GYNAECOLOGICAL

CONDITION
COMPLICATING
PREGNANCY: BENIGN AND
MALIGNANT
TUMORS,CONGENITAL
ANOMALIES
 INTRODUCTION
Non obstetric disorders often complicating
pregnancy; management for pregnant patients
sometimes differ from that for non pregnant
patients.
Gynaecological malignancy during pregnancy is
a stressful problem.
Tumors during pregnancy are rare, but they can
happen.it can be malignant or benign.
HISTOLOGY OF NEOPLASTIC
GROWTH
O Normal tissues are composed of mature cells
of uniform size and shape.
O Each cell contains a nucleus of uniform size
O Nucleus are the chromosomes containing
DNA,RNA(it is the regulator of the growth
and function of the cell)
O Malignant cells are those that have changed
their basic structure and pattern into bizzare
pattern
O The cells divide and grow but no longer
resemble the parent cell.
O Abnormal cells are classified according
to their degree of variation from normal
cells
O Grade 1 tumor is most like the parent
cell and least malignant
O Grade IV tumor is least like the parent
cell and most malignant
O Malignant tumors usually are not
encapsulated and can invade blood
vessels or lymphatics.
O The tumor cells often break away and
are carried by the blood and lymphatics
to other parts of body.
O Benign tumors are composed of cells
that resembles parent cells.
O Usually they are
encapsulated,localized,slow growth and
harmful.
O Benign tumors may not be life
threatening in the non pregnant state, it
can have deleterious effect during
pregnancy.
O Tumors can prevent placental
implantation cause haemorrhagic
disease such as DIC in the mother
,preventing vaginal delivery.
O Tumors derive their names from type of
tissue involved. They may arise from
one or all three of embryonic tissue
structures:mesoderm,ectoderm and
endoderm.
O Benign tumors generally are of one
tissue type
O Malignant tumors are named by the type of
tissue
1. Carcinoma , from epithelial cells
2. Sarcoma, from connective tissue cells
3. Teratoma ,from all three embryonic layers

