Disseminated Intravascular Coagulation (DIC; Rare)
Risk Factors. Abruptio placenta (most common), severe preeclampsia, amniotic fluid embo-lism, and prolonged retention of a dead fetus.
Clinical Findings. Generalized oozing or bleeding from IV sites or lacerations in the presenceof a contracted uterus.
Management. Removal of pregnancy tissues from the uterus, intensive care unit (ICU) support,and selective blood-product replacement.
Uterine Inversion (Rare)
Risk Factors. Myometrial weakness (most common) and previous uterine inversion.
Clinical Findings. Beefy-appearing bleeding mass in the vagina and failure to palpate theuterus abdominally.
Management. Uterine replacement by elevating the vaginal fornices and lifting the uterus backinto its normal anatomic position, followed by IV oxytocin.
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Postpartum Hemorrhage
| Clinical | Diagnosis | Management |
| Uterus not palpable | Inversion (rare) | Elevate vaginal fornices, |
| IV oxytocin | ||
| Uterus like dough | Atony (80%) | Uterine massage, |
| oxytocin, ergot, PG F2α | ||
| Tears vagina, cervix | Lacerations (15%) | Suture & repair |
| Placenta incomplete | Retain placenta (5%) | Manual removal or uterine |
| curettage | ||
| Diffuse oozing | DIC (rare) | Remove POC, ICU care, blood |
| products prn | ||
| Persistent bleeding | Unexplained (rare) | Ligate vessels or hysterectomy |
Unexplained
If despite careful searching, no correctible cause of continuing hemorrhage is found, it may be necessary to perform a laparotomy and bilaterally surgically ligate the uterine or internal iliac arteries. Hysterectomy would be a last resort.
POSTPARTUM FEVER
Definition: Fever≥100.4° F (38° C) on≥2occasions≥6 hours apart, excluding first 24 hourspost-partum
PP Day 0: Atelectasis
Risk Factors. General anesthesia with incisional pain (most common) and cigarette smoking.
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Clinical Findings. Mild fever with mild rales on auscultation. Patient is unable to take deepbreaths.
Management. Pulmonary exercises (e.g., deep breaths, incentive spirometry) and ambulation.
Chest x-rays are unnecessary.
PP Day 1–2: Urinary Tract Infection
Risk Factors. Multiple intrapartum catheterizations and vaginal examinations due to pro-longed labor.
Clinical Findings. High fever, costovertebral flank tenderness, positive urinalysis (e.g., WBC,bacteria) and urine culture.
Management. Single-agent intravenous antibiotics.
PP Day 2–3: Endometritis
Most common cause of postpartum fever.
Risk Factors. Emergency cesarean section after prolonged membrane rupture and prolonged labor.
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| Basic Principles of Gynecology | 1 | |
FEMALE REPRODUCTIVE ANATOMY
Uterus
The embryologic origin of the uterus is from fusion of the two Müllerian ducts. Major struc-tures include the corpus, cornu, isthmus and cervix. Internal layers of the uterus include theserosa, myometrium, and endometrium. The ligaments attached to the uterus include the broad ligament, round ligaments, cardinal ligaments, and uterosacral ligaments. Anatomical positions of the uterus include anteverted, retroverted, mid-position. Normal uterine positiontips slightly anterior in the pelvis.
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Oviducts
The oviducts extend from the uterus to the ovaries. Segments of the oviducts are the intersti-tium, isthmus, ampulla, and infundibulum. The oviducts function in facilitating sperm migration from the uterus to the ampulla and the transportation of the zygote toward the uterus. They are attached medially to the uterine corpus, laterally to the pelvic side wall, and inferiorly to the broadligament.They receive dual blood supply from the ascending uterine artery and ovarian artery.
Ovaries
Functions of the ovaries include containment of oocytes within the ovarian follicles and production of reproductive and sexual hormones. The ovaries are attached by the ovarianligament to the uterine fundus, by the suspensory ligaments to the pelvic side wall, and by the mesovarium to the broad ligament. Lymphatic drainage of the ovaries is through the pelvic and para-aortic lymph nodes.
Vagina
The vagina is a tubular structure, 8–9 cm in length that extends from the introitus to the cervix. The vagina traverses the urogenital diaphragm through the genital hiatus of the levator ani. It functions as the female copulatory organ, an outflow tract for menstrual flow, and birth canal in parturition.
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TANNER STAGES OF DEVELOPMENTThe Tanner stages occur in a predictable sequence in the normal physical development of chil-dren, adolescents, and adults. The stages define physical measurements of development based on external primary and secondary sex characteristics, such as the size of breasts, genitalia, and development of pubic hair.Pubic Hair•Tanner I: none (prepubertal state)•Tanner II: small amount of long, downy hair with slight pigmentation on the labia majora•Tanner III: hair becomes more coarse and curly and begins to extend laterally•Tanner IV: adult-like hair quality, extending across pubis but sparing medial thighs•Tanner V: hair extends to medial surface of the thighsBreasts•Tanner I: no glandular tissue; areola follows the skin contours of the chest (prepubertal)•Tanner II: breast bud forms with small area of surrounding glandular tissue; areola begins to widen•Tanner III: breast begins to become more elevated and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast•Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast•Tanner V: breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla
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IIIFigure II-1-1. Tanner Stages of the Maturing FemaleIIIIVV
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GYNECOLOGIC PROCEDURES
Gynecologic Ultrasound
This imaging modality uses low-energy, high-frequency sound waves.
