Gynecological Emergencies Kamini A Rao, Arveen Vohra
INDEX
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
A
Abacavir 99
Abdominal aortic aneurism 110
Abdominal bloating 120, 169
Abdominal distention 207
Abdominal examination 3, 18
Abdominal pain 93, 110, 134, 149, 181
acute 236
causes of 54
Abdominal tuberculosis 146
Abdominal wall 192
trocar 201
vascular injury 197, 201
Abnormal uterine bleeding 26, 69, 72, 109, 240
acceptable terminology 70t
bleeding diagnosis 70
classification 69
classification acute 69
classification chronic 70
classification intermenstrual 70
etiology 240
management 72, 72fc, 239, 240
terminology 69
Abortions 23, 31
lead to 23
management of 25
repeated 25
unsafe, complications of 236
Abruptio placentae 54
Abscess large 82
Abscess smaller 82
Acid-fast bacillus staining 94
Acid phosphatase test 234
Acquired immunodeficiency syndrome 32, 97
Actinomycin-D 43, 44
Acyclovir 101
Adenocarcinoma 114, 117, 168
Adenofibroma 133, 134
Adenomyomectomy 113
Adenomyosis 71, 63, 65, 110t, 111
management of 111fc
suspicion of 72
Adnexal disorders 214
Adnexal mass 25
Adnexal rings 217
Adnexal torsion 126, 215
Adolescent females 3
gynecologic problem 3
history taking 11b
urinary problems 3
Adolescent population, problems in 11b
Adrenal hyperplasia, congenital 7, 11
Albumin 121
Alkaline 8
Alkalinization of urine 211
Alpha-fetoprotein 136
Alpha receptor blockers 230
Ambiguous genitalia 3
Amenorrhea 47, 70, 93
American College of Obstetricians and Gynecologists 10, 66, 160
Ampicillin 28
Amsel's criteria 84
Anaerobic bacteria 9
Androblastoma 168
Anemia 39
correction of 72
Anesthesia, complications related 203t
Anorectal swab culture 18
Antecedent pregnancy 39
Antiemetics 122
Antiprogesterone (RU486) 30
Antiretroviral drugs 99
Antituberculosis drugs 95t
Antiviral chemotherapy 100
Appendicitis 90, 128, 217
Appendicular abscess 13, 110
Arachidonic acid 61fc
Arteriovenous 77
malformations 222
Ascites, presence of 135
Assault in pediatric patient 17
Assisted reproductive technology 249
Atherogenic lipoprotein profile 147
Atopic dermatitis 3
Atrophic endometritis 160
Atypical proliferating tumor 133
Autonomy 243
Azithromycin 97, 101, 102
B
Bacterial vaginosis 83, 96
Bacterial vaginosis, treatment regimen for 84
Bacteroides 89
Bacteroides species 157
Barberio's test 234
Bartholin's
abscess 83
cyst 114
gland 104
infections of 82
Bartholinitis, recurrent 83
Beneficence 243
Benign cystic
lesions 114
teratoma 127
Benign disorders 34
management of 164
Benign endometrial patterns 164
Benign fibroid polyp 183
Benign ovarian mass 138
Benign solid lesions 115
Benign tumor 110, 134
Benzathine penicillins 234
Beta-human chorionic gonadotropin 35, 38, 40, 50, 51
Biopsy 78, 90, 114, 115
Birth control devices 147
Bisphosphonate therapy 211
Bladder injury 187, 197, 200
incidence of 200
types of 188
Blanket consent 244
Bleeding 147, 148
abnormal uterine 70
heavy menstrual 70
high-dose progesterone 72
intermenstrual 70
per vagina 3, 79, 236
postmenopausal 70
prolonged menstrual 70
shortened menstrual 70
Bleomycin 176
Blood grouping 25, 234
Boari flap repair 200
Body mass index 65
Bone density 146
Bowel injury 187, 189
postoperative ileus 190
Bowel obstruction 207f
in gynecological cancer 207t
Breast cancer 31, 73, 113, 137, 146
Breast examination 3
Breast tenderness 147
Brenner tumor 168
Burst abdomen 146
C
Calcium 65
Calymmatobacterium granulomatis 100
Canal of Nuck 203
Cancer antigen-125 136, 140
level 173
profile 137
Cancer treatment 206
Candida albicans 84
Carbohydrate antigen 19–9 137
Carbon dioxide 204
Carcinoembryonic antigen 137, 170
Carcinoma ovary 206
Cardiac
activity 219f, 220f
arrhythmia 198, 203
Cardiovascular effect 147
Carpopedal spasm 146
Catheter-induced edema 209
Causative organism 82
Cecum cephalad 171
Cefixime 19
Ceftriaxone 29, 87
Centers for Disease Control and Prevention 19, 20, 48
Central nervous system 61, 62
Cervical cancer 155
prevalence of 76
risk of 77t
Cervical culture 18
Cervical injury 190, 191
Cervical intraepithelial neoplasia 76, 77
Cervical polyps 76
Cervical stenosis 63
Cervicitis 76
Cervix, infections of 86
Cesarean scar ectopic 219f
Cesarean section 228
Chancroid 102
clinical features 102
diagnosis 102
treatment 102
Chemotherapy 174
neoadjuvant 173
postoperative 173
radiotherapy after first-line 173
Child sexual assault 17
Chlamydia 19, 82
Chlamydia trachomatis 9, 12, 82, 87
Chlamydial infections 87, 96
clinical features 87
complications 87
diagnosis 87
treatment regimen for 88t
Chlorpromazine hydrochloride 3
Choriocarcinoma 36, 136
Chromosomal analysis 13
Ciprofloxacin 101103
Cisplatin 176
Clindamycin 84
Clindamycin cream 84
Clinical skills 247
Clomiphene citrate 73, 74
Colicky pain 26
Colorectal carcinoma 110
Colposcopy
diagnosis and management 78
indications for 79f
role of 78
Combined oral contraceptives 73, 113
Communication skills 246
Complete hydatidiform mole 35
biparental 36f
Complex ovarian cyst, management of 140f
Conception, retained products of 26
Condyloma acuminata 96, 102
Confidentiality 243
Conjugated equine estrogen 73
Consent 243
Constipation 181
Contraception 247
advice: postabortion 32
complications 144
concept of 144
effectiveness and safety of 145
emergencies 144, 149
evolution 144
major complications 145
practice implications 145
Corpus luteal hemorrhage 218
Cul-de-sac, posterior 170
Culdocentesis 90
Culture methods 94
Cycle cancellation 121
Cyclic endoperoxides, biosynthesis of 61fc
Cyclical oral progesterones 73
Cyclooxygenase-2 64
Cyclophosphamide 43, 44, 176
Cyst wall, removal of 139
Cystadenocarcinoma 168
Cystadenoma 127, 133
Cystic and solid lesions 114t
Cystitis acute 103
Cystitis recurrent 103
Cystocele 116
Cystocele repair 230
Cystoscopy 199
to examine bladder 229
Cystotomy 199
Cytomegalovirus 89
Cytoreductive surgery, secondary 172
D
Danazol 73, 74, 66, 113, 139
Debulking surgery 172
Decidualization endometrium 218
