SlideShare ist ein Scribd-Unternehmen logo
1 von 40
Downloaden Sie, um offline zu lesen
Diagnosis
Of
Endometriosis
Dr. Shashwat Jani.
M.S. ( Gynec)
Diploma In Advance Endoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College,
Sheth V. S. General Hospital, Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com
Introduction
 Endometriosis initially described by Von
Rokitansky in 1860.
 Endometriosis is a clinical and pathological
entity.
 It is characterized by the presence of tissue
resembling functional endometrial glands and
stroma outside the uterine cavity.
3-Sep-15 2Dr Shashwat Jani 9909944160
3-Sep-15 Dr Shashwat Jani 9909944160 3
It is not a neoplastic condition, but
malignant transformation is possible.
3-Sep-15 Dr Shashwat Jani 9909944160 4
Incidence
 3 – 10 % of women of reproductive
age
 20-40% in infertile women
 5-20% with chronic pelvic pain
 20-50% asymptomatic, found during
laparoscopy and sterilization.
 50% dysmenorrhea
3-Sep-15 5Dr Shashwat Jani 9909944160
Etiology
Estrogen dependent disease
 Sampson’s theory
Ectopic transplantation of endometrial tissue.
 Meyer’s theory
Coelomic metaplasia.
 Halban's theory:
Induction theory
Genetic factors
Immunologic factors
Unknown factor
Autoimmune
Combination of the Above
Environmental factors - dioxin
No Single Theory Explains All Cases of
Endometriosis
3-Sep-15 6Dr Shashwat Jani 9909944160
Risk Factors
Family history of endometriosis.
Early age of menarche
Short menstrual cycles (<27 d)
 Long duration of menstrual flow (>7 d)
Heavy bleeding during menses
 Inverse relationship to parity
 Delayed childbearing
 Defects in the uterus or fallopian tubes
 less use of OCs
3-Sep-15 7Dr Shashwat Jani 9909944160
Diagnosis
 Clinical Presentations
 Clinical Examinations
 Imaging Modalities
 Histological Diagnosis
 Biochemical Markers
 Surgical Diagnosis
3-Sep-15 8Dr Shashwat Jani 9909944160
Clinical
Presentation
3-Sep-15 9Dr Shashwat Jani 9909944160
Symptoms
 PELVIC - Dymenorrhoea (50%),
Abnormal menstruation (60%)
Dyspareunia,
Chronic Pelvic Pain,
Premenstrual spotting
 GASTROINTESTINAL- Constipation, Diarrhea,
Hematochezia, Tenesmus
 URINARY COMPLAINTS- Flank pain, Back pain,
Abdominal pain, Urgency,
Frequency,Hematuria
 PULMONARY- Haemoptysis , Pneumothorax
 INFERTILTY
3-Sep-15 10Dr Shashwat Jani 9909944160
Dysmenorrhea
 Most common symptom
 Pain starts a few days prior to menstruation,
gets worse during menstruation( secondary
dysmenorrhoea)
 Pain due to Increased secretion of PGF2α,
Thromboxane β2 from endometriotic tissue.
3-Sep-15 11Dr Shashwat Jani 9909944160
Abnormal Menstruation
- Menorrhagia is a predominant abnormality.
- Polymennorhoea, premenstrual spotting also
occur.
Dyspareunia
It is usually deep, due to stretching of the structures of the
Pouch of Douglas or direct contact tenderness found in
endometriosis of rectovaginal septum or Pouch of
Douglas and with fixed retroverted uterus.
3-Sep-15 12Dr Shashwat Jani 9909944160
Lower Abdominal Pain
Abdominal pain
lower abdominal pain or backache
May be due to inflammation in
peritoneal implants due to cystic bleeding
Irritation or invasion of nerve
Action of inflammatory cytokines
released by the macrophages.
3-Sep-15 13Dr Shashwat Jani 9909944160
Infertility
• Mechanical interference---
• Pelvic adhesions
• Chronic salpingitis
• Impaired oocyte pickup
• Altered tubal motility
• Distortion of tubo-ovarian relations
• Alteration in peritoneal fluid
