AMSEL CRITERIA FOR BACTERIAL VAGINOSIS

Must have at least 3 of the following:

 Vaginal pH > 4.5
 Presence of > 20% per HPF of “clue cells” on wet mount examination
BACTERIAL VAGINOSIS  Positive amine or “whiff” test
 Diagnosed with Amsel Criteria and Gram stain (diagnostic standard)  Homogeneous, non-viscous, milky-white discharge adherent to the
 Gram positive bacilli – can be normal flora of the vagina (Lactobacilli) vaginal walls

NUGENT SCORE FOR BACTERIAL VAGINOSIS

The Nugent Score on gram smears is a diagnostic test that defines normal
vaginal flora, bacterial vaginosis, or intermediate abnormal flora.

Scores:
0-3: “Normal” lactobacilli-dominated microbiota
4-6: Intermediate microbiota
7-10: Bacterial vaginosis

*Scoring based on morphotypes per HPF

0=0 3+ = 5-30
1+ = < 1 4 = >30
2+ = 1-4

Calculated by assessing for the presence of:

 Large Gram-positive rods
Lactobacillus morphotypes; decrease in Lactobacillus scored as 0-4

 Small Gram-variable rods

G. vaginalis morphotypes scored as 0-4

 Curved gram-variable rods

Mobiluncus spp. Morphotypes scored as 0-2

VAGINAL CANDIDIASIS
 thick, white vaginal discharge with consistency of cottage cheese;
odourless
 also with irritation and intense itchiness SYPHILIS
 with concomitant bacterial vaginosis  also treat the partner within the last 90 days

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 MARSUPIALIZATION (NON-PREGNANT)

> Please admit to LR/DR under ____ service/team

> Secure consent for admission and management
> TPR Q shift and record please
> Diet: NPO
>IVF: PLRS 1L x 8 hours
> Diagnostics:
- CBC with PC, Blood Typing
- BUN, Crea
- HBsAg (Qualitative)
- Urinalysis with Preg Test
- Chest X-ray
- GS and KOH of vaginal discharge
- GSCS of drainage/discharge
- COVID RAT, RT-PCR
> Therapeutics:
- Clindamycin 900 mg IV q8 ( ) ANST OPERATIVE TECHNIQUES:
- Gentamycin 24 mg IV OD BARTHOLIN’S CYST INCISION
- Paracetamol 600 mg IV q6
- Chlorhexidine vaginal wash BID  Induction of SA (spinal anesthesia) /
GA (general anesthesia)
> For “E” Marsupialization, please secure consent  Asepsis and antisepsis done
>For Pedia clearance (if Pedia)  Vertical / Elliptical incision over the mucocutaneous junction of the
>Inform OR and AROD of this admission left / right labia majora
>Refer to OB IDS for co-management  Simple interrupted suture around the cyst wall
>Monitor VS q4  Pressure dressing applied
>Refer

CULDOCENTESIS

> Please admit to OB LR/DR under ____ service

> Secure consent for admission and management
> TPR Q shift and record please
> Diet: NPO temporarily
> IVF: D5LR 1L x 30 gtts/min
Diagnostics:
- CBC with PC, Blood Typing
- Urinalysis
> Secure 2 units FWB for possible OR use
> For Culdocentesis
> History & PE c/o ROD
> Refer accordingly

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 ABNORMAL UTERINE BLEEDING

> Please admit to Gyne ward under ___ service

> Secure consent for admission and management
> TPR Q shift and record please
> Diet: DAT

> Diagnostics:
- CBC with PC, Blood Typing
- PT, PTT
- Na, K
- BUN, Creatinine
- Urinalysis with PT
- RAT, RT-PCR
- TVS
- Chest X-ray
- 12L ECG

> Therapeutics:
- IVF: PLRS 1L x 30 gtts/min
- BT Line: PNSS 1L x KVO

Meds:
- Ferrous sulfate 1 tab TID
- Tranexamic acid 1 g IV q8
- Metronidazole 500 mg IV q8
- Furosemide 40 mg IV on 3rd unit post-BT
- Calcium carbonate 1 amp IV post 4 units BT

>Secure and transfuse 4 units of pRBC properly typed and crossmatched for stand-
MECHANISM OF AUB IN MYOMA
by
>Repeat CBC 6 hours post-BT of 4th unit
1. Mechanical distortion leading to increase in endometrial surface area
>BT Rate: TRF 2 ml/min for 1st 15 minutes, then increase rate to infuse over 2 hours
>BT Rate of 2nd to 4th unit: BT x 3 hours
2. Bleeding from ulcerated endometrium overlying submucous myoma
>Monitor VS q1 while on BT
>Monitor VS q4
3. Myoma interfering with normal uterine hemostasis or compressing of the
>Strict I & O q8 and record please
venous drainage at any site
>For possible THBS once anemia is corrected
>Refer to IM Gen Med for CP clearance
4. Dilatation of the venous plexuses draining the endometrium
>Refer

