelvis
beyond 12 weeks. Thereafter, the pregnancy
continues uneventfully.
 UNFAVORABLE: In the minority, spontaneous
rectification fails to occur between 12 weeks
and 16 weeks.
 The developing uterus gradually fills up the
pelvic cavity and becomes incarcerated. The
probable causes of incarceration are: (a)
Projected sacral promontory; (b) Uterine
adhesions; (c) Pelvic tumor; (d) Idiopathic
(majority).