• Increased concentration of prostaglandins
• Increased number of macrophages
• Increased production of cytokines
• Phagocytosis of sperms
3-Sep-15 14Dr Shashwat Jani 9909944160
• Abnormal Systemic Immune system
• Increased cell-mediated gametes injury
• Increased prevalence of autoantibodies
• Hormonal or ovulatory dysfuntion
• Defective folliculogenesis
• Luteinized unruptured follicle syndrome
• Hyperprolactinemia
• Luteal phase deficiency
• Implantation failure
3-Sep-15 15Dr Shashwat Jani 9909944160
Clinical Examination
General conditions-
Pallor + due to Menorrhagia
P/A - Mass may be felt in lower abdomen arising from
the pelvis
Enlarged chocolate cyst or tuboovarian mass,
due to endometriotic adhesions.
The mass is tender with restricted mobility.
L/E- See Vulva and other structures
P/S- See cervix, vagina for any deposits, discharge or
growth.
3-Sep-15 16Dr Shashwat Jani 9909944160
Bimanual Pelvic Examination
o Tender uterosacral ligament
o Cul-de-sac nodularity found
o Induration of the rectovaginal septum
o Fixed retroversion of the uterus
o Adnexal masses and generalized or localized
pelvic tenderness present
o Uterosacral nodules may be found
3-Sep-15 17Dr Shashwat Jani 9909944160
ASRM Classification
3-Sep-15 18Dr Shashwat Jani 9909944160
drshashwatjani@gmail.com 19
ASRM staging has poor correlation with
pregnancy rate.
In 2009 new staging system was proposed
called “ Endometriosis Fertility Index. “
EFI is numerical measure of functional
anatomy based on assessment of tubes,
fimbriae and ovaries.
EFI score 0 to 10
(0 – poorest and 10 – the best prognosis).
3-Sep-15 20Dr Shashwat Jani 9909944160
Imaging Modalities
 TVS & TRS
 CT SCAN
 MRI
3-Sep-15 21Dr Shashwat Jani 9909944160
USG
First line tool for suspected endometriosis
Detects ovarian cysts ( Endometrioma ) and rule
out other causes
 May have role in detection of involvement of
Bladder & Rectum.
Detection of Endometrioma using USG is excellent
with 83 % Sensitivity and 98 % Specificity.
3-Sep-15 22Dr Shashwat Jani 9909944160
Classical Appearance :
 Homogenous , Hypoechoic mass with in the
ovary with diffuse low level internal echoes
with hyperechoic foci within the wall.
 Wall nodularity should be differentiated
from hyperechoic foci within the wall.
 95% of endometriomas display low level of
internal echoes.
D/D : Dermoid , Hemorrhagic , Cystic
neoplasm
3-Sep-15 Dr Shashwat Jani 9909944160 23
TRS :
- To look at Sigmoid for endometriotic infiltrates.
- Rounded or triangular hypoechoic deposits.
- Infiltration of bowel wall is seen as thickening
of Muscularis Propria.
Doppler :
• Better studied in late follicular & early luteal
phase.
• Blood flow in Endometrioma is usually
Pericystic with RI > 0.45.
3-Sep-15 Dr Shashwat Jani 9909944160 24
CT Scan / MRI
 MRI may detect even smallest of lesions
and distinguish hemorrhagic signal of
endometriotic implants; superior to CT scan in
detecting limits between muscles and abdominal
subcutaneous tissues
 MRI demonstrated to accurately detect
rectovaginal disease and obliteration in more
than 90% of cases when ultrasonographic gel was
inserted in the vagina and rectum
3-Sep-15 25Dr Shashwat Jani 9909944160
Sensitivity 90 %
Specificity 98 %
 Major role is to help visualize
laparoscopic blind spots such
as retroperitoneal space and
lesions obscured by dense
adhesions or typical lesions.
DPE is best diagnosed
and located by TRS &
MRI.
3-Sep-15 Dr Shashwat Jani 9909944160 26
I.V. Urography :