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 WOMEN WHO SHOULD UNDERGO EVALUATION FOR ENDOMETRIAL HYPERPLASIA
OR ENDOMETRIAL CANCER

1. Over age 40 years with AUB

2. Under age 40 with AUB and risk factors

(e.g. chronic anovulation, obesity, taking Tamoxifen, Diabetes, family history
of endometrial, ovarian, breast or colon cancer)

3. Failure to respond to medical treatment of AUB

4. Women with uterus in situ receiving unopposed estrogen replacement ENDOMETRIAL HYPERPLASIA
therapy
Surveillance of Endometrial Hyperplasia
5. Presence of atypical glandular cells on cervical cytology  Diagnosis of endometrial hyperplasia requires histological examination of the
endometrial tissue.
6. Presence of endometrial cells on cervical cytology in a woman > 40 years old
 Endometrial surveillance should include endometrial sampling by outpatient
7. Women with hereditary nonpolyposis colorectal cancer endometrial biopsy.

OPERATIVE TECHNIQUES:
ENDOMETRIAL CURETTAGE

 IV sedation
 Asepsis and antisepsis done
 Bladder catheterization
 Internal examination done
 Application of posterior vaginal retractor
 Grasping of the anterior cervix using tenaculum forceps
 Endocervical curetting
 Initial hysterometry done
 Endometrial curetting done GYNE ONCO PATIENTS: IVF
 Final hysterometry done
 Removal of all instruments Doc Janine
 Specimen sent to histopath If non-diabetic: D5LRS 1L + Vitamin B Complex 2 amps x 20 gtts/min
If diabetic: PLRS 1L + Vitamin B Complex 2 amps x 20 gtts/min

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 THBSO

> Please admit to Gyne ward under ______

> Secure consent for admission and management
> TPR Q shift and record please
> Diet: DAT then NPO 8 hours before OR

> Diagnostics:
- CBC with PC, Blood Typing
- Na, K, Cl
- PT, PTT
- Bleeding Time, Clotting Time (?) OPERATIVE TECHNIQUES:
- Urinalysis TOTAL ABDOMINAL HYSTERECTOMY WITH BILATERAL SALPINGO-
OOPHORECTOMY
> Therapeutics:
- IVF: D5LRS 1L x 30 gtts/min  Induction of SA (spinal anesthesia)
- Bisacodyl tablet on ____ and ____, at night before bedtime  Asepsis and antisepsis done
(2 nights before OR)  Bladder catheterization
- Bisacodyl suppository, insert 1 suppository per rectum on ___  Midline vertical infraumbilical incision made on the skin carried down to the
(night before OR) peritoneum
 Inspection of pelvic organs
Pre-op Meds:  Clamping, cutting & suture ligation of infundibulopelvic ligament
- Cefuroxime 1.5 g IV ( ) ANST  Opening of the vesico-uterine fold and the bladder is pushed downward
- Ranitidine 50 mg IV  Skeletonization of uterine vessels
- Metoclopramide 10 mg IV  Clamping, cutting & suturing of uterine vessels, cardinal and uterosacral
ligaments
> Secure __ units of pRBC for OR use  Circumferential incision of uterus along the cervicovaginal angle
> For THBSO  Anchoring of the vaginal stump to cardinal ligaments
> Insert IFC  Closure of the vaginal stump with continuous suture
> Strict I & O please  Peritonealization
> Inform OR and AROD  Closure of the abdominal wall layer by layer after complete sponge and
> For Preop instrument count
> Monitor VS Q4 and record please  Application of sterile dressing
> Refer

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 OPERATIVE TECHNIQUES:
VAGINAL HYSTERECTOMY
(PROCIDENTIA UTERI / CYSTOCOELE)

 Induction of SA (spinal anesthesia) / GA (general anesthesia)