O The mode of treatment depends on the type

and the location of the tumor.
O Treatment may consist of surgery,radiation
therapy,chemotherapy or combination of
these.
BENIGN VULVAR TUMORS
During pregnancy ,Condyloma
accuminatum is the most common tumor
of the vulva.It is sexually transmitted
disease.
Majority of benign tumors of vulva are of
epidermal origin. Less commonly , they
arise from epidermal appendages,
mesoderm or from greater or lesser
vestibular glands.
 CONDYLOMA
ACCUMINATUM
O DEFINITION
Condyloma acuminata are the wart like
growths found most commonly where the
stratified squamous epithelium is thin,
moist and warm. The are caused by a
virus that is transmitted sexually.
 ETIOLOGY
O Human papilloma virus
O Cervical glands hypertrophy, mucus
secretion increases greatly during
pregnancy
O Poor perineal hygiene
O Autoinoculation
O Virus may remain in latent phase for 7
years
SIGNS AND SYMPTOMS
O Wart like growths in the vulva,pubic or
anorectal area
O Growths also can be found in vagina and on
the cervix
O Less commonly found in mouth
O Pain and mal odorous discharge
O Secondary vaginal infection
O Regional lymphadenopathy does not occur
 DIAGNOSIS
Clinical observation in conjunction with
woman's medical and sexual history
O These warts may grow and coalesce into
cauliflower shaped lesions.
O Cervical inspection should be done on all
women with condylomata of the vulva .since
10% will have cervical warts
O A pap smear of the cervix should be taken
since there have been reports of metastic
change in warts that give the appearance of
cervical neoplasia
O Since 20-25% of women with genital
warts have a coexisting sexually
transmitted disease, appropriate
labotary tests should be done
(i.e. wet preparation,gonorrhea
culture,chlamydia culture, serological test
for syphilis)
O Since 50-75% of exposed sexual
partners have or develop genital warts,
contacts should be examined
 MATERNAL AND FETAL
OUTCOME
O The physiological changes of pregnancy can
produce a dramatic stimulus to the
hyperplasia of the condylomata that is
painful
O Alteration of body image change
psychological condition
O The route of transmission of HPV from
mother to baby is unknown. Therefore
caesarean section
MEDICAL MANAGEMENT
O Treatment is difficult because of the persistent
stimulation of the condylomato by the
continuing copious vaginal secretions of
pregnancy.
Secondary vaginal infection should be treated to
decrease the volume and alter the character of
the discharge
O Measure to decrease moisture and to promote
comfort should be suggested
O The treatment of choice for condyloma
accuminatum is cryotherapy with liquid
nitrogen
O Podophyllin is contraindicated during
pregnancy
O Trichloracetic acid can be used in 50%
solution for vulvar,vaginal or anal
warts. The application can be repeated
at weekly intervals.
O During pregnancy ,small warts are
observed to see if they will regress
electrocoagulation may be useful.
O Thompson and grace have developed a
scissor dissection method that spares
normal tissue and prevent scarring and
resultant pain caused by other method
of excision
O Pap smears and atypical or persistent
warts should be biopsied
O Condom use to be advised for the partners of
all women infected with HPV
 NURSING CARE
O Teach patient with condylomata
accuminata to promote comfort and
perhaps inhibit growth( sitz bath,
maintain perineal hygiene, use cotton
panties, avoid tight fitting, synthetic
clothing)
O Evaluate the patient for sexually
transmitted disease or vaginal infection
O Advise evaluation of sexual partners
O Ensure that a pap smear is performed
O Advise the patient to get regular annual
pap smear
O Provide teaching appropriate to the size,
location and planned treatment
O Advise that condylomata often regress in
size after delivery
O Provide pre and post operative teaching if
surgical excision or electrocoagulation is
planned
O Advised caesarean section if required
CARCINOMA OF THE VULVA
O DEFINITION:
Vulvar carcinoma is a malignant
cutaneous cancer of the external
genitalia.the disease progresses from
dysplasia through intraepithelial neoplasia
to invasive cancer.
It is the fourth most common type of
female genital cancer.
 INCIDENCE
O The incidence is highest in women 50-
60 years old. However ,40% of patients
with vulvar carcinoma are under 40
years of age.In pregnancy the