- Serosal deposits are seen at dome of bladder.
- Involvement of Ureter is also seen.
Barium Enema :
Serosal deposits are causing thickening
and fibrosis of Muscularis propria which is
demonstrated as asymmetric narrowing or
eccentric intramural filling defect.
3-Sep-15 Dr Shashwat Jani 9909944160 27
Histological Diagnosis
• Positive confirms But Negative doesn’t
exclude.
• Visual is usually adequate but histology of any
one lesion is ideal
• In > 4 cm endometrioma & Deep infiltrating
disease – histology should be done to identify
endometriosis and exclude malignancy.
3-Sep-15 Dr Shashwat Jani 9909944160 28
• Microscopically :
Implants consist of endometrial glands and
stroma with or without hemosiderin laden
macrophages.
3-Sep-15 Dr Shashwat Jani 9909944160 29
Biochemical Marker
CA - 125
 Cancer Antigen-125, a high molecular weight glycoprotein
expressed on the cell surface of some derivatives of
embryonic coelomic epithelium.
 It is elevated towards the end of the luteal phase and during
menstruation.
 In many other conditions elevated CA-125 concentration
like PID, adenomyosis, uterine leiomyoma, menstruation,
pregnancy, epithelial ovarian cancer, pancreatitis, chronic
liver disease.
3-Sep-15 30Dr Shashwat Jani 9909944160
 The result of most studies suggest that CA-
125 is not sufficiently sensitive to identify
lesser stages of endometriosis.
CA-125 is NOT reliable as a
screening test.
3-Sep-15 31Dr Shashwat Jani 9909944160
Surgical Diagnosis
“ Diagnostic Laparoscopy is
the Gold Standard
investigation for
Endometriosis…”
3-Sep-15 32Dr Shashwat Jani 9909944160
For a definitive diagnosis of endometriosis,
visual inspection of the pelvis at laparoscopy is
the gold standard investigation, unless disease
is visible in the posterior vaginal fornix or
elsewhere…
3-Sep-15 Dr Shashwat Jani 9909944160 33
 Can classify the extent and severity of disease.
 A double puncture technique is essential.
 The grasper placed through the lower abdomen
sheath permits mobilization of the tube and
ovaries.
3-Sep-15 34Dr Shashwat Jani 9909944160
 Inspect the lateral side wall, all ovarian
surface, both sides of the broad ligament,
the bladder, bowel serosa, inferior aspect
of cul-de-sac, evaluation of the
uterosacral ligaments and rectal serosa.
 To avoid under diagnosis it should not
be performed during or within 3 months
of hormonal therapy.
3-Sep-15 Dr Shashwat Jani 9909944160 35
Findings are…
 Typical “powder-burn or “gunshot” lesions on the
serosal surface of the peritoneum. These lesions
are black, blue or dark brown, nodules or small
cysts containing old hemorrhage surrounded by
variable degree of fibrosis.
 White lesions are predominantly fibromuscular
scarring with scattered glandular and stromal
elements.
 Brown lesions are mainly haemosiderin deposits.
Peritoneal defect and subovarian adhesions
contain endometriosis in 40% -70%.
3-Sep-15 36Dr Shashwat Jani 9909944160
drshashwatjani@gmail.com 37
 For ovarian endometriosis- Large ovarian
endometriotic cysts are usually located
on the anterior surface of the ovary and
associated with retraction, pigmentation
and adhesions to the posterior
peritoneum.
 Ovarian endometriotic cyst contain a
thick, viscous dark brown fluid.
(Chocolate fluid)
3-Sep-15 38Dr Shashwat Jani 9909944160
3-Sep-15 39Dr Shashwat Jani 9909944160
Chocolate cyst– sometimes it is confused with
hemorrhagic corpus luteum cysts and neoplastic cysts.
Biopsy must be done.
Thank you

