Exploring lectures in gynaecology

2021-03-20 12:00 AM

In the vaginal fluid, there are epithelial cells of the vagina that have peeled off, with Doderlein bacillus helping to convert glycogen into lactic acid, which has a protective effect on the vagina.

Measure vaginal pH

Principle of the method

The vaginal environment has an acid pH, mainly caused by lactic acid in vaginal fluids. Lactic acid produced by Doderlein directly from the glucogen transfer of vaginal cells is removed, the higher the amount of estrogen, the more glyco-gene in the vagina. Therefore, researching the pH of the vagina, it is preliminarily known about the body's estrogen concentration, knowing whether the vaginal environment has enough acid needed to protect the body against vaginal infections.

                  Bacillus Doderlein

Glycogen -------------------------------> Acid lactic

Technical results

Often using the color paper method, taking vaginal discharge onto paper and read the results on the sample board.

Normal vaginal pH around the date of ovulation is 4.2; Vaginal pH before and after menstruation ranges from 4.8 to 5.2; During menstruation days, the vagina has a pH of 5.4. In women with normal menstruation, if the pH is above 5.5, one must think of possible vaginitis caused by Trichomonas. Particularly vaginal fungus, can live in a normal or acid environment.

Get a test for vaginal cleanliness

Principle of the test

Normally vaginal discharge is a white, powder-like discharge. In the vaginal fluid, there are epithelial cells of the vagina that have peeled off, with Doderlein bacillus that helps to convert glycogen into lactic acid, which protects the vagina. In the vaginal translation there are also some mixed up and white verses. Vaginal testing helps us find the cause of vaginitis and contributes to the treatment of vaginitis by detecting the cause of the disease. This is also a mandatory test when performing a cervical stitching procedure for women with recurrent miscarriages when indicated for this procedure. 

So, what will this test look for in vaginal discharge? The test is intended to find:

Bacillus Doderlein.

Vaginal epithelial cells.

Other bacteria.

White blood cells.

Engineering - results

Do not douche the vagina, do not examine the gynecology before removing the vaginal slide. Take the fluid from the last pocket behind the vagina, spread it on a slide, fix it to the alcohol solution

90 ° + ether (equal ratio of alcohol and ether).

Results: people divided vaginal cleanliness into 4 degrees as follows:

Grade 1:

Bacillus Doderlein: many.

Vaginal epithelial cells: many.

Other bacteria: no, no fungus and Trichomonas.

Leukocytes: not available.

Grade 2:

Bacillus Doderlein: many.

Vaginal epithelial cells: many.

Other bacteria: few, no fungi and Trichomonas.

Leukocytes: few (+).

Grade 3:

Bacillus doderlein: reduced.

Vaginal epithelial cells: very few.

Other bacteria: many, there are fungi or Trichomonas.

Leukocytes: very good (+++).

Grade 4:

Doderlein bacillus: no longer available.

Vaginal epithelial cells: very few.

Other bacteria: very numerous, with fungus or Trichomonas.

Leukocytes: very good (+++).

So degrees 3 and 4 indicate that the vagina has moderate or severe inflammation and estrogen deficiency, depending on how much loss or loss of Doderlein subordinates. In the practice of cervical stitching, if the test shows a grade 3 or 4, then treatment must be done before the procedure.

Endocrine vaginosis

Principles

The ovaries secrete estrogen and, under its action, the epithelium of the vagina collapses, sometimes following the menstrual cycle. By studying the detachable cells of the vaginal epithelium, we can indirectly know the activity of the oocyte. Thus, the assessment of estrogen intake is key and progesterone evaluation is only indirect. Naturally, patients must be stopped on their hormonal drugs for a week before the test.

Proceed - Result

The swab is taken in 1/3 of the vagina or last bag and fixed as vaginal cleaning. The results are then dyed and read.

Normal vaginal slice epithelium consists of 4 cell layers:

Deep bottom layer: cells are small, oval or round, alkaline protozoa, large multiplication. It is common to see this type of cell in people who are postmenopausal.

The base is shallow: the cell is larger than the deep bottom layer, round or oval, large nucleus, alkaline-staining protoplasm. It is common to see shallow basal cells in babies who have not yet puberty, amenorrhoea due to lack of estrogen or in menopausal people.

The middle layer: consists of rhombohedral, semi-circular or elongated cells, 2-3 times larger than the basal cell, enlarged. During pregnancy, these cells have a rhombohedral shape with a folded margin.

Surface cell layer: polygonal cells, rather large. It changes with the menstrual cycle. There are types: types of nucleus loving alkaline and small eosinophilic nucleus loving alkaline (small nucleus, diameter less than 6 mm).