occurrence of vulvar carcinoma is
1:8000.It is thought pregnancy has no
effect on the course of the disease
 Signs and symptoms
O Early symptoms may be complaints of
vulvar pruritis,sore or a lump
O Later symptoms may be persistent
pruritus and pain
 DIAGNOSIS
O The tumor may be detected during
careful examination with a good light
source
O The actual diagnosis is made by a
biopsy of the lesion
O Staging is determined by size,locationof
the tumors.regional node involvement
O During child bearing years, vulvar
carcinoma usually limited to stage I and
stage II
 MATERNAL AND FETAL
OUTCOME
O The 5 years survival rate depends on
lymph node involvement
O 80-85% of patients with negative nodes
are alive at 5 years
O The rate drops to 40-50% for patient
with positive nodes.
MEDICAL MANAGEMENT
O Standard form of therapy for stage I and
stage II vulvar carcinoma was
considered to be radical vulvectomy
with groin node dissection
O Currently vulvar conservation is
possible in certain patient with early
lesion is considered
O In situ vulvar carcinoma rarely progress
to invasive carcinoma
SURGICAL MANAGEMENT
O Surgery is main way to treat vulvar
carcinoma
O Treatment aims to remove the cancer
while leaving sexual function intact
O If diagnosis occur in the early stages of
the cancer, limited surgery is required
O At later stage if the cancer has spread to
nearby organs surgery will be more
extensive
 TYPES OF SURGERY
O Laser surgery: this uses a laser
beam as a knife to remove lesions
O Excision: the surgeon attempts to
remove all the cancer and same
healthy tissue around it
O Skinning vulvectomy: the surgeon
remove top layers of skin , where the
cancer is located.a skin graft from
another part of the body can be used to
replaced what was lost
O Radical vulvectomy: the srgeaon
removes whole vulva,including
clitoris,vaginal lips,the opening of
vagina and nearby lymph nodes
 PREVENTION
O Measures that can reduce vulvar cancer
include
O Practicing safe sex
O Attending scheduled cervical smear tests
O Having the HPV vaccination
O Not smokimg
O There is no standards screening for vulvar
cancer, but women should carry out checkups
and be aware of any changes to their body
BENIGN VAGINAL TUMORS
O Gartners or mullerian duct cysts are collection
of fluid within embryological remnant that can
extend down the vagina.
O The cyst can become large enough to cause
mechanical obstruction of the birth canal
O Simple drainage usually will releie the
dystocia they can create,allowing for vaginal
delivery
O Surgical excision postponed untill delivery
BENIGN CERVICAL TUMORS
O Cervical myomas are growths arising
out muscular tissue and are rare during
pregnancy
O If they occur ,the growth rate is rapid as
a result of hormonal stimulation of
pregnancy
 TREATMENT
O Myomectomy
O Treatment is postponed until after
delivery because of the threat of
abortion and/or haemorrhage
O Delivery by cesaerean section because
of mechanical obstructionand threat of
haemorrhage from myoma
 Cervical polyps
O Cervical polyps are the most common of
benign cervical tumors.Generally they arise
from the intracervical mucosa, are bright red
in colour, have a spongy texture, and are
fragile, they are located usually at the external
OS.
O Polyp can cause slight bleeding, especially
when provoked by muscular exertion, such as
with defecation and coitus
CERVICAL CARCINOMA
O DEFINITION:
The epithelium of the cervix has two type of
tissue. The portion of the cervix ,known as
the external OS,is covered with stratified
squamous epithelium .The point at which the
tissue meet is squamocolumnar
junction.This point is the most common site
of cancer cell growth.
 INCIDENCE
O Adenocarcinoma , the second type,
accounts for less than 10%, it involves
glandular epithelium. The mean age of
a woman with cervical cancer is 46
years. The incidence of cervical cancer
insitu in pregnancy is 1:765 and of
invasive cancer is 1:2205.
 ETIOLOGY
O Cervical carcinoma
O Poor hygiene
O Infectious agent
O Lower socio economic urban areas
O Disease associated with condylomata
SIGNS AND SYMPTOMS
O Poistcoital bleeding
O Abnormal discharge
O Persistent bleeding
O Profuse discharge
O Pain
 DIAGNOSIS
O Pap smear is a diagnostic tool for
screening cervical changes
O Colposcopy – directed biopsy
O Cone biopsy
O Punch biopsy
Squamocolumnar junction
Cone biopsy
Punch biopsy
 Colposcopy

