Organization of the Organization of the teaching teaching - -

gynecology and gynecology and obstetricsobstetrics

Lecture for 5Lecture for 5thth year year

general medicine course and dentist medicine coursegeneral medicine course and dentist medicine course

ContentsContents

lecture'slecture's practice – (obstetrics hall, small gynecology practice – (obstetrics hall, small gynecology

procedures, department of risk pregnancy, procedures, department of risk pregnancy, department of gynecology surgery, ultrasound department of gynecology surgery, ultrasound laboratory, phantom exercise)laboratory, phantom exercise)

seminar'sseminar's practice before SEpractice before SE night duty (14-22; 22-6)night duty (14-22; 22-6)

Synopsis of the choice lecture: www.gyne.cz

State examinationState examination

two credits (winter and summer term)two credits (winter and summer term) 1414thth days practice days practice at the department of at the department of G&OG&O test from G&Otest from G&O practice part (CTG, HSG, phantom, practice part (CTG, HSG, phantom,

obstetrical examination, gynecological obstetrical examination, gynecological examination)examination)

assay (deadline – 4/2005)assay (deadline – 4/2005)

Basic literatureBasic literature

Possible literaturePossible literature

Possible literaturePossible literature

„„Virtual guide of the Virtual guide of the Department of G&O“Department of G&O“

Obstetrics part of the clinic

Entry for students

Outpatient and gynecology department

Lecture hall

Lecture hall

Practice cabinet

Library with the PC

Ultrasound laboratory

Department of gynecology surgery

Department of intensive care

Endoscopic operating hall

Delivery hall

Woman life cyclesWoman life cycles

newborn periodnewborn period childhoodchildhood pubertypuberty adolescenceadolescence fertile agefertile age climacteriumclimacterium senium (old age)senium (old age)

Cycles of woman organismCycles of woman organism

Ovarian cycleOvarian cycle

maturation of the foliculusmaturation of the foliculus ovulationovulation corpus luteumcorpus luteum corpus albicanscorpus albicans

Cycles of woman organismCycles of woman organism

Uterine cycleUterine cycle proliferative phase (picture 1.)proliferative phase (picture 1.) secretory phase (picture 2.)secretory phase (picture 2.) uterine cervix changes (cervical becomes thin uterine cervix changes (cervical becomes thin

through ovulation because of estrogen peak, through ovulation because of estrogen peak, than thick because of progesterone)than thick because of progesterone)

menstruation 28/5menstruation 28/5

Picture 1.Picture 1.

Picture 2.Picture 2.

Cycles of woman organismCycles of woman organism

Vaginal cycleVaginal cycle

in proliferative phase oesinophile cells exist in proliferative phase oesinophile cells exist (influence of estrogens)(influence of estrogens)

in secretory phase intermedial cells + in secretory phase intermedial cells + leucocytes existleucocytes exist (influence of progestin's)(influence of progestin's)

acidity of vaginal secretacidity of vaginal secret

Cycles of woman organismCycles of woman organism

Fallopian tubeFallopian tube and breast cycle and breast cycle

increased motility of tube in first phaseincreased motility of tube in first phase enlargement of the breast, edema, breast pain, enlargement of the breast, edema, breast pain,

increasing sensitivity at the end of the cycleincreasing sensitivity at the end of the cycle

Physiology of female reproduction Physiology of female reproduction systemsystem

Menstruation –Menstruation – periodic discharge of the periodic discharge of the blood, tissue, fluid and endometrial debris blood, tissue, fluid and endometrial debris from the uterus, the mean blood loss is 30 mlfrom the uterus, the mean blood loss is 30 ml

Menarche –Menarche – girl's first menstrual period – girl's first menstrual period – average 12,5 yearsaverage 12,5 years

Menopause –Menopause – last women menstrual period – last women menstrual period – average 50 yearsaverage 50 years

Physiology of female reproduction Physiology of female reproduction system II.system II.

Menstrual cycle –Menstrual cycle – LMP, 28/5, light, mild, LMP, 28/5, light, mild, heavyheavy

The ovarian follicle –The ovarian follicle – liquor folliculi, oocyte, liquor folliculi, oocyte, granulosa cells, theca externa, theca interna, granulosa cells, theca externa, theca interna, size before ovulation (14th day of the cycle) size before ovulation (14th day of the cycle) from 15 to 20 mmfrom 15 to 20 mm

Follicular –Follicular – proliferative phaseproliferative phase (ovulation) (ovulation) Luteal –Luteal – secretory phasesecretory phase (corpus luteum) (corpus luteum)

Sexual and reproductive healthSexual and reproductive health

Puberty Puberty

from first signs of sexual development till from first signs of sexual development till menarchemenarche

P1P1 – prepuberty – 9-10 yrs – prepuberty – 9-10 yrs P2P2 – early puberty – 10-11 yrs (start of hormone – early puberty – 10-11 yrs (start of hormone

secretion)secretion) P3P3 – thelarche 10-11 yrs, pubarche 11-12 yrs – thelarche 10-11 yrs, pubarche 11-12 yrs P4 P4 – breast fully developed– breast fully developed P5P5 – menarche – yrs 12,6 – menarche – yrs 12,6