Monkey identified part of the vaginal map, people pay attention to the following points:

Distinguish the types of peeling cells on the map.

Eosinophil calculated index = ( Number of classes eosinophil b ề face x 100 ) / ( 200 vaginal cells are read )

Calculate the multiplier index = ( Number of supernatant cells x 100 ) / ( 200 vaginal cells read )

Both of these indices are percentages (%) and on the day of ovulation these are the highest (eosinophils are about 50-60%, kernels are about 60-80%). Both of these indicators represent the body's estrogen levels. According to Pundel, the eosinophil index is above 75%, it is considered hyper-estrogen. If this index is reversed, vaginitis occurs. According to Pundel, the progesterone effect can be sure if the cells fall in clumps and fold edges on the plaque.

To evaluate the oocyte: we conduct a vaginal smear as above, but do it every 3 days and do 6-7 times in a cycle. If on the plaque, the eosinophil index skyrocketed along with the nucleus index in 2-3 days, very few leukocytes on the plaque, it is the oocyst phenomenon.

Evaluation of pregnancy development:

During pregnancy, under the effect of estrogen and progesterone, vaginal smear changes sometimes 4 weeks pregnant. Eosinophil index decreased gradually to below 10%, many cells of the middle layer appeared, these cells were rhombohedral, falling in plaques and adjacent to each other. Eosinophil and kernels decreased, sometimes to 0%. Usually at 3 months of pregnancy, the eosinophil is below 10% and the multiplier is less than 15% and is considered a normal developing fetus. If the eosinophil index and the coagulant index increase gradually, the spindle cells will decrease, loss of the lysolysis phenomenon, if there is still a lysolysis, is a sign of miscarriage due to endocrine disorders, requiring treatment.

Vaginal map of cancer

Principles

Cancer of the cervix or genital tract cancers can be detected by examining a vaginal smear because cancer cells are shed from the cancerous organization.

How and results

Take the plaque as an endocrine vaginal plaque. In addition to taking the plaque from the last pocket, it is advisable to take a smear from the cervical area with a suspected lesion, fix with 90 ° alcohol + ether and then dye.

When reading the histogram, it is mainly to look for changes in stripped cells, such as nuclear / protoplasm ratio, nucleus, nucleus, change in protoplasm, change in cell shape; plaque with red blood cells, white blood cells.

According to Papanicolaou, cancer plates are classified into five categories:

Type 1 (pl): no abnormal cells.

Type 2 (p2): the nucleus is even, with slight changes but no cancer is suspected.

Type 3 (p3): abnormal cells, but not enough to conclude cancer.

Type 4 (p4): low number of cancer cells.

Type 5 (p5): has many cancer cells.

So type 3 (p3) is the type that needs reworking to help with diagnosis.

Clinical application: In principle, the tumor cell smear is applied in the diagnosis of genital cancer in the following organs, but the technique of taking the specimen varies slightly depending on the location of the tumor. u:

Cervical cancer (vaginal smear making).

Cancer of the lining of the uterus (making vaginal smear).

Vulvar cancer.

Breast cancer (extraction of fluid from the breast tumor).

Ovarian cancer: through ascites water or puncture through the same Douglas map to take fluid and test cells.

The classification is also divided into 5 levels as shown above.

Investigate cervical mucus

Principles

Normally around the day of oocyte release, the uterine opening is at maximum open on the day of oocyte release, the uterine mucus is clear, thin and can be spun into 8 cm long fibers. The above phenomenon is due to the development of follicles and increased secretion. When the corpus luteum is established, the ratio of progesterone / estradion = 2/1, the loss of cervical mucus decreases. Based on that, we know whether there are ovules or not. It is also important to know that in a cycle there is the following pairing:

After the period is cleared until the 10th day:

The cervix is ​​closed.

Less mucus, white, thick mucus.

From the 11th to the 22nd day of the cycle:

The cervix gradually closes.

The mucus is cloudy because of leukocytes.

From the 23rd to the pre-menstrual period:

The cervix is ​​closed.

Thick, cloudy mucus.

Proceeding and results

Measure the pH of the mucus :

Take cervical mucus onto color paper and compare it with the color chart. It is normal to have pH = 8 in the tube in the cervix, pH = 6-7 around the uterus.

If this substance is acidified, the penetration of sperm into the cervical canal will be difficult and the passage of sperm into the upper genital tract is also poor.

Crystallization of bowel mucus:

When cervical mucus is smeared on a glass, dried and placed on a microscope to see the mucus crystallize into a fern leaf (fern test positive), this occurs around the launch date. ovule.

application user

In clinical practice, we monitor the "uterine index", ie, the opening of the uterus and uterine mucus for the purpose of infertility treatment.

Usually starts on day 11 (for 28-30 days cycle) of the cycle. Including parameters:

The opening of the cervix.