O Colposcopy (Ancient Greek: kolpos hollow,

womb, vagina + skopos look at) is a medical
diagnostic procedure to examine an
illuminated, magnified view of the cervix
and the tissues of the vagina and vulva.
 Nomenclature in cervical
cytology
Pap smear WHO system BETHESDA
SYSTEM
Class I Normal Within normal limit

Class II Atypical Reactive or

reparative change
Class III Dysplasia Squamous
epithelial cell
abnormality
Class IV Carcinoma in situ Squamous cell
carcinoma
Class V Invasive squamous Glandular cell
cell carcinoma abnormalities
 MATERNAL AND FETAL
OUTCOME
O The stage of disease.
O Negatively influence the fetus
MEDICAL MANAGEMENT
O Normal colposcopy
O If this smear is normal , then the next
colposcopic examination between 28-32
week of gestation.
O Abnormal colposcopic examination
 DYSPLASIA AND
CARCINOMA INSITU
O Pap smear and colposcopy are
performed every 4-6 weeks until time
of delivery to ascertain the disease.
 MICROINVASIVE
CARCINOMA
O Treatment consist of an extrafascial
hysterectomy with fetus insitu
O If the diagnosis in the late second or third
trimester, the pregnancy usually is allowed to
go to term without treatment
 FRANKLY INVASIVE
CARCINOMA
O It requires immediate treatment.
O For stages 1b and early 2a radical
hysterectomy and pelvic
lymphadenectomy with preservation of
ovary.
O Radiation therapy is a alternative
therapy for early stage.
 OBSTETRICAL
MANAGEMENT
O Treatment is guided by stages of disease.
O women diagnosed prior to 20 to 24 wks of
gestation are encourage to receive immediately
therapy.
O While those women diagnose after 20 to 24
wks delay treatment.
ALTERNATIVE TREATMENT
O Neoadjuvant chemotherapy
O Surgical management
O Treatment in early gestation particularly
with 5 fluorouracil and
cyclophosphamide associated with fetal
anomalies.
 RECOMMENDATION OF
MODE OF DELIVERY
O Cesarean delivery is recommended for
most women with bulky cervical tumor.
O Other reports have suggested vaginal
delivery is safe for women with small
tumor.
COUNSELLING
 BENIGN TUMORS OF
UTERUS (leiomyoma)
O DEFINITION
Leiomyoma are benign tumors of the
smooth muscle of the uterus.
There are most common in pregnancy.
 INCIDENCE
O The incidence in pregnancy has been
reported to be as high as 1 %.
 CLASSIFICATION
Myomas are classified according to their
location.
1. Submucous myomas
2. Subserous myomas
3. Intramural myomas
4. Pedunculated myomas
 ETIOLOGY
O Estrogen stimulation
O Pregnancy
O Stimulation of hormone enhance blood
supply to uterus.
SIGNS AND SYMPTOMS
O Usually asymptomatic
O Detected in routine pelvic examination
O Focal pain
O tenderness
O Low grade fever
DIFFERENTIAL DIAGNOSIS
O Appendicitis
O Placenta abruption
O Pyelonephritis
 DIAGNOSIS
O Ultrasound
Diagnostic ultrasound findings
O A mass larger than 3cm in diameter
O Mass is spherical
O Myometrial contour is distorted by the
mass
O No echoes behind mass
Maternal and fetal outcome
O Prognosis
O Sub mucous myomas
O Pedunculated myomas
O Sub serous myomas
 Medical management
O Analgesic agent
 Surgical management
O Myomectomy
 Ovarian tumors
O DEFINITION:
Ovarian tumor are difficult to classify
because the organ is made up of four
distinct cell types.
Epithelial
Sex cord
Stromal cells
Lipid cells
Cell of ovary
 INCIDENCE
O It occurs 85% of the time in women
under 30 years of age. Approximately
15% of these tumors occur during
pregnancy or puerperium.
 Etiology
O Trimester of pregnancy
O Tubal pregnancy
O Spontaneous abortion
O Ultrasonography
O Common in black
O Nulliparous
O Asbestos
O Low fibre diet
O Vitamin A
 Signs and symptoms
O 50% of cases,during routine pelvic
examination.
O Ovary elevated
O Abdominal pressure on GI tract or
urinary tract
O Discomforts
O virilization
 DIAGNOSIS
O Laparotomy
 MATERNAL AND FETAL
OUTCOME
O Do not affect fetus growth and
development
O Anesthesia
O Surgical trauma
O Chemotherapy or radiation
O Rupture of uterus
O Virilization
 MANAGEMENT
O Same as non pregnant state
O Laparotomy
O Caesarean section
O Chemotherapy
O Adjuvant therapy
O Radiation therapy
O Unilateral oophorectomy
 CHORIOADENOMA
DESTRUENS
O DEFINITION:
Chorioadenoma destruens is a mole that invades
the myometrium via molar villi. Hydatidiform
mole is followed by chorioadenoma destruens in
15%of all cases.
 Etiology
O The villous structure remains intact in
the presence of myometrial invasion of
the malignant trophoblast
 Management