Decubitus ulcer 181
Deep tension suturing 194
Deep vein thrombosis 211
Dehiscence, management of 194
Delavirdine 99
Deoxyribonucleic acid 35, 94
amplification technique 18
Depo-Provera, injectable 66
Depot medroxyprogesterone acetate 147
Dermoid cyst, spillage of 139
Diffuse macular erythroderma 86
Diphtheroids 9
Diseases, transmissible 249
Disseminated intravascular coagulation 27
Diverticular abscess 110
Diverticulitis 90, 128, 207
Documentation 245
Donovanosis 100
Dopamine agonists 121
Doxorubicin 19, 44, 176, 204
Doxycycline 87, 97, 101
Duphaston 73
Dysfunctional uterine bleeding 11, 14, 69
Dysmenorrhea 1113, 53, 59
assessment 63
classification of 59
membranous 62
ovarian 63
primary 59
secondary 62
secondary, causes of 62
differential diagnosis of 63
effects of recurrent 61, 62fc
epidemiology 63
for practice 67
management of 64fc, 65
pathogenesis 59
risk factors for 63, 63t
severe 221f
sudden onset of 63
Dyspareunia 53, 65, 89
Dyspareunia, cases 76
E
Eastern Cooperative Oncology Group score 206
Ectopic pregnancy 47, 95, 146, 147, 217
case of 218f
clinical presentation 47
diagnosis 48
management of 50, 50fc
site of 47
Ectropion 76
Efavirenz 99
Embryonal carcinoma 168
Embryos 121
Encephalitis 146
Endodermal sinus tumor 168
Endogenous human chorionic gonadotropin 119
Endometrial
ablation 74
biopsy 71, 77, 90, 163
cancer 146, 155, 160, 209
cavity 215
fluid collection 156f
hyperplasia 160, 164
polyps 63
sampling 161, 163
thickness 77
measurement of 162f
Endometrioid borderline tumor 134
Endometrioid stromal sarcoma 168
Endometrioid tumor 134
Endometrioma 110
Endometriosis 63, 65, 115, 127, 218
Endometriotic cyst 135, 139
Endoscopic surgery 248
End-tidal carbon dioxide 203
Enfuvirtide 99
Enterococcus species 81, 104
Enzyme-linked immunosorbent assay technique 88
Enzymes 61fc
Epithelial ovarian cancer 167
classification 167
diagnosis 170
early-stage 172t
epidemiology 167
histologic types of 169
management of 170
advanced-stage disease 172
early stage disease 172
recurrent disease 174
pathogenesis 169
risk factors 168
routes of metastasis 169
signs 169
spread pattern 169
staging 170
symptoms 169
Epithelioid trophoblastic tumor 40
Erythromycin 101, 234
Escherichia coli 9, 28, 81
Estrogen-progestin oral contraceptive pills 66
Ethambutol 95
Ethamsylate 73
Etoposide 43, 44, 176
Exogenous estrogens 160
External genitalia, examination of 3
F
Fallopian tube 47, 92, 215
torsion of 126
Famciclovir 101
Female sterilization 247
Fertility preservation 243
Fetal loss 23
Fibroepithelial polyp 115
Fibroid
acute presentations 221
in pregnancy leads 53
polyp 116
red degeneration of 53
torsion of 54, 221
uterus 111
management algorithm of 112fc
with retroperitoneal abscess 54fc
FIGO
scoring system 42t
staging for primary carcinoma of ovary 171
staging of ovarian tumors 142
Fish oil supplements 65
Fitz-Hugh-Curtis syndrome 215
Florence test 234
Fluid
in abdomen 199
replacement 122
sac 217
Fluorescence in situ hybridization 234
Foley's catheter 229
Folinic acid 43, 44
Foreign body 115
placement of 8
Forensic gynecology 247
Foul-smelling discharge 182
Fractional curettage 163, 164
Freezing 121
Freund's complete adjuvant 50
Functional cyst 135
Furunculosis 81
G
Gangrenous ovary 129f
Gardnerella vaginalis 83, 89
Gartner duct cyst 114
Gas embolism 202
Gastrointestinal tract, obstruction of 206
signs 207
symptoms 207
treatment 207
Genetic mutations 169
GeneXpert 94
Genital examination 233
Genital trauma 77
Genital tuberculosis 92, 155
bacteriological evaluation 94
causative organism 92
clinical presentation 93
diagnosis 93
genital organs 92
incidence 92
investigations 93
mode of spread 92
pathogenesis 92
Genital warts 102
diagnosis 102
prevention 102
treatment 103
Genitourinary infections 81
Gentamicin 28, 234
Germ cell tumor 168
Germline mutation 175, 176
Gestation 30
Gestational age, pregnancies of 31
Gestational sac 219f, 220f
Gestational trophoblastic disease 34, 45
classification of 34fc
clinical features 35
genetics of 35
pathogenesis of 34
pathology 35
risk factors associated with 35t
Gestational trophoblastic neoplasia 39
chemotherapy for low-risk 43b
investigations to determine treatment 42t
management of
high-risk 43
low risk 43, 44fc
regimens for treatment of high-risk 44t
stages of 41f
treatment of 41
Gestational trophoblastic tumor 34, 35, 40t
Gestational tumors, origins of 36t
Gestrinone 73
Ginger 65
Gonadoblastoma 168
Gonadotropin dose 120
Gonadotropin-releasing hormone agonists 7, 7274, 111, 112, 113, 120, 121
Gonorrhea 19, 96
Granuloma inguinale 96, 100
clinical features 100
diagnosis 100
treatment 100, 101
Granulosa cell tumor 175, 176
Granulosa-stromal cell tumor 168
Group B Streptococcus 81
Gynecological problems 10
in adolescent population 8
Gynandroblastoma 168
Gynecological
causes 109
complaints 3b, 8fc
conditions, treatment for 13t
disorders 59
emergency 126, 180, 236, 242
imaging in 214
medicolegal and ethical issues 242
malignancy 158
oncology 206
bowel obstruction 208fc
emergencies 206
medical emergencies 210
psychiatric emergencies 211
surgical emergencies 206,
procedures 248
H
Haemophilus ducreyi 102
Haemophilus influenzae 9, 89
Headache 149
Health and welfare draft medical termination of pregnancy bill, 2014 32
Healthcare setting 246
Hematocolpos 13, 116
Hematogenous 92, 170
Hematomas 187
Hematometra 109
Hemodynamic shock 53
Hemorrhage 145, 209, 217
causes 209
definitive management 209
initial management 209
Hemorrhagic cyst 127
Hemorrhagic infarction 55
Hemorrhoids 161
Hemostatics, roles of 26
Hepatitis B
immunization 19
surface antigen 18, 25
Hereditary ovarian carcinoma 174
Hernia 146, 201
Herpes genitalis 100
clinical features 100
diagnosis 100
treatment 100, 101
Herpes simplex virus 12, 86
Herpesvirus 1 and 2 9
Hilus cell tumor 168
Hodgkin's lymphoma 110
Homogeneous 84
Hormonal contraceptives 147
Hormonal therapy 161, 174
Hormone replacement therapy 78, 96
Human chorionic gonadotropin 23, 49, 136