Cervical mucus (amount, clear, thin) to predict the date of ovulation for the patient.

Diagram of temperature during menstruation

Principles

Estrogen causes body temperature below 37 ° C (about 36.4-36.6 ° C) and progesterone increases body temperature (about 37.2 ° C). Based on that we can monitor the woman's body temperature to predict the date of ovulation.

Conduct method and results

The following regulations must be complied with:

Use the same thermometer.

Take your temperature early in the morning, without your feet on the ground and at the same time (for example at 6am daily).

When there is a difference of 0.6 ° c, it is valid for diagnosis.

Thermocouples are in the same place (eg mouth-to-mouth thermocouple).

Ovulation occurs 6 hours after the body temperature has dropped to its lowest.

Application: serious, self-discipline is required for body temperature monitoring for women with relatively regular menstrual cycles. Reality gives good results when women apply the above regulations. Applied in the treatment of infertility and family planning, to prevent pregnancy, from the time the body temperature lowers to avoid intercourse for another 3 days to ensure no pregnancy.

Endometrial biopsy

Purpose

Assessment of the reception and effect of estrogen and progesterone on the uterine lining: oocyte release, implantation ability ...

Investigation of physical damage to the uterine lining.

Contraindicated

Suspected of being pregnant.

Bleeding.

Genital inflammation.

Proceed and evaluate the results

Open the cervix and use a small spoon to curl or use a Novak pump to suck. The swab was fixed with Bouin solution and sent for testing. If the purpose of a biopsy is to probe the endocrine status of the ovary, curettage is carried out 3-4 days before the period is expected, which is the period of pregnancy, the period when the uterine lining is fully affected enough of the corpuscles.

Typical images that we can have:

The uterine lining in the proliferation period: has a multiplication image, no secretion.

Period of secretion: there is a strong secretion phenomenon (with glycogen and mucus), the layer of the blood vessels is curled, the spines are linked, turning into the product.

Atypical images: images of the uterine lining are not seen at a normal cycle:

Malfunction of uterine lining: ductus less developed, almost straight, and less dividing cells.

Hyperplasia of the uterine lining: the glands dilate, almost encapsulate. Many images of multiplication, edema, congestion.

Thus, the biopsy of the uterine lining, in addition to helping us to know the physical damage such as uterine mucosal cancer or detect silent tuberculosis ... It also works to know the phenomenon of ejection. Whether or not ovule occurs and the endocrine status of the ovaries is assessed.

Intrauterine - oviductal inflation

Principles

A type of gas pump into the uterus (often used C02) to see if the gas escapes the fallopian tube into the abdomen or not.

Point

Check whether the oviduct is clear or not in the treatment of infertility.

Evaporate under pressure to treat tubular clogging. They also pumped under pressure to treat after tubal restoration surgery (pumped on 3, 15 and a month after tissue).

Contraindicated

Genital tract infections.

Vaginal bleeding.

Suspected of being pregnant.

Skill

Take antispasmodics before pumping (atropine is often used). The patient is in a gynecological position. Antiseptic, place the speculum, thoroughly disinfect the vagina, put the pump nozzle into the cervical canal and then inflate with no more than 200mmHg pressure. If the patient reacts: cough, nausea or pain, the pump must be stopped. The gas used is C02 (less irritating and easy to tolerate). Pump for 3 minutes at the rate of 30ml / min and the total amount of C02 gas pumped in was 100ml.

Get the results

On the chart: jagged expression when slightly through the oviduct, the vapor pressure then less than 100mmHg.

Hear sounds in the abdomen: use a two-speaker stethoscope and listen before and after the pump. When the steam begins to descend, you can hear a sound, like a blow, and know which side of the tap is open.

Patient Feeling: after the pump, have the patient sit up, if the catheter is catheterized, he or she has pain in the one-sided or bilateral epigastric fossa. The pain should go away after a day.

Search for sickle gas: if X-ray can see sickle gas in the middle of the liver and diaphragm.

However, the assessment is based on the graph, hearing the patient's sounds or feelings only knows the condition of the oviduct. The rate of fake catheter is 10%.

Dear ear

The rupture of the oviduct is blocked if pumped at high pressure: the patient has severe pain but no bleeding, the rupture usually resolves on its own.

Steam embolism is a potentially fatal complication. Usually occurs due to improper inflation technique when inserting the pump into the uterus, causing friction or inflating immediately after the menstrual period is cleared or the uterine lining abnormally ruptures (atrophic mucosa, uterine adhesions or uterine tuberculosis ). The clinical sign is a dry cough. If you see this, you must stop the pump immediately, immobilize the patient in an upright position for 15 minutes, otherwise the vapor may enter the heart chamber or in the cerebral circulation causing hemiplegia.

