common investigations ued in gynaecology

1. VISHNU NARAYANAN M.R.

2. COMMON INVESTIGTIONS IN
GYNAECOLOGY
1. Blood values 6. Imaging techniques
2. Urine examination 7.Endomitrial sampling
3. Urethral,vaginal,cervic 8. Biopsy
al discharge 9.Culdocentesis
4. Exfoliative cytology 10.Endoscopy
5. Colposcopy 11.hormonal assays

3. BLOOD ROUTINE
• Hemoglobin estimation-Excessive
bleeding
• Total and differential count PID
• ESR
• Platelet count,BT,CT—Pubertal
menorhagia
• Serology-VDRL,australia antigen,HIV

4. URINALYSIS
1. Urine routine and microscopy
• Physical examination
• Chemical estimation of protein and sugar
• Pus cells,casts
2. Culture and drug sensitivity
• Indications—Pus cells>5
UTI
Cystocele
Urinary complaints
Fistula
3.Urine pregnancy test– for diagnosis of
pregnancy

5. Methods of urine collection
1. Midstream collection
2. Catheter collection
3. Suprapubic bladder puncture

6. CATHETERIZATION

7. Suprapubic bladder puncture

8. URETHRAL DISCHARGE
Method of collection
• Urethra squeesed against symphysis
pubis from behind forwards using
sterile gloved fingers.
• Discharge through external urethral
meatus collected with sterile swabs
• Swabs—microscopy and culture

9. Vaginal discharge
Method of collection
• Patient not to have vaginal douche
for 24hrs
• Cusco’s bivalve speculum introduced
• Discharge from posterior fornix on
the blade of speculum or cervical
canal taken with a swab
• microscopic examination-Discharge
mixed with normal saline
• culture

10. Identification of organisms in the slide
1.Normal discharge-normal vaginal cells
with doderlein bacilli
2.Trichomonal vaginalis—hanging drop
preparation shows motile flagellated
organisms of varying shape
3.Gardnerella vaginosis(bacterial/non
specific vaginitis)—clue cells,few
inflammatory cells,free floating clumps of
gardnerella,scanty lactobacilli

11. 4.Vaginal candidasis
• Vaginal discharge + equal amount of
10% KOH
• Caustic potash dissolves all cellular
debris,leaving behind more resistant
yeast like organisms
• Typical hyphae,budding spores or
mycelia detected

12. EXFOLIATIVE CYTOLOGY-
PAPANICOLAOU TEST
• Pap test-Screening test for cancer
• First described by Papanicolaou and Traut in 1943
• Routine gynaecological examination in females,esp
above 35 years
• Yearly screening for 3 years followed by 5 yearly
test
• Uses—
1.screening for cancer
2.identification of local viral infections like herpes and
condyloma accuminata
3.Cytohormonal study

13. Pap smear-screening of cancer
PROCEDURE
• Should be obtained prior to vaginal
examination
• Patient placed in dorsal position with labia
separated
• Cusco’s self retaining speculum inserted
without lubricants
• Cervix exposed,squamocolumnar junction
scraped with concave end of Ayre’s spatula
by rotating all around
• Thin smear is prepared on a glass slide and
fixed by equal amounts of 95% alcohol and
ether
• After 30 min,slide air dried and stained with
papanicolaou or Short stain

14. • Modifications
1. Endocervical sampling –endocervix scraped with a cytobrush
and added to the slide
2. Fixative spray—cytospray used in office setup

15. INTERPRETATIONS
• Normal cells
1.Basal cells-small,rounded basophilic with large
nuclei
2.Squamous cells from middle layer –
transparent and basophilic with vesicular nuclei
3.Cells from superficial layer-acidophilic with
characterestic pyknotic nuclei
4.Endometrial cells,histiocytes,blood cells and
bacteria

16. ABNORMAL CELLS
1)Mild dyskaryosis—
• superficial/intermediate squamous cells
• Angular borders,transcluscent cytoplasm
• Nucleus < half of total area of cytoplasm
• Binucleation is common
• CIN-I

