imperforate hymen

Imperforate hymen

The infant may have a bulging, yellow-gray mass at or beyond the introitus. Several case reports describe the presence of an abdominal mass in association with urinary obstruction.

Ultrasonography is an essential first step in diagnosis, precluding unwise and unplanned surgical intervention with resultant injury to the urethra or other pelvic structures, and excluding other more complicated anomalies

Diagnosis depends on an awareness of the condition as a possible anomaly, and surveillance with well-child care. When the condition presents as abdominal pain or an abdominal mass (see image below), diagnostic testing is often extensive because the condition is not considered.^[1] 

An abdominal mass may prompt the consideration of an ovarian tumor and tumor markers may be obtained. While a false-positive elevation of CA-125 in premenopausal women has numerous causes, and testing has thus been discouraged, elevated CA-125 and 19.9 have been described with imperforate hymen, and may delay the diagnosis.^{[12, 13]}

After initial presentation and suspected diagnosis of an obstructive anomaly in an adolescent, the use of continually-administered oral contraceptive pills to suppress menses allows symptomatic relief and essential time needed to obtain further diagnostic studies. In addition, the use of nonsteroidal anti-inflammatory drugs can provide pain relief; narcotic analgesics may be required.

Surgical intervention for imperforate hymen should require only one definitive procedure to evacuate the retained secretions and to ensure the maintenance of patency. Simple drainage of the material confined beyond the hymen is contraindicated because it does not allow for adequate drainage of the thick fluid, is not definitive, and increases the risk of infection (pyometras).

Two techniques are most commonly advocated: simple incision and small excision of the membrane. Simple incision of the hymen may be associated with postoperative stenosis with strictures, and it is not the method generally preferred at many centers. Use of an X -shaped incision ought to be the method of choice.

An elliptical excision of the membrane is performed close to the hymenal ring, using needle-tip cautery, followed by evacuation of the obstructed material. This technique is considered to be most effective in definitive treatment. Avoid compressing the uterus and fallopian tubes to speed evacuation of the trapped contents after the hymen is incised.

contraindications of cocp

Contra-indications see notes above; 
also pregnancy

personal history of venous or arterial
thrombosis, severe or multiple risk factors for arterial
disease or for venous thromboembolism (see above),

heart disease associated with pulmonary hypertension
or risk of embolus;

sclerosing treatment for
varicose veins;

migraine (but see above);

transient
cerebral ischaemic attacks without headaches;

liver
disease including disorders of hepatic excretion (e.g.
Dubin-Johnson or Rotor syndromes),

infective
hepatitis (until liver function returns to normal);

systemic
lupus erythematosus;

acute porphyria (section
9.8.2);

liver tumour;

gallstones;

active trophoblastic
disease (until return to normal of urine and plasma
gonadotrophin concentration);

history of haemolytic
uraemic syndrome or history during pregnancy of
pruritus, cholestatic jaundice, chorea, pemphigoid
gestationis;

history of breast cancer but can be used
after 5 years if no evidence of disease and nonhormonal
methods unacceptable;

undiagnosed vaginal
bleeding;

breast-feeding (until weaning or for 6
months after birth—Appendix 5)

horner syndrome-syphillis

The neuro-ophthalmic manifestations of early neurosyphilis are diverse.

Early neurosyphilis results in vasculitis and vascular compromise, which often presents as a stroke-like clinical finding.

Therefore, any of the cranial nuclei and their pathways may be affected, which results in isolated as well as complicated palsies of the third, fourth, and sixth cranial nerves.
Abnormalities of the saccadic systems and smooth pursuit systems may also occur.

Other neuro-ophthalmologic manifestations that have been described include the superior orbital fissure syndrome that arises from focal gummas, brainstem infarction, basilar meningitis, homonymous hemianopia, chiasmal syndrome with bitemporal hemianopia, cortical blindness, lateral medullary plate syndrome, Horner’s syndrome, and internuclear ophthalmoplegia.

Late neurosyphilis may cause a general paresis and tabes dorsalis.

HVS

High Vaginal Swab (HVS) is a technique used in Obstetrics and Gynaecology to obtain a sample of discharge from the vagina. This is then sent for culture and sensitivity.

trichomoniasis

Trichomoniasis, sometimes referred to as "trich", is a common cause of vaginitis.

It is a sexually transmitted disease, and is caused by the single-celled protozoan parasite Trichomonas vaginalis producing mechanical stress on host cells and then ingesting cell fragments after cell death.^[1]

Trichomoniasis is primarily an infection of the urogenital tract; the most common site of infection is the urethra and the vagina in women.

Typically, only women experience symptoms associated with Trichomonas infection.