Weitere ähnliche Inhalte

Was ist angesagt?

PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015Aboubakr Elnashar
 
Laparoscopy in recurrent endometriosis
Laparoscopy in recurrent endometriosisLaparoscopy in recurrent endometriosis
Laparoscopy in recurrent endometriosisNiranjan Chavan
 
Medical Management of Fibroids
Medical Management of FibroidsMedical Management of Fibroids
Medical Management of FibroidsSujoy Dasgupta
 
New frontiers in endometriosis.Prof Salah.Roshdy
New frontiers in endometriosis.Prof Salah.RoshdyNew frontiers in endometriosis.Prof Salah.Roshdy
New frontiers in endometriosis.Prof Salah.RoshdySalah Roshdy AHMED
 
Malignant ovarian tumors
Malignant ovarian tumorsMalignant ovarian tumors
Malignant ovarian tumorsrajeev sood
 
Step wise pelvic devascularisation
Step wise pelvic devascularisationStep wise pelvic devascularisation
Step wise pelvic devascularisationNiranjan Chavan
 
Management of endometriosis
Management of endometriosisManagement of endometriosis
Management of endometriosisobsgynhsnz
 
ENDOMETRIOSIS - DR SHASHWAT JANI
ENDOMETRIOSIS - DR SHASHWAT JANIENDOMETRIOSIS - DR SHASHWAT JANI
ENDOMETRIOSIS - DR SHASHWAT JANIDR SHASHWAT JANI
 
Evidence Based Management of Endometrioma
Evidence Based Management of EndometriomaEvidence Based Management of Endometrioma
Evidence Based Management of EndometriomaSalah Roshdy AHMED
 
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE, Mob: 7289915...
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE,  Mob: 7289915...OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE,  Mob: 7289915...
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE, Mob: 7289915...Pradeep Garg
 
Management of Infertility in Endometriosis
Management of Infertility in EndometriosisManagement of Infertility in Endometriosis
Management of Infertility in EndometriosisSujoy Dasgupta
 
Endometriosis emerging treatment 2017
Endometriosis emerging treatment 2017Endometriosis emerging treatment 2017
Endometriosis emerging treatment 2017Aboubakr Elnashar
 

Was ist angesagt? (20)

PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
PREMATURE OVARIAN INSUFFICIENCY ESHRE Guidelines, 2015
 
Adenomyosis
AdenomyosisAdenomyosis
Adenomyosis
 
Adenomyosis
AdenomyosisAdenomyosis
Adenomyosis
 
endometriosis
endometriosisendometriosis
endometriosis
 
Laparoscopy in recurrent endometriosis
Laparoscopy in recurrent endometriosisLaparoscopy in recurrent endometriosis
Laparoscopy in recurrent endometriosis
 
Medical Management of Fibroids
Medical Management of FibroidsMedical Management of Fibroids
Medical Management of Fibroids
 
Endometriosis
EndometriosisEndometriosis
Endometriosis
 
Chronic pelvic pain
Chronic pelvic painChronic pelvic pain
Chronic pelvic pain
 
New frontiers in endometriosis.Prof Salah.Roshdy
New frontiers in endometriosis.Prof Salah.RoshdyNew frontiers in endometriosis.Prof Salah.Roshdy
New frontiers in endometriosis.Prof Salah.Roshdy
 
Malignant ovarian tumors
Malignant ovarian tumorsMalignant ovarian tumors
Malignant ovarian tumors
 
Uterine compression sutures
Uterine compression suturesUterine compression sutures
Uterine compression sutures
 
Managing adenomyosis
Managing adenomyosisManaging adenomyosis
Managing adenomyosis
 
Step wise pelvic devascularisation
Step wise pelvic devascularisationStep wise pelvic devascularisation
Step wise pelvic devascularisation
 
Management of endometriosis
Management of endometriosisManagement of endometriosis
Management of endometriosis
 
ENDOMETRIOSIS - DR SHASHWAT JANI
ENDOMETRIOSIS - DR SHASHWAT JANIENDOMETRIOSIS - DR SHASHWAT JANI
ENDOMETRIOSIS - DR SHASHWAT JANI
 
adenomyosis
adenomyosisadenomyosis
adenomyosis
 
Evidence Based Management of Endometrioma
Evidence Based Management of EndometriomaEvidence Based Management of Endometrioma
Evidence Based Management of Endometrioma
 
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE, Mob: 7289915...
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE,  Mob: 7289915...OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE,  Mob: 7289915...
OPERATIONS FOR NULLIPAROUS PROLAPSE AND VAGINAL VAULT PROLAPSE, Mob: 7289915...
 
