Meet the Expert

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Survival Sebagai Pelajar Perubatan di Mansurah

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Delayed Puberty

Definition:

• Absence of breast development by the age 14 years
• If more than 3 years elapsed between the onset of breast development & menarche
• Absence of menses by the age of 16 years in presence of good secondary sex characters

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Puberty

Definition: It is the period of life having a physiological changes proceeds over an average 4-5 years after initiated during which-

• Sex character develop
• Sex organ mature
• Reproductive capacity attained- maturation of hypothalamus, pituitary and gonads

Adolescence - Includes the physiologic, social, behavioral & personal independence leading to the development of adult identity. It is broader term than puberty.

Theories of Pubertal Initiation:
The exact cause of the initiation of pubertal changes is not fully understood

• Gonadostat theory
• Critical weight & body fat mass
• Onset of adrenal activity
• Sleep mechanism
• Central nervous system maturation

Pubertal Changes:
The sequence of events occurring at the time of puberty:

• Thelarche (breast development)- breast bud appears at age 9-11, sign of ovarian production & completed over 3 years.
• Adrenarche (maturation of adrenal gland)- production of 17 ketosteroids, DHEA & DHEAS, development of pubic (pubarche) and axillary hairs, follows after thelarche but can be first sign in 20% of girls.
• Growth spurt- 3 phases; 5cm/year of minimum growth velocity, 8.5cm/year of peak height velocity & stage of decrease velocity.
• Menarche (spontaneous first menstrual flow)
• Anatomical maturation of the genital tract
• Behavioral changes and psychic maturation

Pubertal Stages: Tanner's Classification:
Tanner's staging is a system based on the orderly, progressive development of breast (thelarche) & pubic hair in females.

Stages of pubic hair growth	Stages of breast development
No pubic hair.	No breast tissue (elevation of papilla only).	Stage  1
Sparse, long pigmented hair along the labia major.	Breast bud.	Stage  2
Darkening, coarsening, curling of hair which extends upwards and laterally.	Enlargement of breast and areola without separation.	Stage  3
Hair of adult consistency limited to the mons.	Areola and nipple form a mound on top of underlying breast tissue.	Stage  4
Hairs spread to the medial aspect of the thighs.	Adult configuration with areola and breast having smooth contour.	Stage 5

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Factors Affecting the Age of Menarche:
Age of menarche varies from society to society and in Egypt, it usually occurs around 12.5 years. Many factors can affect the age of menarche such as:

• Socio-economic factors
• Environmental factors
• Racial & geographical factors
• Medial & endocrinological diseases- blindness, deafness, epilepsy, obesity & diabetes (all accelerates puberty development)

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Gynecology Book

Contents

• Anatomy of the Female Tract
• Embryology of the Female Genital Tract
• Gynecology Case Taking

1. History Taking- (Personal History, Chief Complaint, Menstrual history, Obstetric history, Past History, Family History, Present History)
2. Clinical Examination- (General examination, Abdominal Examination)
3. Investigation
4. Diagnosis

• Reproductive Endocrinology & Infertility

1. Gynecology Endocrinology
2. Physiology of the Menstrual Cycle
3. Puberty, Delayed Puberty & Precocious Puberty
4. Menopause
5. Menstruation Related Symptoms
6. Amenorrhea
7. Abnormal Bleeding from Genital tract
8. Sexuality & Sexual Dysfunctions
9. Female Genital Cutting (Mutilation)
10. Infertility
11. Ovulation Dysfunction
12. Virilization in Female

• Reproductive Tract Infections

1. Sexual Transmitted Disease (STD)
2. Pelvic Inflammatory Disease (PID)
3. Infection of Female Genital Tract
4. Female Genital Tuberculosis
5. Bilharziasis of Female Genital Tract
6. Leukorrhea
7. Pruritus Vulvae

• Displacements of Female Genital Tract
• Traumatic Lesions & Urogynecology
• Uterine Fibroid
• Endometriosis
• Adenomyosis
• Cysts & Swellings Related to Vulva
• Chronic Vulval Dystrophies (Dermatoses) 
• Gynecologic Oncology
• Contraception
• Breast Evaluation for the Gynecologist