Symptoms

• Symptoms include inflammation of the cervix (cervicitis), urethra (urethritis), and vagina (vaginitis) which produce an itching or burning sensation. 
• Discomfort may increase during intercourse and urination.
• There may also be a yellow-green, itchy, frothy foul-smelling ("fishy" smell) vaginal discharge. 
• In rare cases, lower abdominal pain can occur. 
• Symptoms usually appear in women within 5 to 28 days of exposure.^[2] 
• In many cases, men may hold the parasite for some years without any signs (dormant). 
• Some sexual health specialists have stated that the condition can probably be carried in the vagina for years, despite standard tests being negative.^[3] 
• While symptoms are most common in women, some men may temporarily exhibit symptoms such as an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation

diagnosis 
Trichomoniasis is diagnosed by visually observing the trichomonads via a microscope.

TreatmentTreatment for both pregnant and non-pregnant patients usually utilizes metronidazole (Flagyl) but with caution especially in early stages of pregnancy^[7] 2000 mg by mouth once. Sexual partners, even if asymptomatic, should be concurrently treated.

Syphilis

http://www.babycenter.com/0_syphilis-during-pregnancy_1427386.bc?page=2
Syphilis progresses in stages, with symptoms that differ from one stage of the disease to the next and from person to person. In some cases, the symptoms aren't noticeable and you may not know you have the disease until you're tested.

first  stageIn the first stage, known as primary syphilis, the characteristic symptom is a painless and highly infectious sore (or sores) with raised edges called a chancre.
The chancre shows up at the site of infection, usually about three weeks after you're exposed to the bacteria, though it may appear earlier or up to three months later.
Because the chancre may be inside your vagina or your mouth, you might never see it.
A chancre could also show up on your labia, perineum, anus, or lips, and your lymph nodes may be enlarged in the area where the sore develops.

If you get appropriate treatment at this stage, the infection can be cured. If you're not treated, the sore lasts three to six weeks and then heals by itself. However, the spirochetes are likely to continue to multiply and spread throughout the bloodstream. When this happens, the disease progresses to the next stage, called secondary syphilis.

secondary stageIn the secondary stage, syphilis can have a variety of symptoms that show up in the weeks or months after the sore first appeared, but again, they might not be noticeable.

Most people with secondary syphilis develop a non-itchy rash, commonly on their palms and soles, though it may also appear on other parts of the body.
You might also have lesions in your mouth and vagina, as well as painless but infectious wart-like sores in the genital area, flu-like symptoms, weight loss, and hair loss. The infection is still curable with treatment at this stage.
Without treatment, the symptoms generally clear up on their own within a few months, but the infection stays in your body. The bacteria continue to multiply during this latent phase and can cause very serious problems years later.

In fact, about 1 in 3 people who don't get proper treatment will progress to what's called tertiary syphilis.

tertiary syphilis
This late stage of the disease can develop up to 30 years after you were first infected and can cause serious heart abnormalities. Damaging and potentially lethal lesions can develop in your bones, on your skin, and in a host of organs. Fortunately, most people get treated early enough these days that very few end up with tertiary syphilis.
Syphilis can also infect your central nervous system – your brain and spinal cord. This is called neurosyphilis, and it can occur at any stage of the disease. Early on, it may cause problems like meningitis. Late neurosyphilis can lead to seizures, blindness, hearing loss, dementia, psychosis, spinal cord problems, and eventually death.

Fibroids in Pregnancy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2876319/Management of Fibroids in Pregnancy
Uterine fibroids are a very common finding in women of reproductive age.
 The majority of fibroids do not change their size during pregnancy, but one-third may grow in the first trimester. Although the data are conflicting and most women with fibroids have uneventful pregnancies, the weight of evidence in the literature suggests that uterine fibroids are associated with an increased rate of spontaneous miscarriage, preterm labor, placenta abruption, malpresentation, labor dystocia, cesarean delivery, and postpartum hemorrhage.

Fibroids (leiomyomas) are benign smooth muscle cell tumors of the uterus. Although they are extremely common, with an overall incidence of 40% to 60% by age 35 and 70% to 80% by age 50, the precise etiology of uterine fibroids remains unclear.¹
Only 42% of large fibroids (> 5 cm) and 12.5% of smaller fibroids (3–5 cm) can be diagnosed on physical examination.

Early Pregnancy

Miscarriage. Spontaneous miscarriage rates are greatly increased in pregnant women with fibroids compared with control subjects without fibroids (14% vs 7.6%, respectively).¹⁴ The weight of evidence in the literature suggests that the size of the fibroid does not affect the rate of miscarriage, but multiple fibroids may increase the miscarriage rate compared with the presence of a single fibroid only (23.6% vs 8.0%).¹⁴ The location of the fibroid may also be important. Early miscarriage is more common in women with fibroids located in the uterine corpus (body) than in the lower uterine segment¹⁰ and in women with intramural or submucosal fibroids.^7,15–17 The mechanism by which fibroids cause spontaneous abortion is unclear. Increased uterine irritability and contractility, the compressive effect of fibroids, and compromise to the blood supply of the developing placenta and fetus have all been implicated.¹⁸