Human endometrial stromal cells 26
Human immunodeficiency virus 19, 25, 85, 97, 98, 238
diagnosis of 99
infection 12
test 20
transmission 249
Human papilloma virus 19, 102
Human placental lactogen 40
Hydatidiform mole 36
complications of 39
early complete 36f
genetic origins of 36f
immunohistochemistry in 37
Hydrosalpinx 109
bilateral 216f
Hydrothermal ablation 74
Hydroureteronephrosis 182
Hydroxyethyl starch 121
Hydroxyprogesterone caproate 26
Hydroxyurea 44
Hypercalcemia, causes of 211
Hypercarbia 198
Hyperthyroidism 39
Hypoglycemia 146
Hypomenorrhea 69
Hyponatremia 211
Hypotension 86
Hypothalamic-pituitary-ovarian 11, 14
Hysterectomy 67, 74, 113, 158, 248
Hysterosalpingogram 93
Hysteroscopic procedure 74
Hysteroscopy 163, 248
I
Iatrogenic complication 122
Ibuprofen 66
Illness, severe 91
Impetigo 81
Implantation bleeding 24
In utero diethylstilboestrol 114
In vitro fertilization 47, 119, 215
Inappropriate antidiuretic hormone 211
Indinavir 19, 99
Infections 81104
and febrile neutropenia 210
Inferior vena cava 145
Infertility 95, 126, 216f
Inflammatory bowel disease 63
Informed consent 244f
Infundibulopelvic 126
Inhibin 136
Initiate antiretroviral therapy 99
Injury 248
to urinary tract 187
Inotropes 29
Inpatient care, treatment regimen 91t
Integrase inhibitor 99
Intermenstrual bleeding 76
International Ovarian Tumor Analysis Rules 138
Interstitial cystitis 63
Intestinal injury 196, 197
Intraluminal tumor 207
Intraperitoneal
chemotherapy 172
instillation 173
therapy 173
Intrauterine contraceptive device 30, 77, 147, 239
failure 148
forgotten 156f
Intrauterine insemination 215
Intrauterine pregnancy 49
Intrauterine walls, perforation of 148
Intravenous urography 189
Ionization-time of flight 137
Irritable bowel syndrome 63
Ischiorectal fossa 192
Isoniazid 95
J
Japanese herbal remedy 65
Jaundice, symptoms of 39
Justice 243
K
Khorana score 211
Kidney disease
acute 211
chronic 230
Klebsiella granulomatis 100
Krukenberg tumor 176
L
Labia minora 233
Labial agglutination 3
Lactate dehydrogenase 136
Lactobacilli 9, 83
Lamivudine 19, 99, 100
Laparoscopy 48, 90, 248
and hysteroscopy 93
complications in 196
gasless 204
gynecologic surgery, complications of 197t
hysterectomy 199
oophorectomy 129f, 130
revealed ovarian torsion 216f
surgery 196
uterine nerve ablation 67
Laparotomy 191
Leiomyoma 25, 115, 155
complicating pregnancy 56
pedunculated 55f
subclassification system 71f
subserosal 55
uterus 53, 56
carneous degeneration 53
impacted fibroid 56
red 53
torsion of fibroid 54
Leukorrhea 13
Leuprolide acetate 66
Levonorgestrel intrauterine device 73, 99
Levonorgestrel-releasing intrauterine system 66
Leydig cell tumor 168
Lichen planus 3
Lichen sclerosus 3
Lichen simplex lichenification 3
Lifestyle changes 65
Lipid cell tumors 168
Liver disorders 147
Liver function, impaired 113
Lymph nodes, enlarged 135
Lymphatic 92
dissemination 170
Lymphogranuloma venereum 96, 100
clinical features 101
diagnosis 102
treatment of 102, 102t
M
Magnesium 65
Malignancy 77, 180, 183
index, risk of 137, 140, 170
Malignant cells 139
Malignant cyst features 135
Malignant disorders 34
Malignant endometrioid tumor 168
Malignant lesions 117
Malignant mucinous tumor 168
Malignant ovarian cancer
classification of 168t
management of 141
Malignant serous tumor 168
Malignant tumor 110, 141
Mantoux test 94
Mass per abdomen 13
causes of 11b
Mass per vaginum 180
Massive tumor cell lysis 211
Maternal chromosome, loss of 36f
Matrix-assisted laser desorption 137
Matrix metalloproteinases 26
Medical termination of pregnancy 25, 30
above 12 weeks of gestation 31
Act, 1971 31
eugenic grounds 31
humanitarian grounds 31
medical grounds 31
social grounds 31
authorized place for conducting 32
between 9 weeks and 12 weeks 30
methods for medical abortion in situations 31
protocol 30
up to 9 weeks gestation 30
Medicolegal problems, prevention of 243
Medroxyprogesterone 113
Mefenamic acid 66, 111
Meigs’ syndrome 134
Melphalan 44
Menometrorrhagia 148
Menorrhagia 53, 69, 93
Menstrual abnormalities 13
cases of 12
Menstrual
changes 146
cycle 243
disorders 11
disturbances 93
dysfunction in adolescents 11b
fluid 59, 61
history 76
pain, mechanism of 65
Menstruation duration of 76
Meperidine 3
Metabolic abnormalities 211
Metabolic effects 147
Metastasis, port-site 203
Metastatic deposits 135
Metastatic tumors 176
Metformin 120
Methicillin-resistant S. aureus 82
Methotrexate 43, 44, 50, 204
contraindications 51
single-dose protocol for 51t
Metronidazole 19, 28, 29, 84, 86, 234
Metrorrhagia 69
Micronized progesterone 26
Mifepristone 30, 31, 149
Migraine 147
Minimally invasive methods 74
Ministry of Health and Family Welfare 249
Mirena 66
Miscarriage 23
case of 24
early pregnancy 23
types of 24, 24t
complete 24, 25
incomplete 24, 27
induced 30
inevitable 26
missed 24, 27
septic 24, 27
spontaneous 24
threatened 24, 25
Misoprostol 27, 30, 31
Mittelschmerz pain 239
Mixed epithelial tumor 134, 168
Mobiluncus species 83
Mobius syndrome 30
Molar pregnancy
metastases of 39
pre-evacuation investigations 38t
treatment of 38
chemotherapy 38
hysterectomy 38
suction and evacuation 38
Molecular methods 94
Molluscum contagiosum 9, 96, 103
treatment 103
Mucinous ascites 134
Mucinous carcinoma 134
Mucinous tumors 133
Multidrug-resistant disease 96
Mycobacterium genitalium 89
Mycoplasma hominis 9, 83, 89
Myoma 110t
nonsurgical management 57f
uterine fundus 56f
Myomectomy 74, 113, 220f
Myometrial scar pregnancy 220f
Myometrium, derived from 53
N
Nail scrapings 234
Naproxen sodium 66
Neisseria gonorrheae 9, 12, 82, 87
Nephrolithiasis 128
Nerve injury 192, 203
Nervous system, disruption of 228
Neuralgic pain 192
Neuroblastoma 110
Neuropathy, post-traumatic 192
Neuropraxia 192
Nevirapine 99
Nifedipine 66
non-Hodgkin's lymphoma 110
Nonhysteroscopic procedure 74
Nonmaleficence 243
Non-nucleoside reverse transcriptase inhibitors 99