1. Benign Breast Disease  (History, Clinical Examination)
2. Breast Cancer (History, Clinical Examination)

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Partograph

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Introduction:

• A partograph is a graphical record of the observations made of a women in labour
• For progress of labour and salient conditions of the mother and fetus
• It was developed and extensively tested by WHO
• Friedman’s partogram devised in 1954 was based on observations of cervical dilatation and fetal station against time elapsed in hours from onset of labour. The time onset of labour was based on the patient’s subjective perception of her contractility. Plotting cervical dilatation against time yielded the typical sigmoid or ‘S’ shaped curve station against time gave rise to hyperbolic curve.
• The partograph can be used by health workers with adequate training in midwifery who are able to:

o   Observe and conduct normal labour and delivery

o   Perform vaginal examination in labour and assess cervical dilatation accurately

o   Plot cervical dilatation accurately on a graph against time

• There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery
• Whether used in health centers or in hospitals, the partograph must be accompanied by a partogram of training in its use and by appropriate supervision and follow up

Objectives:

• Early detection of abnormal progress of a labour
• Prevention of prolonged labour
• Recognize cephalopelvic disproportion long before obstructed labour
• Assist in early decision on transfer, augmentation or termination of labour
• Increase the quality and regularity of all observations of mother and fetus
• Early recognition of maternal or fetal problems
• The partograph can be highly effective in reducing complications from prolonged labour for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc) 

Functions:

• The partograph is designed for use in all maternity settings, but has a different level of function at different levels of health care
• In health center, the partograph’s critical function is to give early warning if labour is likely to be prolonged and to indicate that the woman should be transferred to hospital (ALERT LINE Function)
• In hospital settings, moving to the right of alert line serves as warning for extra vigilance, but the action line is the critical point at which specific management decisions must be made
• Other observations on the progress of labour are also recorded on the partograph and are essential features in management of labour

Components:

The partograph can be divided into three parts:

• Part 1: Fetal Condition (top)
• Part 2: Progress of labour (middle)
• Part 3: Maternal Condition (bottom)

Outcomes:

[A] Part 1: Fetal Condition

This part of the graph is used to monitor and assess fetal condition:

• Fetal heart rate
• Membranes and liquor
• Moulding of the fetal skull bones

Fetal heart rate	Membrane & Liquor		Moulding of fetal skull bones
(1) Basal fetal heart rate >160 bpm = tachycardia <120 bpm = bradycardia <100 bpm = severe bradycardia	I	Intact Membranes	0	Separated bones, suture felt easily
	C	Rupture membranes + clear liquor	+	Bones just touching each other
	M	Rupture membranes + meconium-stained liquor	++	Overlapping bones (reducible)
(2) Deceleration Yes or No
	B	Rupture membranes + blood-stained liquor	+++	Severely overlapping bones (non-reducible)
(3) Relation to contraction Early Variable Late
	A	Rupture membranes + absent of liquor	↑ molding with head high in pelvis is an ominous sign of cephalopelvic disproportion

[B] Part 2: Progress of Labour

This section of the graph has its central feature; a graph of cervical dilatation against time, use to assess the following:

• Cervical dilatation
• Descent of fetal head
• Fetal position
• Uterine contractions

It is divided into a latent phase and active phase:

Latent phase:	Active phase:
It starts from onset of labour until the cervix reaches 3 cm dilatation	Once 3 cm dilatation reached, labour enters the active phase
Lasts 8 hours or less	The cervix should dilate at a rate of 1 cm/h or faster
Contractions at least 2/10 min	Contractions at least 3/10 min
Each lasting < 20 seconds	Each lasting <40 seconds

Alert Line (health facility line)

• The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm/hour
• Moving to the right or the alert line means referral to hospital for extra vigilance

Action Line (hospital facility line)

• The action line drawn 4 hours to the right of the alert line and parallel to it
• This is critical line at which specific management decisions must be made at the hospital