Management of Infertility in Endometriosis
Management of Infertility in EndometriosisManagement of Infertility in Endometriosis
Management of Infertility in Endometriosis
 
Endometriosis emerging treatment 2017
Endometriosis emerging treatment 2017Endometriosis emerging treatment 2017
Endometriosis emerging treatment 2017
 

Ähnlich wie DIAGNOSIS OF ENDOMETRIOSIS BY DR SHASHWAT JANI

ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANIADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANIDR SHASHWAT JANI
 
Endoscopy skills 2 2-2015
Endoscopy skills 2 2-2015Endoscopy skills 2 2-2015
Endoscopy skills 2 2-2015HeshamAnwar
 
Diagnostic Laparoscopy for Pelvic Disorders
Diagnostic Laparoscopy for Pelvic DisordersDiagnostic Laparoscopy for Pelvic Disorders
Diagnostic Laparoscopy for Pelvic DisordersGeorge S. Ferzli
 
Obstetrics fistula.pptx
Obstetrics  fistula.pptxObstetrics  fistula.pptx
Obstetrics fistula.pptxmichael217117
 
urethral mass DD.pptx
urethral mass DD.pptxurethral mass DD.pptx
urethral mass DD.pptxIslamMansy4
 
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal Lifecare Centre
 
Diagnosis of Endometriosis
Diagnosis of EndometriosisDiagnosis of Endometriosis
Diagnosis of EndometriosisTevfik Yoldemir
 
Bowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flagBowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flagKETAN VAGHOLKAR
 
appendicitis_compress.pdf
appendicitis_compress.pdfappendicitis_compress.pdf
appendicitis_compress.pdfRolakThapa
 
3. Obstetrics fistula.pptx
3. Obstetrics  fistula.pptx3. Obstetrics  fistula.pptx
3. Obstetrics fistula.pptxMesfinShifara
 
Endometriosis and Infertility
Endometriosis and InfertilityEndometriosis and Infertility
Endometriosis and InfertilityMarwan Alhalabi
 
Female urethral diverticula
Female urethral diverticulaFemale urethral diverticula
Female urethral diverticulaNawaz Ali
 
Endometriosis.ppt
Endometriosis.pptEndometriosis.ppt
Endometriosis.pptabdelnaser5
 
role of Imaging in female infertility
role of Imaging in  female infertilityrole of Imaging in  female infertility
role of Imaging in female infertilitycharusmita chaudhary
 
radiology.Gynecology.(dr.nasreen)
radiology.Gynecology.(dr.nasreen)radiology.Gynecology.(dr.nasreen)
radiology.Gynecology.(dr.nasreen)student
 
Dysmenorrhea - endometriosis
Dysmenorrhea - endometriosis Dysmenorrhea - endometriosis
Dysmenorrhea - endometriosis veerendrakumar cm
 

Ähnlich wie DIAGNOSIS OF ENDOMETRIOSIS BY DR SHASHWAT JANI (20)

ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANIADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
ADHERENT PLACENTA DIAGNOSIS & MANAGEMENT BY DR SHASHWAT JANI
 
Adherent placenta
Adherent  placentaAdherent  placenta
Adherent placenta
 
Endoscopy skills 2 2-2015
Endoscopy skills 2 2-2015Endoscopy skills 2 2-2015
Endoscopy skills 2 2-2015
 
Diagnostic Laparoscopy for Pelvic Disorders
Diagnostic Laparoscopy for Pelvic DisordersDiagnostic Laparoscopy for Pelvic Disorders
Diagnostic Laparoscopy for Pelvic Disorders
 
Obstetrics fistula.pptx
Obstetrics  fistula.pptxObstetrics  fistula.pptx
Obstetrics fistula.pptx
 
urethral mass DD.pptx
urethral mass DD.pptxurethral mass DD.pptx
urethral mass DD.pptx
 
Radiology 5th year, 7th lecture (Dr. Nasrin Alatrushi)
Radiology 5th year, 7th lecture (Dr. Nasrin Alatrushi)Radiology 5th year, 7th lecture (Dr. Nasrin Alatrushi)
Radiology 5th year, 7th lecture (Dr. Nasrin Alatrushi)
 
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal
Sonosalpingography. Dr. Sharda Jain, Dr. Jyoti Agarwal
 
Diagnosis of Endometriosis
Diagnosis of EndometriosisDiagnosis of Endometriosis
Diagnosis of Endometriosis
 
Bowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flagBowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flag
 
appendicitis_compress.pdf
appendicitis_compress.pdfappendicitis_compress.pdf
appendicitis_compress.pdf
 