O Methotrexate
O Hysterectomy
Breast
 Galactocele
O A galactocele (also: lacteal cyst or milk
cyst) is a retention cyst containing milk
or a milky substance that is usually
located in the mammary glands.
 Diagnosis

O Ultrasonography
O Incisional biopsy
Fibrocystic disease
Maternal and fetal outcome
O No adverse effect
 Medical management
O Careful monitoring
O xanthine
 Adenomas

O Definition:
Adenomas of the breast are benign
neoplasms
that rank as third most frequent breast
lesion in u.s women
 Types

O Three types
1. Fibroadenomas, are
benign breast tumours
characterized by an
mixture of stromal and
epithelial tissue. Breasts
are made of lobules (milk
producing glands) and
ducts (tubes that carry the
milk to the nipple).
2. Pure adenomas:
Tubular adenomas or pure adenomas are
rare benign epithelial tumors of the breast
accounts for 0.13 - 1.7% of benign breast
lesions , that are common in the young
women with mean age of 10-20 years
Clinically pure adenomas are
indistinguishable from fibroadenomas.
3. Nipple adenomas:
A nipple adenoma is a benign epithelial
cell proliferation that frequently develops
beneath the areola, or nipple. An
“adenoma” can occur anywhere in the
body that has gland.
 Management

O Careful follow up
 Breast carcinoma
O Breast cancer is classified as either
noninvasive or invasive. Noninvasive
carcinoma refers to cancer in the ducts or
lobules and is also called carcinoma in situ
(5% of breast cancers). Invasive carcinoma
(also known as infiltrating carcinoma) occurs
when the cancer cells invade the tissue beyond
the ducts or lobules.
Breast carcinoma
 Etiology

O High risk
1. Older age
2. Country of birth
3. Family history
4. Biopsy showing proliferative lesioHigh risk
O Moderate risk
1. Upper socioeconomic class
2. Obesity
3. Postmenopausal
4. Radiation to chest
5. Nulliparous
O Low risk
1. Moderate alcohol intake
2. Menarche before 12 yr
3. Menopause after 55year
 Signs and symptoms
O Lump
O Dimpling of skin
O Retraction
O Abnormal contour
O Increase venous
prominence
O Thickened skin with
enlarged pores
 Medical management

O Local regional treatment-

O Systemic treatment
O Radiation
 Radical mastectomy
O Radical mastectomy is
a surgical procedure in
which the breast,
underlying chest muscle
(including pectoralis
major and pectoralis
minor), and lymph nodes
of the axilla are removed
as a treatment for breast
cancer
Comparison in breast disease
FIBROCYSTI CARCINOMA FIBRO
C DISEASE ADENOMA
Median age More than 30 yr More than 40 yr 20 yr
Pain or Premenstrual,m none none
tenderness enstrual
Nipple Absent Usually absent Absent
discharge
Retraction Absent Present Absent

Mobility Mobile Fixed Mobile

Consistency and Firm ,multiple Firm Rubbery usually

number ,usually single single
 Malignant melanoma
O Malignant
melanoma is a
tumor made up of
melanocytes.
During pregnancy
a benign nevus
become malignant .
 Prognosis

O poor
 Nursing management
O Participate to minimize or
prevent the complications
1. Disease process
2. Treatment
O Assess for manage
discomfort
O Provide emotional
support
O Educate patient
 Nursing diagnosis
O Anxiety
O grieving related to actual or perceived threat
O High risk for infection
O Knowledge deficit regarding etiology, disease
process, treatment
O Nutrition
O Body image,self esteem disturbance
O Altered sexual pattern