[C] Part 3: Maternal Condition

• Name / DOB / Gestation
• Medical / Obstetrical issues
• Assess maternal condition regularly by monitoring:

o   Drugs, IV fluids 7 oxytocin, if labour is augmented   

o  Pulse, blood pressure  

o  Temperature  

o  Urine volume, analysis for protein & acetone

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Genital System Changes During Pregnancy

• Uterus

a) Body of uterus - 

Anatomy
Position	Pelvic organ at 1st trimester, abdominal organ after 12weeks & dextrorotated as it enlarges due to presence of left side rectosigmoid colon.
Shape	Pear shape at 1st few weeks, globular shape in the 1st trimester & ovoid shape at term.
Size	Similar to fetal head at 12th weeks, at the level of umbilicus at 24th weeks & at the level of xiphi-sternum at 36th weeks.
Consistency	Softening of the uterus is due to ↑ vascularity & presence of amniotic fluid.
Weight	↑ from 50-70 gm to 1000 gm at full term (20x ↑ in weight).
Capacity	↑ from 10 ml to 5L or more (500-1000x ↑ in capacity)

Histology
Endometrium	Differentiated into deciduas
Myometrium	- Hypertrophy & hyperplasia of the muscle fibers due to ↑ synthesis of polyamines. - Differentiated into 3 layers: outer longitudinal- push fetus during delivery, middle interlacing- preventing post-partum hemorrhage & inner circular- hold the fetus up. ↑ elastic fibers facilitating uterine distension.
Peritoneum	Hypertrophied & firmly attached to the upper uterine segment & loosely attached to the lower uterine segment. (important in caesarean section)
Uterine ligaments	Hypertrophy of the broad, round, cardinal & uterosacral ligaments.
↑ contents	Blood vessels, lymphatics & nerves.

Physiology
Palmer’s sign	Uterine contraction felt during vaginal examination in early pregnancy [these are irregular & painless]
Braxton-Hick’s	Uterine contraction felt during 2nd & 3rd trimester of pregnancy [sporadic, unpredictable, non-rhythmic & its intensity not exceeding 25mm Hg]
False labour pains	Uterine discomfort & account for false labour pain as pregnancy advances [↑ in frequency & intensity, no effects on dilation & effacement of cervix]
Uteroplacental blood flow	Progressive ↑ in uteroplacental blood flow to reach 450-650ml / minute at term

b) Isthmus - is transformed into the lower uterine segment.

Upper uterine changes during pregnancy (click at the image to enlarge)

Lower uterine changes during pregnancy (click at the image to enlarge)

• Cervix

- Hypertrophy & softening of the cervix

- Hypertrophy of cervical mucosa

- Increased vascularity of the cervix

- Cervical mucous plug closes the cervical canal due to excess cervical secretion, it is discharged as bloody show with the onset of labor

- Rearragement of collagen fibers 

• Vagina & vulva

- Hypertrophy & softening

- Varicose veins of the vulva (Kluge's sign)

- Blue or violet discoloration of the vulva (Chadwick's sign)

- Vaginal pH is acidic (3.5 - 6) due to increased production of lactic acid by lactobacilli

- Vaginal cytology show increased small intermediate cells under the effect of progesterone  

• Ovary

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1. Genital System Changes
2. Breast Changes
3. Cardiovascular Changes
4. Respiratory Changes
5. Gastrointestinal Changes
6. Liver & Gall Bladder Changes
7. Urinary Changes
8. Skin Changes
9. Skeletal Changes
10. Nervous System Changes
11. Metabolic Changes
12. Endocrinal Changes
13. Immune System Changes

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Scapula

Posterior View

Shoulder girdle & thoracic cage

Definition: scapula is a flat bone that connects the trunk to the upper limb. It is the posterior bone of shoulder girdle. It is also known as shoulder blade.

Shape: triangular in outline.

Site: lies on the postero-lateral aspect of the chest wall extending from the 2nd to 7th rib.

Side determination:

1. Glenoid cavity: is directed laterally & upwards.
2. Spine is directed backwards.
3. Subscapular fossa: is directed fowards.