Sexual and reproductive healthSexual and reproductive health

AdolescenceAdolescence

from menarche till stabilization of ovulatory cycles from menarche till stabilization of ovulatory cycles

duration 2,5 yearsduration 2,5 years after that fertile periodafter that fertile period

PerinatologyPerinatology

Independent scientific discipline

Screening test in pregnancyScreening test in pregnancy

screening interviewscreening interview weightweight Rh factor, HBRh factor, HB urine protein and sugarurine protein and sugar BPBP cytologycytology AFP, hCG, E3AFP, hCG, E3 Rh antibodyRh antibody

Abnormal pregnancyAbnormal pregnancy

pathological pregnancypathological pregnancy risk gravidityrisk gravidity pregnancy with increased probability of pregnancy with increased probability of

perinatal morbidity and mortalityperinatal morbidity and mortality

Risk factorsRisk factors

lack of antenatal carelack of antenatal care Social –Social – unmarried woman, smoking, drugs, unmarried woman, smoking, drugs,

alcohol, low education, low social class, poor alcohol, low education, low social class, poor diet, agediet, age

Biological –Biological – obesity, small height, breech obesity, small height, breech presentation, twins, disease of mother (DM, presentation, twins, disease of mother (DM, Rh incompatibility, cardiopathy, nephritis, Rh incompatibility, cardiopathy, nephritis, hypertension, hepatitis)hypertension, hepatitis)

Risk factors leading to prematurityRisk factors leading to prematurity

previous termination of pregnancyprevious termination of pregnancy twinstwins preeclampsiapreeclampsia hepatitishepatitis zoonosiszoonosis uterine malformationuterine malformation social risk'ssocial risk's

Antenatal visitAntenatal visit

The first visit ideally at 8-10 weeks gestation, monthly until 28 weeks, fortnightly until 36

weeks, weekly until delivery

HistoryHistory

DMDM tuberculosistuberculosis hypertensionhypertension past obstetrics historypast obstetrics history allergiesallergies LMPLMP first movementfirst movementss

Examination, investigationExamination, investigation

palpation, colposcopy, cytology, breastpalpation, colposcopy, cytology, breast urine (sugar, protein, bacilluria)urine (sugar, protein, bacilluria) blood (blood (HHb, red cell, b, red cell, ABOABO and rhesus group) and rhesus group) screening test for syphilis (RRR)screening test for syphilis (RRR) test for test for AAustralian anustralian antitigengen rubella antibodiesrubella antibodies anti HIV antibodiesanti HIV antibodies

Special visit 16Special visit 16thth week week

AFP, hCG and E3AFP, hCG and E3 Ultrasound examination:Ultrasound examination: to establish gestational age accuratelyto establish gestational age accurately to exclude major abnormalities of the fetusto exclude major abnormalities of the fetus to diagnose multiple pregnancyto diagnose multiple pregnancy localization of the placentalocalization of the placenta

PsychoprofylaxisPsychoprofylaxis

mother craftmother craft relaxation classesrelaxation classes books availablebooks available Social welfareSocial welfare iron (300 iron (300 μg a day)μg a day) iodine 100 mg a dayiodine 100 mg a day folic acid 500μg a dayfolic acid 500μg a day vitamin supplementationvitamin supplementation

Psychoprofylaxis II.Psychoprofylaxis II.

smoking -smoking - premature delivery, small babies premature delivery, small babies alcohol –alcohol – is cell poison, alcohol syndrome of is cell poison, alcohol syndrome of

fetus (short nose, low bridge, small eyes, fetus (short nose, low bridge, small eyes, mental retardation)mental retardation)

intercourse –intercourse – no restriction in normal G no restriction in normal G exercise –exercise – walking, swimming walking, swimming cloth –cloth – brassieres are not required, shoes – flat brassieres are not required, shoes – flat

heels, comfortable dressheels, comfortable dress bathing –bathing – not hot water, better shower not hot water, better shower

Vital statisticsVital statistics

Birth ratesBirth rates

Crude birth rateCrude birth rate iis the number of live birth per 1000 total s the number of live birth per 1000 total

population (includes men, children and population (includes men, children and women)women)

General fertility rateGeneral fertility rate iis the number of live births per 1000 women s the number of live births per 1000 women

between 15 and 44between 15 and 44

Obstetrical statisticsObstetrical statistics

StillbirthStillbirth (SB) (SB) child delivered after 24th week of pregnancy child delivered after 24th week of pregnancy

that did not show any sign of life + birth that did not show any sign of life + birth weight is greater than 500 grams or less than weight is greater than 500 grams or less than 500500 grams but not alive 24 hoursgrams but not alive 24 hours

Stillbirth rateStillbirth rate (SBR) (SBR) iis defined as the number of stillbirth per 1000 s defined as the number of stillbirth per 1000

total birth (still and live)total birth (still and live)

Obstetrical statistics II.Obstetrical statistics II.