17. 2)Moderate dyskaryosis—
• Intermediate/parabasal/superficial squamous
cell type
• More disproportionate nuclear enlaregement
and hyperchromasia
• Nucleus-1/2-2/3 of total cytoplasm area
• CIN II

18. 3)SEVERE DYSKARYOSIS
• Cells- basal type
round/oval/polygonal/elongated
singly/in clumps
• Nucleus- almost fills the cell
thick,dense,narrow rim of cytoplasm
irregular with coarse chromatin pattern
• CIN III
• Fibre cells- severly dyskaryotic elongated cell
• Tadpole cell- severly dyskaryotic cell with an
elongated tail of cytoplasm

19. 4.Carcinoma in situ 5.Invasive carcinoma
• Parabasal cells with • Cells-single/clusters
increased nucleo- • Tadpole cells
cytoplasmic ratio • Irregular nuclei
• Cytoplasm scanty • Coarse clumping of
• Nucleus- chromatin
irregular,sometimes
multiple
• Chromatin pattern-
granular

20. 6)Koilocytosis
• Nuclear abnormalities due to HPV infection
• Condyloma accuminata
• Cells-perinuclear halo,peripheral conensation
of cytoplasm
• Nucleus-irregularly enlarged,hyperchromatic
with multinucleation
• Disappears with dysplasia

21. • Positive pap smear in genital herpes-giant cells with
viral inclusion bodies
• Silver pap test– pap test+PCR– used for diagnosis of
herpes

22. Reporting system
• normal/abnormal
• Abnormal-CIN/papilloma infection/invasive
malignancy
• Doubtful/inconclusive smear-repeat smear
PAPANICOLAOU CLASSIFICATION-GRADING
I. Normal cells
II. Slightly abnormal-inflammatory change
III. Cells suspicious of malignancy-biopsy indicated
IV. Few Distinctly abnormal,possibly malignant cells
V. Malignant cells seen-numerous

23. Papanicolaou World Health Bethesda System
Class I Normal Within normal limits
Class II AtypiaI inflammatory Inflammation-HPV
Squamous, glandular ASCUS, AGCUS
Class III Mild dysplasia CIN-I Low SIL
Class IV Moderate dysplasia CIN -II High SIL
Severe dysplasia CIN -III
Carcinoma in situ
Class V Squamous cell carcinoma Squamous cell
Adenocarcinoma carcinoma
Adenocarcinoma

24. LIMITATIONS OF PAP SMEAR
• Detect only 60-70% of cervical cancer and 70% of
endomitrial cancer
• Reliability depends on slide preparation and skill
of cytologist
• 10-15% false negative results
• False positive results in presence of infections
• Difficulty if squamocolumnar junction-indrawn as
in post menopausal women(10 day course of
oestrogen cream suggested)
• Postradiation cytology difficult- scarring and
atrophy of vagina

25. Liquid based cytology-cancer
screening
• Plastic spatula after scraping placed in
buffered methanol solution-hemolytic and
mucolytic
• Cells separated by centrifugation and gently
sucked thrrough a filter membrane
• Filter pressed onto a glass slide to form thin
monolayer which is stained

26. CYTOHORMONAL EVALUATION
• Exfoliative cytology
• Non invasive study of epithelium for hormonal
status
• Principle-vaginal epithelium highly sensitive to
oestrogen and progesterone.
oestrogen—superficial cell maturation
progesterone—intermediate cell maturation
• Procedure—scrapings taken from lateral wall
of upper third of vagina

27. INFERENCE
• Normal smear-parabasal,intermediate and
superficial cells
• Oestrogen predominant smear-large
eosinophilic cells with pyknotic nuclei and clear
back ground
• Progesterone predominant smear-
predominantly basophilic cells with vesicular
nuclei and dirty background
• Pregnancy-intremediate and navicular cells
• Post-menopausal smear- parabasal and basal
cells