Posterior, anterior & lateral sides of scapula

General features: It is consist of 2 surfaces, 3 angles, 3 borders, 3 processes

• Surfaces:

Costal (anterior) surface	Dorsal (posterior) surface
- It is directed forwards & medially - Facing the ribs - It carries subscapular fossa	- It is directed backwards & laterally - Palpated from back - Spinous process, divides it into two fossae: infraspinous fossa & supraspinous fossa

• Angles:

Superior angle	Lateral angle (head)	Inferior angle (apex)
- Thin, smooth & rounded - Right angle - Between superior & medial borders - Opposite the 2nd rib	- Thickest part of the bone - Glenoid cavity - Articulate with head of humerus - Supra & infraglenoid tubercles	- Thick & rough - Acute angle - Between medial & lateral borders - Opposite the 7th rib

• Borders:

Superior border	Lateral (axillary) border	Medial (vertebral) border
- Thinnest & shortest - Extend from the superior angle to coracoids process - Near the root of coracoids process, there is suprascapular notch	- Thickest - Extend from the glenoid cavity to the inferior angle - At the upper end, there is infraglenoid tubercle	- Average thickness & longest - Extend from the superior angle to the inferior angle - Presents anterior lip, posterior lip & an intermediate narrow area

• Processes:

Spinous process	Acromion process	Coracoid process
- A triangular plate of bone - Divides the dorsal surface into 2 fossae - It has 2 ends: §  Lateral end- continuous with acromion process §  Medial end- forms the root of the spine - It has 2 surfaces: §  Upper surface §  Lower surface - It has 3 borders: §  Anterior border- attached to scapula §  Posterior border- free, subcutaneous (crest of spine), has upper &lower lips §  Lateral border- free, bounds the spinoglenoid notch	- A projecting forwards from the lateral end of the spine making right angle - It has 2 surfaces: §  Upper surface §  Lower surface - It has 2 borders: §  Medial border- continuous with upper lip of crest of spine, carries small articular facet for articulation with clavicle (acromioclavicular joint) §  Lateral border- continuous with lower lip of the crest of spine at the acromial angle	- A projection from the upper border of the head (glenoid cavity - Directed fowards & slightly laterally - Root of process is related medially to the supraglenoid tubercle & laterally to the suprascapular notch - It has 2 surfaces: §  Upper surface- carries a rough area for muscle attachment §  Lower surface - It has 2 borders: §  Medial border §  Lateral border

Anterior surface of scapula (click at the image to enlarge)

Posterior surface of scapula (click at the image to enlarge)

Lateral border of scapula (click at the image to enlarge)

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Hazard of Smoking to the Individual, Family & Environment

Smoking is associated with significant morbidity and mortality. Smoking still remains one of the leading cause of preventable death. Smoking has the dubious distinction of affecting all the systems from head to foot. Citizens of western countries no longer regard smoking as a good option to relieve their stress. Numerous universities worldwide do not allow their students to smoke in the campus.

General facts about smoking:

• About 111, 000 people die every year due to smoking or passive smoking.
• One person dies every 5 minutes from smoking related diseases.
• The NHS spend over four hundreds million pounds each year on treating smoking related illness.
• Cigarettes and other smoking materials are a very common cause of fires.
• Smoking materials account for almost 240 deaths every year.
• Out of 6, 600 fires 40% are cause by smokers- thats 2, 640 fires!

How smoking ruin the body:

• Heart disease- nicotine raises blood pressure making the heart work harder therefore it need more oxygen which is cut down from carbon monoxide from getting to the heart. This cause severe heart attacks. 
• Lung cancer- this start with the smokers cough producing lots of phlegm. Chest infection and bronchitis begins causing the lungs to be destroyed.

How does smoking affect non-smokers:

• Non smokers can suffer from passive smoking.
• Non smokers can suffer from sore eyes, sneezing, runny nose, headaches, coughing, wheezing and hoarseness all due to other people's smokes
• Children of smokers have a very high risk of getting bronchitis, pneumonia and other chest infections.
• Asthmatic have a high risk of getting attacks due to other people's smoke.
• Non smokers have a high risk of getting lung cancer due to other people's smoke.