 Vaginal prep done
 Labial mucosa temporarily sutured back to skin
 Bladder catheterization
 Localization of the bladder neck done
 Prolapsed cervix grasped with tenaculum forceps OPERATIVE TECHNIQUES:
 Transverse curvilinear cervical incision made thru the mucosa starting anteriorly below the VAGINAL HYSTERECTOMY
bladder (PROCIDENTIA UTERI / CYSTOCOELE)
 Incision carried down around both sides posteriorly (Cont.)
 Blunt scissor dissection to separate vaginal wall attached bladder base from the underlying
cervical stroma  Anterior vaginal mucosa grasped
 Same procedure done on the posterior  Scissor dissection made to separate mucosa from underlying fascia
 Plicae vesicouterine identified  Mucosa cut in the midline separating & cutting until about 1 cm from the external urethral
 Entry made into the peritoneal cavity meatus
 Uterosacral ligament exposed, clamped, cut and sutured on both sides  Allis forceps applied serially on the edges of the vaginal mucosa
 Successive clamping, cutting, and suture ligation of cardinal ligaments  Dissection of the vaginal mucosa to the endopelvic fascia laterally
 Corpus uteri exposed anteriorly  Placation of sutures placed on the submucosal condensation of tissue anterior to the bladder
 Successive clamping, cutting, and suture ligation of cardinal ligaments and adnexal pedicles  Excision of excess mucosa
 Examination of the ovaries done  Closure of vertical incision with interrupted sutures
 Single purse string suture made on the peritoneum after removal of the ovaries to obliterate  Anterior & Posterior wall approximated with transverse closure or vaginal circular incision
the opening of the peritoneal cavity interrupted suture
 Uterosacral stump ligature done on both posterolateral marginal wall for support  Repositioning of stump done
 Tying of stump ligature in the midline for further support (AP repair)  Anchoring suture in labia released

MATERIALS FOR OR USE:

THBSO

 D5LR 1L #1
 Macroset #1
 Urine bag #1
 Foley catheter FR16 #1
 IV Cannula, G.18 #1
 Co-amoxiclav 1.2g/vial #2
 Phospho-soda #2
 Irrigation solution #3
 Safil -0 round #4
 Silk strands #3
 Monosyn 4-0 #2
 Chromic 1-0 round #2
 Chromic 2-0 round #3
 Plain 2-0 round #2
 Fresh whole blood #2 units

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 SASSONE SCORE
A scoring system that uses traditional gray scale ultrasound to characterize
ovarian lesion

*If the ovary was normal or not seen, then it was considered to have an
ultrasound score of <5

Interpretation:
 Minimum ultrasound score: 4
 Maximum ultrasound score: 15

 Sore of <9: Low risk of malignancy

 Score of >9: Increased risk of malignancy

Note: Mature teratomas (dermoid cysts) and other benign cysts may have a
score of >9

ADNEX MODEL

Sassone Scoring: more sensitive in screening of ovarian lesions

ADNEX Model: more specific as to what type of ovarian malignancy

The ADNEX model is the first risk model that differentiates between benign
and four subgroups of malignant adnexal tumors.

The model consists of:

 3 clinical predictors
 6 ultrasound predictors

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 OPERATIVE TECHNIQUES:
OPERATIVE TECHNIQUES: SALPINGO-OOPHORECTOMY
OOPHORECTOMY (OVARIAN NEW GROWTH) (OVARIAN CYST TWISTED)

 Induction of SA (spinal anesthesia) /  Induction of SA (spinal anesthesia) /

GA (general anesthesia) GA (general anesthesia)
 Asepsis and antisepsis done  Asepsis and antisepsis done
 Bladder catheterization  Bladder catheterization
 Midline vertical suprapubic incision made on the skin carried down to the  Midline vertical incision made on the skin carried down to the peritoneum
peritoneum  Gangrenous ovary with double twist on the pedicle noted
 Peritoneal sampling done  Mass exteriorized & double clamped below the twisted pedicle
 Inspection of the pelvic organs  Incision made between clamps until the tube & ovarian mass are removed
 Right/Left ovarian cyst exteriorized  Chromic & absorbable suture placed on stump and rest of pelvic sutures
 Successive pairs of clamps placed on the mesosalpinx freeing the ovarian cyst inspected
 Figure of 8 using chromic 2-0 sutures placed around the cyst  Closure of the abdominal wall layer by layer after complete sponge and
 Closure of the abdominal wall layer by layer after complete sponge and instrument count
instrument count  Application of sterile dressing
 Application of sterile dressing

MATERIALS FOR OR USE:

SALPINGO-OOPHORECTOMY

 Vicryl 1-0 round #2 MATERIALS FOR OR USE:

 Silk 0 round #2 CHROMOTUBATION
 Chromic 2-0 round #2
 Silk 0 strands #1  Methylene blue #1
 Foley Catheter C Guide, Fr 8 #1

HISTOPATH SPECIMEN

 Small specimen: < 3 cm

 Medium specimen: 3-7 cm
 Large specimen: > 7 cm

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CASTRO NOTES Page 9
 CORRECTION OF HYPERKALEMIA

 Give Calcium gluconate 10 mEqs now for 10-15 mins

 Ideally, hook to cardiac monitor

 Give GI solution 10 units RI IV + 1 vial D5050 q4 x 3 doses

 Salbutamol + Ipratropium nebule, 1 neb q15 x 3 doses

 Furosemide 20 mg IV now

 Repeat Serum K after correction

Dr. Jaraya: Salbutamol and Furosemide kung sobrang taas ng Potassium

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