Retrograde infections: inflammation of the ovaries, inflammation of the lining of the uterus. Therefore, gynecological examination must be performed before inflating and after inflating, to give antibiotics to prevent infection.

Hysteroscopy - oviduct with Cotte's test

Principles

It is a scan of the uterus and two ovaries by injecting a contrast agent with a strong contrast, a certain viscosity, that does not cause reactions into the uterus. The drug used is an iodine contrast agent. There is an oil-soluble type (lipiodol) and a water-soluble type (visotrate). The oil-soluble type looks better, but can cause a blockage if the drug gets into the bloodstream. The water-soluble type is less dangerous, but the picture is unclear and not good because the drug passes quickly through the fallopian tube.

Point

Infertility has no known cause.

Hemorrhage, menstrual disorders.

Amenorrhea.

Suspected genital tumor.

Suspected of having genital deformities.

Contraindicated

Genital tract inflammation.

Suspect tap water.

Suspected of being pregnant.

Skill

The patient is in a gynecological position, antiseptic such as uterine inflation - ovary. Put him in the uterus and pump slowly 1 / 2ml of medicine one by one. Pump just right

check pressure gauge. When the 2 ml pump is pumped, it is done on X-ray to see how the medicine is entering the uterus and fallopian tubes. Normally only need to pump 5ml of drug and with a pressure of 150mmHg, the drug is absorbed into the two ovaries. Then shoot the movie.

If you need to see how the drug has spread into the peritoneal cavity, a screening scan is needed - called the Cotte's test. If using oil medicine, take the scan after 24 hours. If using drugs with iodine dissolved in water, the scan will be done after 1 hour.

Symptoms

Failure of the oviduct: due to the pump with a high pressure of more than 150mmHg, the patient has severe pain, the pump must be stopped immediately and lay motionless.

The drug is absorbed into the blood vessels (oil-soluble iodine). X-ray scans will be clear. The procedure must be stopped immediately and the patient immobilized, otherwise pulmonary embolism will occur.

Tumors of the uterine lining in the oviduct or in the peritoneum due to images of the uterine lining being removed during the injection.

Tubular infections, especially if the tubes are filled with water, can become stagnant

egg. Therefore, antibiotics must be used after the procedure.

Get the results

Hysteroscopy with Cotte's test shows an image of the uterus and its two tubes and the location of the lesions, if any.

Laparoscopy - microscopy

Principles

Laparoscopy is localized in the subframe after abdominal distention has been inflated. There are two pathways: through the abdominal wall and through the vagina.

Point

Infertility: for the condition of the ovaries, two ovaries, and fibrosis.

Suspected pregnancy outside the womb.

Amenorrhea.

Small tumors in the subframe.

Contraindicated

Old surgical scars (relatively).

History of peritonitis.

Skill

Prepare the patient as tissue: enema, hygiene ...

Anesthesia either with intravenous or general anesthesia.

Peritoneal inflatable (using C02 gas), pump 4 liters of C02 vapor.

Insertion of the bronchoscope.

A gauge should be placed in the uterine cavity to move the uterus to make it easier to see. Must see the uterus, two ovaries and two ovaries.

After bronchoscopy is complete, the patient is immobilized for 24 hours so as not to slightly stimulate the diaphragm.

Symptoms

Intestinal puncture: when the tube is inserted through the abdominal wall or through the posterior sac (transvaginal).

Subcutaneous air spillage: when poking a needle to pump C02 gas into the abdominal cavity, the needle is not fully inserted into the abdominal cavity that has pumped air in, thus causing an overflow of air under the skin of the abdomen, much spread to the chest, shoulders.

Infections: antibiotics must be given after the procedure.

Clinical application

A microscope can be used to check whether the two ovaries are open by pumping 5 ml of 9% salt water mixed with methylene blue through the cervical opening. If the fallopian tube clears, blue fluid will be released from the two tubes.

Today, due to the widely used endoscopic technique, through microscopy we can give an electric knife to sterilize, cut the fibrous function, biopsy of the ovary ...

Ultrasound in gynecology (ultrasound imaging)

Principles

Imaging ultrasound uses high frequency energy (from 2 to 7 million cycles), it produces echoes again after it encounters tissue structures from solid to liquid tissue and then transmits different echogenic images. This is a modern method of secondary exploration - obstetrics because it can predict quickly, accurately, and perform everywhere.

Apply

Diagnostic ultrasound imaging is applied in gynaecology for diagnosis "

The size of the uterus and uterine tumors.

Uterine malformation.

Chamber and body of the uterus.

Use the tap water.

Ovarian tumors.

Out of womb pregnancy.

Maturation of follicles.