How the environment affect the environment:

• Each cigarette manufacturing machines uses 4 miles of paper per hour which could be used instead for many other important things.
• Tobacco is the most widely grown non-food crop in 120 countries therefore less land is available for food crop. Between 10 to 20 million people could be fed if food crop was grown in its place.
• Burning tobacco is the main source of indoor pollution in the developed world as it contains over 4,000 dangerous chemicals.
• One whole tree is needed to cure the tobacco for 300 cigarettes.
• Cigarette smoke generates contains two of the main gases related to the greenhouse effect they are carbon dioxide and methane.
• If  smoker smoked a packet of cigarettes a day, the habits would cost around $1800 per year. Wouldn't they rather do something fun or beneficial with that money, like donate to the orphan.
• A broken leg of a smoker takes 80% longer to heal than a nonsmoker (276 days compared to 146).
• Secondhand smoke cause 3,000 causes of lung cancer in nonsmokers each year.

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Chief Complaint

• The 1st complaint in any obstetric case should be cessation of menstruation since the last normal menstrual period (LNMP). 
• This is followed by the main complaint (s) that brings the patient to hospital.

- Use patient own words

- Arranged in chronologically if the complaint is more than one. 

Obstetric History:

Past History
Family History
Present history

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Menstrual History

The items of menstrual history include the following items in sequence:

• [1] Menarche- it is the 1st menses in the woman's life. Normal age is between 9-16.

Precocious puberty: earlier than 9 years old

Delayed puberty: later than 16 years old

• [2] Cycle rhythm- whether the menses occur in regular or irregular period of time.
• [3] Cycle length- it is the duration from 1st day to the next 1st day of menses cycle. Normal cycle length ranges from 21 to 35 days.

<21 days - polymenorrhea

>35 days - oligomenorrhea 

• [4] Duration of menstrual flow- It is the period of time during which the menstrual blood flow through the vagina. Normal duration of menstrual flow ranges from 2-7 days.

Menorrhagia: prolonged >7 days and/or 80cc occurring at regular intervals = hypermenorrhoea

Metrorrhagia: irregular uterine bleeding not related to menstruation 

Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals

Polymenorrhagia: frequent heavy/ prolonged menstruation

Postmenopausal bleeding: irregular vaginal bleeding following menopausal cessation of menstruation by 1 year

Intermenstrual bleeding: irregular vaginal bleeding in between regular normal menstruation = breakthrough bleeding

Contact bleeding: irregular vaginal bleeding following tissue contact (examination/intercourse)

• [5] Character of flow- it is regarding the amount, colour and odour of the blood. Normal amount is not more than 80 ml of the total volume. Normal colour of mense blood is dark red.

Excessive flow- indicated by present of clots

Bright red- may indicate excessive flow especially if associated with clots

Polymenorrhea: frequent menstruation occurring at regular intervals (<21 days)

Oligomenorrhoea: infrequent menstruation varying between 35 days and 6 months

Hypomenorrhoea: scanty regular menstruation (<20 ml)  

Amenorrhoea: absence of menses  for 3 successive regular cycles or 6 months 

• [6] Dysmenorrhea- It is pain related to menses. It is severe enough to prevent the woman from doing her daily activities. Dysmenorrhea may be primary or secondary. The tolerable pain at menses is called 'menstrual molimina'.

Primary (spasmodic) dysmenorrhoea

Secondary (congestive) dysmenorrhoea 

Special types of dysmenorrhoea

• [7] Intermenstrual Period (IMP)- It is the period from the last day of flow to the next 1st day of flow. Abnormal pain, bleeding or discharge may be presence or absence. 

Normally ovulation may cause pain (Mittleschmerz's pain), bleeding (ovulation spotting) or increase of vaginal discharge (ovulation cascade). 

• [8] Last Normal Menstrual Period (LNMP)- The 1st day of the last normal menstrual period should be asked for. To certain that the last menstrual period was normal it should fulfill the following criteria:

1. It should be normal characters
2. It should be preceded by 3 consecutive normal cycles
3. It should not be preceded by the use of hormonal contraceptive

NB- The expected date of delivery (EDD) is calculated & mentioned before. 

• [9] Current use of contraceptive- It should be mentioned here if it is currently used. The type of contraceptive method and the duration of its use should be asked.

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