Nonsteroidal anti-inflammatory drugs 14, 54, 64, 66, 7273, 111112, 121122, 139
Norethisterone enanthate 147
Nucleic acid amplification test 88, 87
Nucleoside reverse transcriptase inhibitors 99
Nugent criteria 84
Nulliparity 63, 190
Nulliparous 168
Numbness 192
O
Obstetrical puerperal sepsis 155
Obstructed hernia 110
Obstructive uropathy 208
causes 208
investigations 209
signs 209
symptoms 209
treatment 209
Obstructive vaginal disorders 3
Ogilvie's syndrome 207
Oligomenorrhea 69, 93
Omental prolapse 146
Oncologic emergency 206
Oocytes 121
Oophorectomy
bilateral 129
unilateral 142
Open gynecological surgery, complications in 187
Oral contraceptive pill 14, 64, 66, 78, 112, 137, 169
Oral sex 83
Ormeloxifene 73, 74
Ovarian borderline tumors 175
management of 175
Ovarian cancer 109
genetic counseling 137
genetic risk assessment 137
indications for 137
lifetime risk of dying of 109
Ovarian cyst 111
Ovarian cyst management of 112fc
Ovarian hyperstimulation syndrome 119, 122, 217
classification of 120
critical 120
mild 120
moderate 120
severe 120
management 121
pathophysiology 119
prevention 120
Ovarian ligament 126
Ovarian malignancies 167
Ovarian mass 11
guidelines on management of 177
management of 133, 138, 167
Ovarian origin 110
Ovarian peritoneal malignancies 204
Ovarian reserve markers 120
Ovarian sex cord-stromal tumors 175
Ovarian stimulation parameters 120
Ovarian torsion 110, 126, 127
clinical features 127
diagnosis 128
differential diagnosis 128
etiology 127
hemorrhagic, left 216f
imaging features 128
management 128
Ovarian tumors
borderline 141
classification 133
Ovary
detorsed 129f
endometriotic cyst of 136f
malignant lesion of 136f
normal anatomy of 126, 127f
simple cyst of 135f
Ovulation induction 119
Ovulatory cycles 61
Ovulatory pain 59, 63
P
P57KIP2 gene 37
P57KIP2 immunostaining 37
Padua score 211
Pain, mechanism of 53
PALM COEIN system 71t
Pap smear 78
Papillary cystadenocarcinoma 168
Para-aortic lymph nodes 170
Paramesonephric duct cyst 114
Paraovarian cyst torsion 214
Paravesical space 192
Partial hydatidiform mole 36, 37
Partial thickness defect 188
Pediatric patient
examination of 3
management of 10t
Pediatric population
management in 9t
problems in 47t
Pedunculated fibroid, prolapse of 221
Pelvic adhesions 63
Pelvic adhesive disease 90
Pelvic examination 8, 25
Pelvic floor dysfunction 243
Pelvic hematoma 192
Pelvic inflammatory disease 47, 63, 87, 88, 89, 127, 146, 148, 209, 214, 215
chronic 63
diagnostic criteria for 90
Pelvic mass 109
classification 114
etiology 109
investigations 110
management 111
symptoms 110
Pelvic organ injury 146
Pelvic organ prolapse 180
emergencies 181t
Pelvic pain
acute 214
chronic 61, 62, 90
Pelvic side wall 192
Pelvic spleen 110
Pelvic structure in primary dysmenorrhea 60f
Pelvic tumors 53
Pelvic ultrasound 25
Penicillin allergy 97
Penile shaft 234
Peptic ulcer disease 51
Peptococcus species 89
Percutaneous nephrostomy 209
Perforation and fistulas 210
causes 210
management 210
Peritoneal fluid aspiration 90
Peritoneal masses 135
Peritoneal serous carcinoma, primary 176
Persistent nonhealing fistula 96
Physical abuse 18
Placental site trophoblastic tumor 40
Ploidy, determination of 37
Pneumoperitoneum related complications 202
Polycystic ovary syndrome 14, 71, 168,
Polymenorrhea 69
Polymerase chain reaction 88
Postcoital bleeding 65, 76
etiology 76, 77f
examination 77, 78fc
management 76
Postexposure prophylaxis 19, 99
Postmenopausal bleeding 159
causes of 160
complications 164
diagnostic pathways for 162fc
etiology of 160t
evaluation of 160
significance of 159
Postmenopausal women 167, 177
gynecological emergencies in 180
Postmolar surveillance 39
Postradiation strictures 207
Pouch of Douglas 28
Povidone-iodine solution 204
Pregnancy 13, 23, 53, 149
adolescent 12
biochemical 23
loss early 24
loss late 24
teenage 11
unknown location 24, 49fc
Premenopausal ovarian cysts, management of 139
Premenopausal women 133
Premenstrual tension syndrome 63
Preterm births 26
Progesterone 111
Progesterone only contraceptives 47
Progesterone, use of 121
Progestin-only 26
long-acting
reversible contraception 26
Progestogens 26, 72, 73
Promethazine hydrochloride 3
Prostaglandins 30, 59, 64
Prostate specific antigen detection 234
Protease inhibitor 99
Proteomics 137
Pseudo-Meigs’ syndrome 135
Pseudomyxoma peritonei 134
Pseudosac 48
Psoriasis 3
Pubic hair 234
Puerperal septic thrombosis 222
Pulmonary embolism 146
Pyelonephritis, acute 104
Pyogenic infection 81
Pyometra 77, 93, 109, 155
common causes of 155
diagnosis 156
differential diagnosis 156
etiology 155
investigations 157
management of 157, 157fc
pathogenesis 156
signs and symptoms 156
Pyosalpinx 109, 146
Pyrazinamide 95
Q
QuantiFERON-TB gold 94
R
Radiation
enteritis 207, 208
exposure 215
therapy 174
postoperative 172
Raltegravir 99
Rape 233
Rape and sexual assault 238
Rape crisis centers 235
Rectal bleeding 169
Rectal examination 8
Rectocele repair 230
Rectosigmoid colon 171
Renal tumor 110
Reproductive age group 69
Reproductive tract abnormalities 12
Retroperitoneal major vascular 202
Rh typing 25
Rifampicin 94, 95
Ring of fire 218
Ring worm 82
Risk management, components of 246
Ritonavir 99
Round ligament 247
Ruptured adnexal cyst 220f
S
Saline infusion sonography 161
Salpingo-oophorectomy, bilateral 171
Salpingotomy, case of 51
Saquinavir 99
Scabies 96, 103
Scar ectopic 219f
Seborrheic dermatitis 3
Self-help techniques 65
Seminal fluid, test for 234
Senile
cervicitis 155
endometritis 155
Septate vagina 3
Septic abortion 27
case of 28
investigations 29fc
management of 29fc
types of 28
Septic shock 198
Septicemia 90
Serologic tests 99
Seromucinous tumors 134
Serous tumors 133
Serum progesterone 48
Sex cord-stromal tumors 168, 175
Sex during menses 83
Sex partners, multiple 83
Sexual abuse 17, 20
clinical manifestation 18
examination 18
incidence 17
investigation 18
management 18
Sexual active population 215