28. KARYOPYKNOTIC INDEX/MATURATION INDEX
• KPI = Mature squamous cells
Intermediate +basal cells
• Proliferative phase-KPI>25%
• Secretory phase-KPI-very low
• KPI> 10% in pregnancy – progesterone
deficiency
• KPI peaks on the day of ovulation

29. UTERINE ASPIRATION
CYTOLOGY
• Screening test for endometrial
cancer-endometrial sampling
• Sample obtained by
endometreal pipelle/uterine
aspiration syringe or brush
• 90% accuracy with no false
positive findings
• Hormonal studies also done

30. ENDOMETRIAL BIOPSY
• Most reliable method to study endometrium
• Endometrial tissue obtained by curretage and
subjected for histopathology
Indications–
• suspected cases of Endometritis,endometrial
cancer
• Infertility
• Abnormal menstrual bleeding
• Diagnosis of corpus luteal phase defect

31. CERVICAL BIOPSY
• Confirmatory diagnosis of cervical pathology
• Done at OP if pathology detectable
• Wider tissue excision as in cone biopsy – IP
procedure

32. COLPOSCOPY
• Colposcope-binocular microscope-
10-20 X
• Use-colposcope directed biopsy
colposcopic examination of
cervix and vagina

33. CULDOCENTESIS
• Transvaginal aspiration of peritoneal fluid from the
pouch of douglas
• Diagnostic procedure-
pelvic abcess
ectopic pregnancy in haematocele
detect malignancy in ascitis with
ovarian cyst
• Instruments- vulsellum forceps,posterior vaginal
speculum,aspiration syringe

34. PROCEDURE
• Patient-lithotomy position
• Posterior lip of cervix-downwards and
forwards with vulsellum forceps
• Speculum-retracts posterior vaginal wall
• Area disinfected
• Aspiration syringe inserted into the pouch and
aspirated
• Done best in OT under full asceptic
precautions and to proceed
laproscopy/laprotomy if indicated

35. HORMONAL ASSAYS
• RIA,ELISA
• Hormones assayed-
FSH,LH,PRL,ACTH,T3,T4,TSH,progesterone, oestradio
,testosterone,aldosterone,cortisol, hCG,dehydroepia
ndrosterone,andostenedione
• Uses- Diagnosis of menopause,PCOD,prolactinemia
Monitoring treatment regimes in ovulation
induction and AST

36. IMAGING TECHNIQUES-Overview
1.X-RAY
• Plain x ray chest and intravenous urogram- pelvic malignancy esp
cervical cancer,prior to staging.
• Plain x ray pelvis- To locate misplaced IUCD
Visualize bone/teeth in benign cystic teratoma
• Hysterosalpingography-to test tube patency,
Intracavity uterine mass and mullerian anomalies of uterus
• Lymphangiography-to locate lymph nodes involved
in pelvic malignancy

37. 2.ULTRASONOGRAPHY
• Simple,non invasive,painless,safe procedure
• Pelvis and lower abdomen scanned longitudinally and
transversely
• D3 ultrasound-3-D images of pelvic organs
Transabdominal sonography(TAS)-
• Done with transducer operating at 2.5-3.5Mhz
• Bladder full
• Large masses examination –ovarian tumour/fibroid

38. Transvaginal sonography(TVS)
• Probe placed close to organ
• High frequency waves used-5-8MHz
• No need of full bladder
• Detailed evaluation of pelvic organs possible
• Better image resolution but poor tissue
penetration
• Difficulty in narrow vagina
Transvaginal colour doppler sonography
• Information regarding blood flow to,from or
within the uterus or adnexa

39. Diagnostic USG in gynaecology
• Infertility workup
1)folliculometry-measurement of ovarian follicle diameter
2)measurement of endometrial thickness
3)evidence of ovulation-internal echoes and free fluid in
pouch of douglas
4)timing of ovulation-helps in ovulation induction,AI,ovum
retrieval
5)sonographic guided oocyte retrtieval
• Ectopic pregnancy-tubal ring in adnexa with
empty uterine cavity
• Evaluation of pelvic mass