Early neonatal deathEarly neonatal death (END) (END) is defined as the number of infants dying in the is defined as the number of infants dying in the

7 days after delivery per 1000 live birth7 days after delivery per 1000 live birth

Perinatal mortality rate (PMR)Perinatal mortality rate (PMR) nnumber of stillbirth + early neonatal death per umber of stillbirth + early neonatal death per

1000 total birth1000 total birth

Rectified perinatal mortalityRectified perinatal mortality nnumber of dead babies above 1000 gumber of dead babies above 1000 g

PMRPMRPMR

END

SBR

‰

Priority of PMRPriority of PMR

END ≤2000g

END ≥2000g

SA

SBR ≥2000g

‰

Causes of perinatal deathCauses of perinatal death

Ante partumAnte partum unknown in 25%unknown in 25% congenital abnormality 30%congenital abnormality 30% hypoxia (torsion of umbilicus, placental hypoxia (torsion of umbilicus, placental

abruption, eclampsiaabruption, eclampsia, vasa praevia, vasa praevia etc.) etc.)

Neonatal deathNeonatal death 80% due to preterm 80% due to preterm labourlabour, babies born before , babies born before

26th week have chance to survive 40%26th week have chance to survive 40%

Perinatal morbidityPerinatal morbidity

disorders of child development in perinatal disorders of child development in perinatal periodperiod

malformationmalformation - (genetic, infectious, toxic) – - (genetic, infectious, toxic) – sensoric (deafness); motoric (children's brain sensoric (deafness); motoric (children's brain paralysis); mental (slight brain dysfunction)paralysis); mental (slight brain dysfunction)

causecause - - prematurity, prolonged labour, prematurity, prolonged labour, mechanical damage, chronic hypoxia, late mechanical damage, chronic hypoxia, late solution of acute hypoxia, mother's disease – solution of acute hypoxia, mother's disease – DM, preeclampsiaDM, preeclampsia

Maternal mortalityMaternal mortalitymeans death connected to gravidity, labour till means death connected to gravidity, labour till

60 day's after the labour60 day's after the labour the number is 0,the number is 0,004 per 1000 total birth4 per 1000 total birth A. Specific risk –A. Specific risk – preeclampsia (I.), preeclampsia (I.),

haemorrhage (II.), shock, uterine rupture (III.), haemorrhage (II.), shock, uterine rupture (III.), puerperal infection (IV.), thrombosis (V.), puerperal infection (IV.), thrombosis (V.), connection with abortion (VI.)connection with abortion (VI.)

B. Unspecific risk –B. Unspecific risk – internal medicine (I.), internal medicine (I.), surgical disease (II.)surgical disease (II.)

C. Death without relation to GC. Death without relation to G

Maternal mortalityMaternal mortality

MM complete

MM rectified

Number of death women per 100 000 total birth in Czech Republic

MM in Czech Republic 1997 (0,08)MM in Czech Republic 1997 (0,08)

Decrease of maternal mortality due to:Decrease of maternal mortality due to:

control of infectioncontrol of infection blood transfusionblood transfusion advances in anesthesia and resuscitationadvances in anesthesia and resuscitation improvement in the health and nutritionimprovement in the health and nutrition prevention of disease in gravidityprevention of disease in gravidityDetailed analysis of any maternal mortality (Annual Report on Maternal Deaths).

MM - notesMM - notes

Hypertensive disease of pregnancy –Hypertensive disease of pregnancy – deaths deaths from eclampsia and preeclampsia can be from eclampsia and preeclampsia can be avoided i n 75% (early admission to hospital, avoided i n 75% (early admission to hospital, nutrition, control of BP)nutrition, control of BP)

Pulmonary embolism –Pulmonary embolism – prevention in prevention in puerperium, right checking of puls rate, puerperium, right checking of puls rate, heparinisation (LMWH), early mobilization, heparinisation (LMWH), early mobilization, therapy of thrombophlebitis, decrease of therapy of thrombophlebitis, decrease of cesarean section rate, no estrogen's in lactation cesarean section rate, no estrogen's in lactation inhibitioninhibition

MM - notesMM - notes

Amniotic fluid embolism – Amniotic fluid embolism – sudden collapse, sudden collapse, strong contraction's, dyspnoe, cyanosis, blood strong contraction's, dyspnoe, cyanosis, blood stained sputum – treatment oxygen, steroid's, stained sputum – treatment oxygen, steroid's, correction of coagulopathycorrection of coagulopathy

Hemorrhage –Hemorrhage – placental placental abruptionabruption, placenta , placenta praevia, coagulopathy, postpartum atonia, praevia, coagulopathy, postpartum atonia, uterine rupture, risk of home birthuterine rupture, risk of home birth

Cesarean section –Cesarean section – death's from associated death's from associated and undercurrent condition's (cardiac disease)and undercurrent condition's (cardiac disease)