Sexual assault 11, 12, 232
counseling 234
effects of rape 232
forms of 232
incidence of 232
management 233
types 232
with evidence of penetration 19fc
Sexual behavior 14
Sexual contact date 17
Sexual intercourse, early age 83
Sexual practices, safe 14
Sexual transmitted diseases 9, 11, 12, 14, 77, 234, 238
organisms causing 12t
Sexual transmitted infection 19, 32, 87, 96
Sexual violence, risk factors to 232
Shigella 9
Shoulder pain, postoperative 203
Simple ovarian cyst
management of 140fc
unilateral 177
Small extraperitoneal defect 188
Smooth muscle cells 53
Speculum examination 27
Sperm creatine phosphokinase test 234
Spermatozoa, detection of 234
Spinal cord injury 228
Spontaneous abortion, cause of 23
Staphylococcus 81, 82, 104, 157
Staphylococcus aureus 9
Staphylococcus epidermidis 9
Staphylococcus saprophyticus 103
Sterilization 145
immediate complications 145
long-term complications 146
Steroids 29
Streptobacillus 102
Streptococcus 82
Streptococcus pyogenes 9
Streptococcus species 157
Streptomycin 95
Stromal hypercellularity 37
Stromal karyotypic debris 37
Submucosal fibroids 74, 113
Submucous fibroid polyp 155
Submucous myoma 180
Submucous polyp 182
Suprapubic tenderness 236
Surface-enhanced laser desorption 137
Surface papilloma 133
Swabs from prepuce 234
Syndrome of inappropriate antidiuretic hormone 211
Syphilis 96
diagnosis 97
serology test 89
test 20
treatment 97
treatment regimen for 98
T
Tamoxifen 163, 164
Taurolidine 66, 204
Tetanus toxoid 28
Thiamine 65
Thiozine 3
Thread worm 82
Thromboembolism 119, 211
Thrombosis of ovarian vein 222f
Thyroid-stimulating hormone 25
Tingling 192
Tinidazole 84
Tissue culture 88
Tissue necrosis 53
Tissue retrieval in endobag 129f
Torsion ovarian cyst 90, 238
evaluation 238
management 238, 239fc
Torsion ovarian
pathophysiology of 127
pathophysiology of 127f
pedicle 127
Toxic shock syndrome 86
Training and education 247
Tranexamic acid 72, 73
Transcutaneous electrical nerve stimulation 64, 65
Transitional cell tumor 134
Transvaginal sonography 37, 161, 170
Transverse septum 3
Transverse sinus thrombosis 146
Treitz ligament 171
Trendelenburg position 203
Treponema pallidum 96
Trichomonas vaginalis 9, 85, 104
Trichomoniasis 12
Trimethoprim-sulfamethoxazole 101, 103
Trophoblastic tissue 218
Tubal ectopic 47
Tubal origin 109
Tubal scarring leading 88
Tubal stump bleeding 146
Tubectomy 145
Tuberculosis of
endometrium 92
fallopian tube 92
ovary 93
pelvis 92
Tubo-ovarian
abscess 13, 109
mass, left 215f
Tumor lysis syndrome 211
Tumor markers 136
U
Upper genital tract, infections of 88
Ureaplasma urealyticum 9, 83, 89
Ureter, dissection of 199
Ureteral injury 188, 197, 199, 200
diagnosis of 189, 199
incidence of 199
prevention 200
Urethra, blockage of 228
Urethral
caruncle 116
culture 18
orifice 234
prolapse 6
stricture 230
Urethritis 103
Urinary frequency 169
Urinary infection 181
Urinary output 188
Urinary problems 47
Urinary retention 146, 181, 227, 236
acute 227, 236
causes of 237
evaluation and management 237fc
causes of 228
chronic 236
complications 230
evaluation 227, 228t
investigations 227
management of 229, 229fc, 236
symptoms 227
Urinary tract infection 102, 128
Urinary tract injury 199
Urodynamic tests 229
Urogenital malformations 11, 14
Urogynecology 248
Uterine and cervical injuries 187, 190
Uterine arteriovenous malformations 222
Uterine artery embolization 57, 74, 112, 113
Uterine cavity 47, 48, 110
pus in 155
Uterine cervix 55f
Uterine disorders 214
Uterine fibroids 109
Uterine inversion 116, 180, 182
causes 182
diagnosis of 182
main clinical symptoms 182
Uterine leiomyoma 128
Uterine myomas 63
Uterine origin 109, 110
Uterine perforation, management of 191
Uterine prolapse 180
Uterine torsion 56
Uterine vessels 59
Utero-ovarian ligament plication 130
Uterovaginal prolapse 117, 155
V
Vagina
infections of 83
normal 83
prolapsed fibroid in 221f
Vaginal
bleeding 25, 183, 214
irregular 47, 182
culture 18
discharge 11, 65, 77, 84
douching 85
epithelial cells 83
examination 65
instrumental delivery 228
introitus 233
leiomyoma 115
masses 113
mucosa 8
pH 8
pressure 182
swabs 13, 25, 157
vault 192
Valacyclovir 101
Vascular endothelial growth factor 119
Vascular injuries 187, 191
major 197, 202
primary hemorrhage 191
reactionary hemorrhage 191
secondary hemorrhage 192
Vascular permeability 119
Vascular thrombosis 113
Vasopressin 61
Vasopressors 29
Vasovagal reaction 148
Venereal disease research laboratory 18, 25
Venous thromboembolism 147
Venous thrombosis 203
Verapamil 66
Veress needle, insertion of 202
Vincristine 43, 44
Violin string 90
Volvulus 207
Vulva 192
infections 81
causes of 82t
Vulval
region 78
skin 8
ulcers 78
Vulvar
abscess 81
edema 203
Vulvovaginal candidiasis 84
classification of 85t
Vulvovaginitis 3, 8, 9
organisms causing 9t
W
Wet mount 85, 86
Whiff test 84
Wound cellulitis 211
Wound dehiscence 187, 193, 210
Wound healing 193
primary intention 193
secondary intention 193
Wound hematoma 211
Wound infection 145
Wound sepsis 187, 193
management of 193
measures to prevent 193
risk factors for 193
treatment 193
Y
Yolk sac fetal pole 219f
Z
Zalcitabine 99
Zidovudine 19, 99, 100
Ziehl-Neelsen 94
×
Chapter Notes

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1Adolescents
  • Common Gynecologic and Urinary Problems in Pediatric and Adolescent Females
    Meghana V Nyapathi
  • Sexual Abuse and Assault in Pediatric Patient
    Priyanka Yadav2

Common Gynecologic and Urinary Problems in Pediatric and Adolescent FemalesCHAPTER 1

Meghana V Nyapathi
 
INTRODUCTION
About 13.1% of Indian population is in the 0–6 years age group.1 About 236.5 billion people in India are adolescents in the age group of 10–19 years.2 Children (Box 1) and adolescents (Flowchart 1) are a unique subset of patients in our outpatient clinic with varied complaints requiring tact and a different line of management in comparison to the adult population.