3. Obstetrics fistula.pptx
3. Obstetrics  fistula.pptx3. Obstetrics  fistula.pptx
3. Obstetrics fistula.pptx
 
Posterior urethral valve
Posterior urethral valvePosterior urethral valve
Posterior urethral valve
 
Endometriosis and Infertility
Endometriosis and InfertilityEndometriosis and Infertility
Endometriosis and Infertility
 
Female urethral diverticula
Female urethral diverticulaFemale urethral diverticula
Female urethral diverticula
 
Endometriosis.ppt
Endometriosis.pptEndometriosis.ppt
Endometriosis.ppt
 
Laparoscopic Ovarian Surgery
Laparoscopic Ovarian SurgeryLaparoscopic Ovarian Surgery
Laparoscopic Ovarian Surgery
 
role of Imaging in female infertility
role of Imaging in  female infertilityrole of Imaging in  female infertility
role of Imaging in female infertility
 
radiology.Gynecology.(dr.nasreen)
radiology.Gynecology.(dr.nasreen)radiology.Gynecology.(dr.nasreen)
radiology.Gynecology.(dr.nasreen)
 
Dysmenorrhea - endometriosis
Dysmenorrhea - endometriosis Dysmenorrhea - endometriosis
Dysmenorrhea - endometriosis
 

Mehr von DR SHASHWAT JANI

STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptx
STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptxSTANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptx
STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptxDR SHASHWAT JANI
 
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANI
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANIEARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANI
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANIDR SHASHWAT JANI
 
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANI
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANITHYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANI
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANI
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANIIMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANI
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
DENGUE IN PREGNANCY BY DR SHASHWAT JANI
DENGUE IN PREGNANCY BY DR SHASHWAT JANIDENGUE IN PREGNANCY BY DR SHASHWAT JANI
DENGUE IN PREGNANCY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANIDEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANIDR SHASHWAT JANI
 
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANIVASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANIDR SHASHWAT JANI
 
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANI
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANITRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANI
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANIDR SHASHWAT JANI
 
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANIPREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANIDR SHASHWAT JANI
 
ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI
ECTOPIC PREGNANCY -  FOGSI GUIDELINES BY DR SHASHWAT JANIECTOPIC PREGNANCY -  FOGSI GUIDELINES BY DR SHASHWAT JANI
ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANIDR SHASHWAT JANI
 
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANI
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANIOVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANI
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANI
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANIOBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANI
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANIDR SHASHWAT JANI
 
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANI
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANINONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANI
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...DR SHASHWAT JANI
 
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING BY DR SHASHWAT JANI
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING  BY DR SHASHWAT JANIMEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING  BY DR SHASHWAT JANI
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING BY DR SHASHWAT JANIDR SHASHWAT JANI
 
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIMANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIDR SHASHWAT JANI
 
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANIMANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANIDR SHASHWAT JANI
 
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANIMANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
GENITAL TB - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANI
GENITAL TB - HOW TO DIAGNOSE  & WHEN TO TREAT  BY DR SHASHWAT JANIGENITAL TB - HOW TO DIAGNOSE  & WHEN TO TREAT  BY DR SHASHWAT JANI
GENITAL TB - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANIDR SHASHWAT JANI
 
EXAMINATION OF MALE IN INFERTILITY - WHAT NOT TO MISS BY DR SHASHWAT JANI
EXAMINATION OF MALE IN INFERTILITY  - WHAT NOT TO MISS BY DR SHASHWAT JANIEXAMINATION OF MALE IN INFERTILITY  - WHAT NOT TO MISS BY DR SHASHWAT JANI
EXAMINATION OF MALE IN INFERTILITY - WHAT NOT TO MISS BY DR SHASHWAT JANIDR SHASHWAT JANI
 

Mehr von DR SHASHWAT JANI (20)

STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptx
STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptxSTANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptx
STANDARD TECHNIQUES OF BREAST FEEDING BY DR SHASHWAT JANI.pptx
 
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANI
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANIEARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANI
EARLY PREGNANCY CHALLENGES IN ART BY DR SHASHWAT JANI
 
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANI
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANITHYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANI
THYROID DISEASES IN PREGNANCY BY DR SHASHWAT JANI
 