40. • Oncology-to assess vascularity of tumour and
confirm malignancy
• Endometrial study in DUB
• Diagnose uterine pathology-fibroids,adenomyosis
• Location of misplaced IUD
• Falloposcopy-to study medial end of tube
• Diagnose endometriosis
• To study ovarian pathology-PCOD,ovarian
cyst,tumour
• Congenital anomalies of uterus
• Diagnose adnexal mass

41. 3) Computed tomography
• Supplements information from USG
• Whole abdomen and pelvis visualised in one sitting after
taking 600-800ml of a dilute contrast medium 1 hour prior to
procedure
• Patient scanned in supine position
• Accurate in accesing local tumour invasion and enables
accurate localisation in biopsy
• Diagnose pelvic vein thrombophlebitis, intraabdominal abcess
and other extra genital abnormalities
• Metastatic implants and lymphnodes < 1 cm—not detected
• Contraindicated in pregnancy

42. 4) Magnetic resonance imaging
• Well established cross sectional imaging modality
• High soft tissue contrast resolution without air/bone
interference
• Limitations-cost,time,availability
• Indicated only when a sonar or CT fails to detect a lesion or to
differntiate post-tratment fibrosis or tumour
5)Positron emission tomography(PET)
• To differentiate normal tissue from cancerous one based on
the uptake of 18F-FLURO-2DEOXYGLUCOSE

43. DIAGNOSTIC ENDOSCOPY-Overview
• To visualize body cavity
Lapraroscopy-
• Diagnose uterine,tubal,ovarian,generalised
diseases affecting pelvic organs-
endometriosis,PID,genital TB
• Staging of genital cancers
• Infertility workup
• a/c pelvic lesions-ectopic pregnancy,salphingitis
etc

44. 2)Hysteroscopy
• Visualise endometrial cavity
• Diagnostic uses
1. Unresponsive irregular uterine bleeding
2. Congenital uterine septum
3. Missing threads of IUD
4. Intrauterine adhesions
5. Endometrial polyps/ malignant growth
3)Salphingoscopy and falloposcopy
• Visualise of fallopian tube
• Permits selection of patients for IVF rather than
tubal surgery

45. 4)Culdoscopy
• Visualise pelvic structures via an incision in pouch
of Douglas
5)Cystoscopy
• To evaluate cervical cancer prior to staging
• Investigate urinary symptoms-
haematuria,incontinence and fistulae
6) Proctoscopy and sigmoidoscopy
• To evaluate rectal invovement in genital
malignancy

47. INFERTILITY IN FEMALES
TESTS FOR TUBAL PATENCY
• Hysterosalpingography
• Laproscopic chromotubation
• Sonosalpingography
• Hysterofalloscopy
• Ampullary and fimbrial salpingography
TESTS FOR OVULATION
• Basal body temperature
• Examination of cervical mucus-fern test
• Ultrasound
• Hormonal assays-estrogen and progesterone

48. INFERTILITY IN MALES
• Semen analyisis
• Post-coital test-Sim’s test
• Sperm penetration test
• Semen-cervical mucus contact test
• Urine examination
• Patency of vas-vasogram
• Testicular biopsy
• Hormonal assays-FSH,LH,testosterone,prolactin
• Chromosomal study
• Immunological tests-ELISA, RIA
• Ultrasound scanning

49. PRE-OPERATIVE INVESTIGATIONS IN
GYNAECOLOGY
• Complete blood count
• Urinalysis
• FBS,PPBS
• BT,CT
• Blood group and Rh factor
• RFT
• LFT
• Serology- VDRL
• Serum electrolytes-Na,K,Cl,HCO3
• Chest radiograph
• ECG
• IVP

50. • Tumour markers
1. CA-125-Adenocarcinoma ovary
2. CEA,α-fetoprotein,β-hCG—Ovarian teratomas
• Bacterial examination of genital tract
1.Smear and microscopy
2.Culture
3.PCR