 
EXAMINATION OF A PEDIATRIC PATIENT (TABLE 1)
  • Good communication skills to make the child comfortable.
  • Drugs like meperidine 50 mg, chlorpromazine hydrochloride (Thiozine) 12.5 mg, or promethazine hydrochloride 12.5 mg can be given to sedate the patient. Examination under anesthesia is an option in noncooperative children.
  • Breast examination: Evaluated for Tanner staging. Slight bilateral asymmetry is a common finding.
  • Abdominal examination: To look for tenderness and any palpable mass.
  • Examination of the external genitalia: Tanner staging, skin lesions and to look for any disfigurements.4
    TABLE 1   Problems in pediatric population.412
    Condition
    Age
    Cause
    Symptoms
    Physical examination
    Anatomical area
    Treatment
    Long-term outcome
    Labial agglutination Incidence: 0.6–3%4
    13–23 months
    Hypoestrogenic state, inflammation
    Irritation, urinary tract infections, dribbling of urine
    Thin vertical lucent line seen in central area of labia
    Commonly posterior aspect of the labia minora
    Estrogen cream BDX 2–4 weeks, zinc oxide ointment, perineal hygiene, sitz baths, bland creams, manual separation under sedation (acute cases and those not responsive to medical management)6
    Spontaneous resolution within 18 months. Recurrence in 40%5
    Iatrogenic precocious puberty due to estrogen use
    Vulvovaginitis (noninfective/nonspecific) MC (74–80%)7
    Prepubertal
    External irritants and poor hygiene
    Trauma to the sensitive mucosa by chemical, environmental causes
    Neutral vaginal pH
    Itching, foul smelling discharge, pain, dysuria, bleeding
    Tanner staging, presence of erythema, edema, discharge noted. Sometimes foreign body may be seen. Wet mount examination and culture of discharge if any.
    Labia majora and minora, clitoris, introitus and vagina
    Pesonal hygiene, proper fitting undergarments, sitz bath, mild steroid cream in acute cases for about 2 weeks
    Recurrence common
    Vulvovaginitis (infectious)
    Prepubertal
    Poor hygiene, sexual abuse
    Discharge, ulcerative lesions
    Wet mount examination and culture of discharge
    Labia majora and minora, clitoris, introitus and vagina
    Antibiotic based on culture report, personal hygiene
    Recurrence common with low personal hygiene5
    Dermatological conditions
    Beyond 24 months usually
    Autoimmune
    Vulvar irritation, pruritus
    Tiny pink-white papules (lichen sclerosus), pale lesions with increased skin margin markings (lichen simplex lichenification), well-demarcated erythematous papules with scales (psoriasis)
    Labia majora and minora. Also in nongenital areas
    Personal hygiene, emollients, mild steroid cream like clobetasol ointment for 2–4 weeks and then tapered8
    Vulvar biopsy in cases resistant to treatment
    Prolonged steroid use in some cases
    Congenital disorders
    From birth
    Chromosomal disorders, maternal drug intake, congenital adrenal hyperplasia, pseudohermaphroditism
    Detected at birth, may be associated with other symptoms
    Look for abnormalities of clitoris/ phallus, palpate for gonads in the inguinal/ labioscrotal folds (undescended gonads), lower abdominal mass, blood tests as required
    Inguinal region, labioscrotal folds
    Surgical correction in amenable cases
    Symptomatic management
    Proper counseling
    Precocious puberty
    Onset before 8 years
    GnRH dependent, GnRH independent
    vaginal bleeding, breast development, pubic hair
    Tanner staging, hormonal evaluation
    Breast, external genitalia
    Treatment of the cause (tumors, CAH), hormonal therapy (GnRH agonist)
    6
    Genital trauma (0.2–0.8% of trauma and accidents in children10
    Mean age: 7.1 years9
    Peak age: 6 years8
    MC-straddle injury (70–81%) leading to lacerations8
    Bleeding from genital tract, pain
    Examination under anesthesia in all cases to avoid missing periurethral and perianal injuries10
    Abrasions over labia minora and fourchette
    Bruising of mons pubis and labia majora10
    Conservative—analgesics, cold packs, catheterization in cases of urinary retention
    Surgical— required in 9–20% of cases11
    Associated anal sphincter, bladder and urethral injuries, deep penetrating injuries with persistent bleeding requiring suturing
    Long-term follow-up
    Urethral prolapse
    5–8 years
    Hypoestrogenism. Usually resolves around puberty with estrogenization
    Painless vaginal bleeding. Vaginal irritation and discharge are usually absent
    Mass per vaginum, surrounding genital anatomy is normal
    Urethra protruding through vagina
    Observation till puberty
    Topical estrogen over the area BDX2—4 weeks
    Resection of the necrotic area may be rarely required12
    Recurrence can be seen till puberty7
    Ulcers
    Rare in premenarchal age
    Solitary ulcer— syphilis, Crohn's disease, chancroid, cancer
    Multiple ulcers— secondary syphilis, scabies, Varicella zoster virus, Behçet syndrome, infectious mononucleosis13
    Painful and recurrent in cases due to herpes and Behçet syndrome. Painless in syphilis. Can be associated with malaise, fever (Epstein-Barr virus, cancer) or GI symptoms (Crohn's)
    Examine vulva and perineum for erosion of both dermis and epidermis. Presence of fluid filed vesicles causing erosion of skin. Also look for oral ulcers. Swabs taken and biopsy from the edge of the lesion including normal skin done for diagnosis6,14
    Vulva, perineum
    Depending upon the culture and biopsy report
    Relapse can occur in cases of Behçet's syndrome, herpes shingles, Crohn's disease, etc.
