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PEDIATRIC GYNECOLOGY

PEDIATRIC GYNECOLOGY. By DR. ARCHANAVIKRAM ASST. PROF DEPT OF OBG. INTRODUCTION. ▪ An awareness of the problems that are unique to pediatric and adolescent gynecology is invaluable for proper management of the young patient .

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PEDIATRIC GYNECOLOGY

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  1. PEDIATRIC GYNECOLOGY By DR. ARCHANAVIKRAM ASST. PROF DEPT OF OBG

  2. INTRODUCTION ▪ An awareness of the problems that are unique to pediatric and adolescent gynecology is invaluable for proper management of the young patient . Particular care is essential in addressing gynecologic concerns in this age group because both physical and emotional trauma may be inadvertently inflicted .

  3. Normal findings in a pediatric patient . A mucoid vaginal discharge . An introitus that is located more anteriorly than normal and a clitoris that is more prominent than normal ( 1 to 2 cm ) . A redundant hymen that may protrude on straining and that remains essentially the same size until 10 years of age . A vaginal epithelium that is uncornified and erythematous with an alkaline pH . A small uterus ( 2.5 to 3 cm ) in length . A cervical os that is covered with glandular epithelium and normally appears red ( ectropion )

  4. Trauma Tears , abrasions , ecchymoses , and hematomas are common in preadolescent girls . The incidence is highest in children between 4 and 12 years of age . The most common causes of injury are sexual abuse, straddle injuries , accidental penetration , sudden abduction of the extremities , and pelvic fractures .

  5. Management . Visualize vagina to locate sources of bleeding - Superficial abrasions and lacerations of the vulva , if not actively bleeding , can be cleaned and left alone . In sexual abuse , antibiotic therapy is advised as prophylaxis against sexually transmitted diseases .

  6. Labial agglutination

  7. Labial agglutination • Clinical picture Adhesion of the labia minora in the midline is the usual presentation. • The agglutination encourages retention of urine and vaginal secretions and can lead to vulvovaginitis or urinary tract infection. • Management • If asymptomatic, improved hygiene may be all that is necessary. • Lubrication of the labia with a bland ointment. • Topical estrogen. • Surgical separation is rarely necessary.

  8. Vaginal Discharge

  9. Clinical Picture • A mucoid discharge is common in infants for up 2 weeks after birth;it result from maternal estrogen. • It is also a common finding in prepubertal girls, who experience increased estrogen production by maturing ovaries. • Pathologic discharge may result from any of the following conditions: • Infections with organisms, such as E.coli, Proteus, Pseudomonas. • Hemolytic streptococcal vaginitis. • Monilialvaginitis. • A foreign body.

  10. Managment • Conservative management is advisable, as follows: • Culture to identify causative organisms. • Urinanalysis to rule out cystitis. • proper hygiene. • Perianal examination with transparent tape to test for pinworms. • In cases of persistent discharge, examination under anesthesia is indicated to rule out foreign body.

  11. Neoplasms A. Tumors of the vagina

  12. Clinical Picture • It appears as an edematous, grape-like mass that bleeds readily on touch. It is usually multi-centric and extension is usually local, with rare instances of distant metastases. • Management A combination of surgery and chemotherapy is most commonly used.

  13. B. Ovarian Tumors • Clinical Picture: • Non-germ cell origin • Lipoid cell tumors( estrogen producing) • Granules theca cell tumors(estrogen producing) • Germ cell origin • Benign cystic teratomas. • Benign cysts. • Arrhenoblastomas (androgen producing). • Dysgerminomas and gonadoblastomas ( tumors of dysgenetic gonads). • Endodermal carcinomas ( human chorionic gonadotropin [hcg]- secreting tumors). • Immature teratomas.

  14. Managment • Treatment is surgical, alone or in combination with chemotherapy, depending on the tumor. Radiation is sometimes used to treat dysgerminomas.

  15. Congenital Anomalies in the Pediatric Patient

  16. A. Mullerian agenesis (Mayer-von Rokitansky- Kauster-Hauser [MRKH] syndrome) Amenorrhea Ovarian development is normal The uterus is usually absent Vaginal agenesis(normal 46xx karyotype) Management Surgical creation of neovagina

  17. B-Ectopic ureter with vaginal terminus • Ectopic ureter,the most common cause of vaginal cysts in infants. • Irritation • Vaginitis may be presenting signs • Hydroureter • Hydronephrosis

  18. Diagnosis • Intravenous pyelography, which allows visualization of the entire urinary tract . Management • Resect the lowest portion of the ureter and implant it into the bladder . • Remove the ureter and associated portion of the kidney

  19. C-vaginal ectopic anus • Imperforate anus associated with rectovaginal communication Management • Surgical correction is indicated

  20. V-Developmental defects of the External Genetalia (Ambiguous Genitalia) • hormones with androgenic activity are present during development of female fetus, or androgens or androgen activity are absent during development of male fetus.