• Transvaginal transducers are utilized for lower pelvic masses, producing high-resolutionimages that are not influenced by the thickness of the maternal abdominal wall.
• Transabdominal transducers provide images throughout the entire pelvis as well asabdomen.
• Ultrasound works best when adjacent tissues have differing echodensities, particularly fluid/tissue interfaces.
Cervical Pap Smear
This is an outpatient office procedure. It is a screening, not diagnostic, test for premalignant cervical changes; it allows for early intervention, thus preventing cervical cancer.
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The diagnostic test for cervical dysplasia or cancer requires a histologic assessment made on a tissue biopsy specimen.
Specimens required. Pap smear should include cytologic specimens from 2 areas: stratifiedsquamous epithelium of transformation zone (TZ) of the ectocervix and columnar epithelium of the endocervical canal (EGG).
• Ectocervix specimen. Screening for squamous cell carcinoma, the most common can-cer of the cervix (80%), involves scraping the TZ. The TZ is the area of the ectocervix between the old or “original” squamocolumnar junction (SCJ) and the new SCJ.
– At puberty the vaginal pH falls, causing the “native” columnar epithelium to be transformed by metaplasia into normal-appearing “metaplastic” stratified squa-mous epithelium.
– The TZ is the location where 95% of cervical dysplasia and cancer develop.
• Endocervix specimen. Screening for adenocarcinoma, the second most common can-cer of the cervix (15%), involves scraping the endocervical canal with cytobrush.
Columnar epithelium Stratified squamous
epithelum
Old squamo- New squamo-
columnar junction columnar junction
Endocervical canal 
Transformation zone
Figure II-1-2. Development of T-Zone
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Specimen collection methods. Studies show that while the “liquid-based” methods, compared with the “traditional” method, reduces the percentage of unsatisfactory specimens, the 2 meth-ods are equivalent in performance for detection of cervical dysplasia.•Traditional Pap smears. – Samples are obtained using a wooden spatula on the ectocervix and a cyto-brush for the endocervical canal rotating in one direction 360°. The cells from each area are then smeared evenly onto a glass slide, which is then fixed in formalin, then stained and examined under a microscope by a cytologist. – Potential problems include insufficient smearing of all abnormal cells onto the glass slide, air-drying artifacts if fixing is delayed, and clumping of cells, making cytology assessment difficult.•Liquid-based Pap smears. – Specimens can be collected using cervical broom. Long central bristles are placed into the endocervix and short outer bristles over the ectocervix. The broom is rotated 5 times in the same direction, collecting and sampling both endocervical cells and transformation zone. The cervical broom is placed in the preservative solution and rotated 10 times vigorously to release collected material into the solution. – Advantages include less chance of abnormal cells being discarded with the collect-ing instrument, less likelihood of air-drying artifacts, and cells spread more evenly on glass slide surface.
BladderCervixSlide with cellsFigure II-1-3. Taking a Sample of Cells during Pap SmearSpeculum
Uterus
ColposcopyColposcopy is an outpatient office procedure. It uses a binocular, short focal-length instrument with a built-in light source to look at the cervix through a speculum. The purpose is to (1) visually identify where the abnormal Pap smear cells originated, and (2) biopsy that area to send for histologic diagnosis.
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• The ectocervix is visually examined to localize areas of abnormal epithelium. Dilute acetic acid should be applied to the cervix to aid in the detection of dysplasia. Areas of abnormal-appearing tissue that are biopsied include punctation, mosaicism, white epithelium, and abnormal vessels. The specimens are sent to pathology for definitivediagnosis.
Figure II-1-4. Colposcopy
Cold Knife Cone Biopsy
Cold knife cone biopsy is a minor outpatient surgical procedure performed in the operating room under either local or general anesthesia. It is a diagnostic test that examines the histology of cervical lesions.
• A cone-shaped tissue specimen is obtained with a scalpel by performing a circumfer-ential incision of the cervix with a diameter that is wider at the cervical os and nar-rower toward the endocervical canal. This tissue is sent to pathology for histologic diagnosis.
• Wide-shallow cone is performed if the Pap smear shows changes more severe than thecolposcopically directed biopsy.
• Narrow-deep cone is performed if a lesion extends from the exocervix into the endo-cervical canal.
• Long-term risks include cervical stenosis, cervical insufficiency, and preterm birth.
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Figure II-1-5. Cold Knife Cone Biopsy
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