    (CAH: congenital adrenal hyperplasia; GnRH: gonadotropin-releasing hormone; MC: most common)
    8
    zoom view
    Flowchart 1: Gynecological complaints in adolescents.
    Also look for the presence of hypertrophied clitoris and urethral abnormalities.
  • Pelvic examination: Performed with the child in frog-leg or knee-chest position to visualize the vulvovaginal area. Look for discharge, edema, erythema, foreign body, and congenital anomalies.
  • Examination of the hymen.
  • Wet preparation of the discharge for management in cases of infective vulvovaginitis
  • Rectal examination: When abdominopelvic mass is suspected (can be substituted by ultrasound evaluation).3
Vulvovaginitis is the most common gynecological complaint in the pediatric population.6,15 Causes and management enumerated in Tables 2 to 4. Most of the cases are nonspecific and usually present with vaginal discharge and soreness in the region as the most common complaint. Other symptoms include itching in the vulva and vagina, dysuria. Bleeding and pain are less frequent symptoms.
 
ETIOLOGY
  • Thin vaginal mucosa due to nonestrogenized state
  • Thin vulval skin
  • Vaginal pH which is alkaline
  • Short distance from the vagina to the anus
  • Poor hygiene
  • Placement of foreign bodies in the vagina
  • Chronic constipation.4,6
 
GYNECOLOGICAL PROBLEMS IN ADOLESCENT POPULATION
By World Health Organization (WHO) definition, adolescents are individuals in the age group of 10–19 years. In the South-east Asian region, adolescents comprise approximately 22% of the population.17 India has the distinction of having the largest population of adolescent girls (20%).18,19 Early adolescent period extends from 10 years to 13 years, middle adolescents are girls between 14 years and 16 years and late adolescence comprises the ages from 17 years to 19 years.20,219
TABLE 2   Organisms causing vulvovaginitis.4,15
Commensals
Nonsexually transmitted
Sexually transmitted
Staphylococcus epidermidis
Diphtheroids
Lactobacilli
Anaerobic bacteria like Bacteroides
Bacteria—Streptococcus pyogenes (59%),
Escherichia coli
Shigella (enteric transmission)
Haemophilus influenzae (respiratory contact)
Viral—adenovirus, varicella-zoster
Helminths—Enterobius vermicularis
Fungal—Candida albicans (rare)
Neisseria gonorrheae (5–20%)
Chlamydia trachomatis (2–13%)
Trichomonas vaginalis
Mycoplasma hominis
Ureaplasma urealyticum
Herpesvirus 1 and 2
Human papillomavirus
Molluscum contagiosum
TABLE 3   Vulvovaginitis and its management in pediatric population.3,16
Condition
Causative agent
Symptoms
Physical examination
Investigation
Treatment
Noninfective
Chemical irritants, poor hygiene, foreign body in the vagina, pin worm infestations, dermatological conditions
Pain, itching, dysuria, discharge (usually thin and copious)
Obese girls, vulvar erythema, inflammation, excoriation, foreign body
Vaginal swab for culture
  • Vaginal irrigation for removal of foreign body,
  • Lukewarm sitz bath BD
  • Application of emollients and zinc ointment
  • Personal hygiene, proper cleaning of the area after bowel movement (wiping from front to back),
  • Antibiotics in cases with secondary infection
  • Topical steroids in severe cases
  • Antihistamines to relieve pruritus
Infective (nonsexual)
Streptococcus pyogenes (MC), Staphylococcus aureus, Proteus mirabilis, etc.
Itching, persistent vaginal discharge
Vaginal swab for c/s
Specific antibiotic, personal hygiene10
Infective (sexually transmitted)
Neisseria gonorrheae, Chlamydia trachomatis, Trichomonas vaginalis
Itching, persistent vaginal discharge with history of sexual abuse
Purulent (N. gonorrheae)/serous (C. trachomatis) vaginal discharge. Look for other signs of sexual abuse
Vaginal swab for c/s
Specific antibiotic, personal hygiene, psychological counseling
(MC: most common)
TABLE 4   Management of pediatric patients with gynaecological problems.6,7,9,14
History:
  • Proper history from the child and attendant
  • History of trauma, foreign body insertion, sexual abuse, chronic infections and illness, immunocompromised state
  • Duration of symptoms
  • Any previous medications
  • Questions pertaining to Personal hygiene
  • General physical examination
  • Tanner staging
  • Local examination in frog-leg position of external genitalia for hygiene, erythema, excoriation, ulcers, signs of trauma
  • Vaginal examination when required with or without sedation to look for discharge, foreign body, swab for culture
  • Rectoabdominal examination in suspected mass
Nonspecific vulvovaginitis:
  • Personal hygiene
  • Proper cleaning of the anal region after bowel movement (cleaning from front to back)
  • Sitz bath
  • Emollients/barrier creams
  • Proper fitting cotton undergarments.
Infective vulvovaginitis:
  • Specific antibiotic
  • Sitz bath
  • Personal hygiene
Foreign body in the vagina:
  • Vaginal irrigation using saline with moderate pressure
  • Removal under sedation/anesthesia
Dermatologic complaints:
  • Treatment of specific cause
The physical and psychological problems of adolescents are different from the adult population and needs to be dealt accordingly (Box 2).
The most commonly encountered gynecological problem in this age group is menstrual disorders which may vary from amenorrhea to menstrual dysfunction (Box 3).22,23
As recommended by the American College of Obstetricians and Gynecologists (ACOG), the initial visit to the gynecologist should occur between the ages of 13 and 15 years (Box 4).24,25
Menstrual disorders are the most commonly encountered problem in the adolescent girls. It comprises about 45–58% of complaints in adolescent girls seeking treatment.30,31 Amongst the various causes for menstrual disturbances, anovulatory dysfunctional uterine bleeding (DUB) accounts for the majority.2311
This is mostly due to the immaturity of the hypothalamic–pituitary–ovarian (HPO) axis and it may be 5 years before normal and regular ovulatory cycles are established.32
Vaginal discharge is the second most common complaint in the adolescent age group and is mostly due to physiological leukorrhea.33,34 Leukorrhea accounts for approximately 25% of gynecological complaints of adolescent girls.35
Dysmenorrhea is a common complaint in girls attending outpatient with the onset usually 6–12 months following menarche. Postpubertal girls usually present with lower abdominal or pelvic pain with or without pain radiating to the back or legs occurring with the onset of menstrual bleeding.36 In this age-group, dysmenorrhea is usually of the primary type with no obvious pelvic pathology. Dysmenorrhea persisting in spite of medications usually of secondary type indicating underlying pelvic organ disease which needs investigation.37,38 A pelvic pathology like endometriosis or uterine pathology is noted in about 10% of adolescents suffering with dysmenorrhea.38
Mass per abdomen is a relatively uncommon complaint in adolescent girls. Ovarian masses are estimated to have an incidence of 0.0026% (Box 5). Majority of ovarian tumors are benign with mature cystic teratoma being the most common neoplastic tumor seen in adolescents.