  21. Congenital adrenal hyperplasia (CAH) • Cortisol and aldosterone pathways are impaired . • The 21-hydroxylase defect is the most common cuse of distinct virilization of the female newborn. • The chromosomes,gonads,and internal genitalia are female,but the external genitalia are virilized to varying degrees. • Urogenital orifice closed . • Clitoral enlargement and accentuation of labial folds are characteristic .

  22. Adrenal tumors • These tumors,which may cause virilization of the external genitalia after infancy, should be suspected in children with high levels of dehydroepiandrosterone sulfate (DHEAS). C-maternal ingestion of androgenic substances Causal agents identified include androgens,danazol,any synthetic progestins(in doses much higher than in oral contraceptive pills).

  23. Clinical picture • The clitoris is enlarged and the labia may be fused, but the vagina, tubes, and uterus are normal . • Growth and development are normal, and progressive viritization does not occur. Diagnosis • The condition can be diagnosed based on positive history and on exclusion. Management • Clitoral reduction and surgical correction of the fused labia maybe necessary.

  24. Androgen insensitivity syndrome • A 46xy genotype is present, but a female phenotype develops. • Androgens are produced by the testes (which develop in the presence of y chromosome) and by adrenal glands. • External genitalia are feminized • No uterine, cervical,upper vaginal, or fallopian tube development. • A short vagina . • Labia, may contain testes.

  25. Diagnosis • Primary amenorrhea. • A blind or absent vagina. • Lack of pubic and axillary hair development. Breast development does occur because estrogen concentration is high due to conversion of testosterone produced after puberty. • A karyotype-This syndrome is distinguished from MRKH by absent axillary and pubic hair development and high testosterone level. • Management • The gonads should be removed because of an incresed risk of malignancy

  26. True hermaphroditism Clinical picture • The genotype is 46xx • The external genitalia may appear male,female,or ambiguous. • Both male and female internal genitalia may be present. Management • The genitlia that are inconsistent with sex assignment should be surgically removed or modified.

  27. G-maternal virilizing tumor during pregnancy(luteoma of pregnancy)

  28. Abnormal pubertal development Delayed puberty: • Hypergonadotropic hypogonadism : It includes conditions in which the ovaries or gon ads are not functioning. • Hypogonadotropic hypogonadism : The ovary is normal ,however, there is a lack of production of hormonal stimulation from the hypothalamus, includes Kallmann syndrome (isolated GnRH deficiency ) Eugonadotropic: constitutional delay accounts for 10% to 20% of cases .

  29. Managment • Treatment is based on the etiology of the delay . • In cases of gonadal dysgenesis when a Y chromosome or fragment of a Y chromosome is present , the gonads should be removed at diagnosis because of the risk of neoplastic degeneration . • Otherwise , hormone replacement with estrogen and subsequently both estrogen and progesterone , is required to promote sexual development and menarache.

  30. Special problems of the adolescent A. Dysmenorrhea : • Primary dysmenorrhea accounts for most cases and is attributed to increased prostaglandin production with menses in the presence of normal anatomy . • Secondary dysmenorrhea results from conditions such as endometriosis and anomalies with obstruction in a portion of the outflow tract . Clinical picture • Sever , cyclic , cramp-like pain located in the lower abdomen and pelvis is associated with menses

  31. Managment • First-line therapy is prostaglandin inhibitors (nonsteroidal anti-inflammatory drugs [NSAIDs] • If the symptoms are not reduce- start oral contraceptives or obtain a pelvic ultrasound to evaluate for abnormal anatomy depending on the loction, progression, and severity of the symptoms • Laparoscopy is recommended if medical treatment fails to control the symptoms .

  32. Precocious Puberty Def – appearance of appropriate secondary sexual characters before age of 8 yrs & occcurence of menstruation before 10 yrs of chronological age. Causes • Constitutional • Hypothalamic neoplasm- hamartoma • Pituitary tumors • Ovarian feminizing tumor • Adrenal tumors • Infections – meningitis, encephalitis • Mc Cune Albright syndrome • Iatrogenic

  33. Dysfunctional uterine bleeding • DUB is defined as excessive , prolonged , or irregular bleeding not associated with an anatomic lesion. • Most adolescent girls have anovulatory menstrual periods for the first 2 to 3 years following menarche . • The cause of DUB in 75% of cases is an immature hypothalamic –pitutary axis resulting in anovulation • Other cases include psychogenic factors ,juvenile hypothyrodism and coagulation disorders (von willebrand disease )

  34. Clinical picture • Menometrorrhagia ( irregular , heavy bleeding) is the most characteristic symptom . • Bleeding can be prolonged and heavy in some cases leadng to sever anemia . • The condition is usually self – limited Management Cyclic hormonal manipulation with progestins or comined oral contrceptive pills .

  35. Thank You

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