Bleeding in early pregnancy. The location of the fibroid determines the risk for bleeding. Bleeding in early pregnancy is significantly more common if the placenta implants close to the fibroid compared with pregnancies in which there is no contact between the placenta and fibroid (60% vs 9%, respectively).^2,19

Late Pregnancy

 

Preterm labor and preterm premature rupture of membranes. Pregnant women with fibroids are significantly more likely to develop preterm labor and to deliver preterm than women without fibroids (16.1% vs 8.7% and 16% vs 10.8%, respectively; Table 1).⁷ Multiple fibroids and fibroids contacting the placenta appear to be independent risk factors for preterm labor.^10,19 In contrast, fibroids do not appear to be a risk factor for preterm premature rupture of membranes (PPROM). Indeed, a recent systematic review suggests that fibroids are associated with a decreased risk of PPROM

Placental abruption. Although reports are conflicting, pooled cumulative data suggest that the risk of placental abruption is increased 3-fold in women with fibroids (Table 1).⁷ Submucosal fibroids, retroplacental fibroids, and fibroid volumes > 200 cm³ are independent risk factors for placental abruption.²⁰ One retrospective study reported placental abruption in 57% of women with retroplacental fibroids in contrast with 2.5% of women with fibroids located in alternate sites.³ One possible mechanism of placental abruption may be diminished blood flow to the fibroid and the adjacent tissues which results in partial ischemia and decidual necrosis in the placental tissues overlaying the leiomyoma.³

Placenta previa. The relationship between fibroids and placenta previa has been examined in only 2 studies, both of which suggest that the presence of fibroids is associated with a 2-fold increased risk of placenta previa even after adjusting for prior surgeries such as cesarean section or myomectomy (Table 1).^4,7,21

Fetal growth restriction and fetal anomalies. Fetal growth does not appear to be affected by the presence of uterine fibroids. Although cumulative data and a population-based study suggested that women with fibroids are at slightly increased risk of delivering a growth-restricted infant, these results were not adjusted for maternal age or gestational age (Table 1).^7,22 Rarely, large fibroids can compress and distort the intrauterine cavity leading to fetal deformities. A number of fetal anomalies have been reported in women with large submucosal fibroids, including dolichocephaly (lateral compression of the fetal skull), torticollis (abnormal twisting of the neck), and limb reduction defects.^23–25

Labor and Delivery

Malpresentation, labor dystocia, and cesarean delivery. The risk of fetal malpresentation increases in women with fibroids compared with control subjects (13% vs 4.5%, respectively; Table 1).^7,22 Large fibroids, multiple fibroids, and fibroids in the lower uterine segment have all been reported as independent risk factors for malpresentation.^4,10,21,26

Numerous studies have shown that uterine fibroids are a risk factor for cesarean delivery.^{3,7,10,21,22,27–29} In a systematic review, women with fibroids were at a 3.7-fold increased risk of cesarean delivery (48.8% vs 13.3%, respectively).⁷ This is due in part to an increase in labor dystocia, which is increased 2-fold in pregnant women with fibroids (Table 1).^7,22 Malpresentation, large fibroids, multiple fibroids, submucosal fibroids, and fibroids in the lower uterine segment are considered predisposing factors for cesarean delivery.^{5,10,21,27–29} Despite the increased risk of cesarean, the presence of uterine fibroids-even large fibroids (> 5 cm)-should not be regarded as a contraindication to a trial of labor.^4,21,22

Postpartum hemorrhage. Reports on the association between fibroids and postpartum hemorrhage are conflicting.^{2,10,27,30–32} Pooled cumulative data suggest that postpartum hemorrhage is significantly more likely in women with fibroids compared with control subjects (2.5% vs 1.4%, respectively; Table 1).⁷ Fibroids may distort the uterine architecture and interfere with myometrial contractions leading to uterine atony and postpartum hemorrhage.³³ This same mechanism may also explain why women with fibroids are at increased risk of puerperal hysterectomy.^3,7,20

Retained placenta. One study reported that retained placenta was more common in women with fibroids, but only if the fibroid was located in the lower uterine segment.¹⁰ However, pooled cumulative data suggest that retained placenta is more common in all women with fibroids compared with control subjects, regardless of the location of the fibroid (1.4% vs 0.6%, respectively; Table 1).⁷

 

Uterine rupture after myomectomy. Uterine rupture after abdominal myomectomy is extremely rare.^34–36 In a retrospective study of 120 women delivering at term following abdominal myomectomy in which the uterine cavity was not entered, there were no cases of uterine rupture reported.³⁶ Whether the same is true also of laparoscopic myomectomy is not known, because there are numerous case reports and case series describing intrapartum uterine rupture after laparoscopic myomectomy.^37–45 Recent data suggest that such uterine ruptures occur prior to the onset of labor at the site of the prior laparoscopic myomectomy.^37–39,44 Fortunately, the absolute risk of uterine rupture following laparoscopic myomectomy remains low at 0.5% to 1%.