12In women less than 20 years, mature cystic teratoma accounts for more than half of the ovarian neoplasms.39
Adolescent pregnancy is an important social issue in recent times. It is defined as pregnancy in an underaged or teenage girl between 13 years and 19 years.41 In India, teenage pregnancies vary between 5% and 33% as shown by various studies.42 A teenage pregnancy poses great risk to the pregnant mother and the fetus in terms of increased rates of unsafe abortions, anemia, preeclampsia and eclampsia, preterm delivery, cephalopelvic disproportion leading to cesarean section, low birth weight, and complications due to prematurity.
Reproductive tract abnormalities can be seen in 7% of females which might be diagnosed before or after puberty.43 Urogenital malformations in adolescents requiring visit to the gynecology OPD includes imperforate hymen, vaginal atresia with or without the presence of urogenital sinus, and transverse vaginal septum leading to hematocolpos.44 The girls usually present with pain, mass per abdomen, and primary amenorrhea. There can be an increased incidence of renal and spinal abnormalities in these girls and should be looked for.43
Many adolescents are victims of sexual abuse. Studies reveal that 1 in 4 girls are victims of sexual assault.45 The incidence of sexual abuse in children worldwide is about 18–20%.46 Though sexual assault is an underrated complaint amongst the girls attending the hospital, clinicians should be sensitized to this condition, which requires skill and tactful approach.
In sexually active adolescents, sexually transmitted diseases (STDs) can be a problem in about 30% having had at least one sexual partner (TABLE 5).
TABLE 5   Organisms causing sexually transmitted diseases.47
Organism
%
Chlamydia trachomatis
>10%
Neisseria gonorrhoeae
0–12%
Trichomoniasis
5–34%
Herpes simplex virus-2
5.6%
Human immunodeficiency virus (HIV) infection
Increased
High-risk factors for STDs:48,49
  • Level of education (more in school dropouts)
  • Alcohol and drug abusers
  • Lack of knowledge about STDs
  • Peer pressure
  • Low usage of barrier contraceptives
  • Western influence.
Other conditions requiring hospital visit may include appendicitis and appendicular abscess, urinary tract infections, and ano-rectal malformations leading to chronic constipation and cachexia. Though anorectal malformations are usually identified at birth, approximately 20% might not be detected till about pubertal age.50
Investigations should include:
  • Routine blood work up, which includes complete blood count to rule out anemia, blood group and typing, and fasting blood sugar.
  • Platelet count, bleeding and clooting time, and coagulation factors in girls with menorrhagia and suspected coagulation disorders.
  • Transabdominal ultrasound of the pelvic organs in cases of menstrual abnormalities, dysmenorrhea, and mass and pain abdomen. A transvaginal ultrasound examination can be done in sexually active girls after due consent.13
  • Magnetic resonance imaging (MRI)—abdomen and pelvis in cases presenting with pain and mass in the abdomen to diagnose conditions like benign/malignant ovarian tumors, appendicular abscess, tubo-ovarian abscess, hematocolpos/hematometra, endometriosis, etc.
  • Chromosomal analysis as and when required (cases of primary and some cases of secondary amenorrhea)
  • A high vaginal swab is indicated in sexually active adolescents with symptoms of pelvic inflammatory disease. Vaginal swab can also be taken in sexually active girls without symptoms to rule out infections.
  • Hysteroscopy can be performed in cases of intractable and nonresponsive menorrhagia.51
  • Laparoscopy might be required in the diagnosis and treatment of mass per abdomen, intractable dysmenorrhea, and management of large endometrioma.52
Treatment of the gynecological conditions in the adolescents will be according to the condition they present with as enumerated in Table 6.
TABLE 6   Treatment for various gynecological conditions in pediatric and adolescent girls.
Condition
Treatment
Menstrual abnormalities
  • Reassurance (in view of immaturity of HPO axis)
  • Management of specific cause (coagulopathies, anemia)
  • Tranexamic acid can reduce menstrual blood loss by 50% due to its antifibrinolytic property. C/I—personal/family history of thromboembolic diseases
  • Mefenamic acid can help to reduce menstrual blood loss by about 20% along with being an effective drug for management of dysmenorrhea. Most effective when started before the onset of menstruation. C/I—asthma and renal diseases
  • Low dose oral contraceptive pills to reduce menstrual blood loss in both ovulatory and nonovulatory DUB). Useful in girls with PCOS
  • Oral progestogens (nonovulatory DUB)
  • Medroxyprogesterone acetate—given once every 12 weeks as an intramuscular injection. Can cause decrease in bone mineral density on prolonged usage. Should be used with caution in girls below 18 years.53 Intrauterine levonorgestrel implant inserted under sedation in refractory DUB51
Dysmenorrhea
  • NSAIDs for pain relief
  • If no relief with NSAIDs in three cycles—low dose OCP can be used38
  • Nonpharmacological therapies like topical heat application, acupuncture, yoga, nutritional interventions, etc. (without sufficient evidence)36
  • Management of specific condition like endometriosis, imperforate hymen, etc.
Leukorrhea
  • Personal hygiene
  • Avoid use of chemicals and harsh detergents
  • Specific treatment in cases of pathological white discharge
Mass per abdomen
Treatment of the specific condition, mostly surgical intervention
Pregnancy
Management depends upon the stage of pregnancy14
Urogenital malformations
  • Cruciate incision, trimming of the hymen and marsupialization in cases of imperforate hymen54,55
  • Creation of neovagina in cases of vaginal atresia
  • Resection of the transverse vaginal septum
Sexually transmitted diseases
  • Treatment of the specific cause
  • Advice on contraceptive usage and safe sexual practices
  • Counseling against promiscuous sexual behavior
Other nongynecological conditions
Treatment directed at the cause
(C/I: contra indications; DUB: dysfunctional uterine bleeding; HPO: hypothalamus–pituitary–ovary; NSAIDs: Nonsteroidal anti-inflammatory drugs; OCP: oral contraceptive pills; PCOS: polycystic ovary syndrome)
 
CONCLUSION
With about 13.5% of the indian population in the 0–6 years age group and 236.5 billion adolescents, we will often come across pediatric gynecological problems in our outpatient clinics. With a sound knowledge of the problems affecting girls of this age group and good communication skills, gynecologists can successfully treat many of the conditions affecting these young girls and adolescents.
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