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANI
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANIIMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANI
IMPACT OF DEEP ENDOMETRIOSIS ON PREGNANCY & DELIVERY BY DR SHASHWAT JANI
 
DENGUE IN PREGNANCY BY DR SHASHWAT JANI
DENGUE IN PREGNANCY BY DR SHASHWAT JANIDENGUE IN PREGNANCY BY DR SHASHWAT JANI
DENGUE IN PREGNANCY BY DR SHASHWAT JANI
 
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANIDEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI
DEBATE - SHORT CERVIX - OS TIGHTNING BY DR SHASHWAT JANI
 
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANIVASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI
VASOMOTOR PROBLEMS IN MENOPAUSE BY DR SHASHWAT JANI
 
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANI
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANITRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANI
TRANSFER OF A CRITICALLY ILL MOTHER BY DR SHASHWAT JANI
 
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANIPREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
PREVENTION OF PRETERM LABOUR - EVIDENCES FOR PROGESTERONE BY DR SHASHWAT JANI
 
ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI
ECTOPIC PREGNANCY -  FOGSI GUIDELINES BY DR SHASHWAT JANIECTOPIC PREGNANCY -  FOGSI GUIDELINES BY DR SHASHWAT JANI
ECTOPIC PREGNANCY - FOGSI GUIDELINES BY DR SHASHWAT JANI
 
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANI
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANIOVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANI
OVARIAN REJUVENATION - ROLE OF PLATELET RICH PLASMA THERAPY BY DR SHASHWAT JANI
 
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANI
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANIOBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANI
OBSTETRIC PRACTICES IN PRESENT SCENARIO BY DR SHASHWAT JANI
 
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANI
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANINONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANI
NONHORMONAL DRUGS FOR MALE INFERTILITY BY DR SHASHWAT JANI
 
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...
F.I.G.O. GUIDELINES & MEDICAL MANAGEMENT OF A.U.B. ( FOCUS ON PROGESTERONE ) ...
 
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING BY DR SHASHWAT JANI
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING  BY DR SHASHWAT JANIMEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING  BY DR SHASHWAT JANI
MEDICAL MANAGEMENT OF ABNORMAL UTERINE BLEEDING BY DR SHASHWAT JANI
 
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANIMANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
MANAGEMENT OF PREECLAMPSIA BY DR SHASHWAT JANI
 
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANIMANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI
MANAGEMENT OF GESTATIONAL DIABETES MELLITUS BY DR SHASHWAT JANI
 
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANIMANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI
MANAGEMENT OF COMPLICATIONS OF HYSTEROSCOPY BY DR SHASHWAT JANI
 
GENITAL TB - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANI
GENITAL TB - HOW TO DIAGNOSE  & WHEN TO TREAT  BY DR SHASHWAT JANIGENITAL TB - HOW TO DIAGNOSE  & WHEN TO TREAT  BY DR SHASHWAT JANI
GENITAL TB - HOW TO DIAGNOSE & WHEN TO TREAT BY DR SHASHWAT JANI
 
EXAMINATION OF MALE IN INFERTILITY - WHAT NOT TO MISS BY DR SHASHWAT JANI
EXAMINATION OF MALE IN INFERTILITY  - WHAT NOT TO MISS BY DR SHASHWAT JANIEXAMINATION OF MALE IN INFERTILITY  - WHAT NOT TO MISS BY DR SHASHWAT JANI
EXAMINATION OF MALE IN INFERTILITY - WHAT NOT TO MISS BY DR SHASHWAT JANI
 

Kürzlich hochgeladen

Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismusChandrasekar Reddy
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptxNIKITA BHUTE
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfHongBiThi1
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologyDeepakDaniel9
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu Medical University
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 

Kürzlich hochgeladen (20)

Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
power point presentation of Clinical evaluation of strabismus
power point presentation of Clinical evaluation  of strabismuspower point presentation of Clinical evaluation  of strabismus
power point presentation of Clinical evaluation of strabismus
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptxORAL HYPOGLYCAEMIC AGENTS  - PART 2.pptx
ORAL HYPOGLYCAEMIC AGENTS - PART 2.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...American College of physicians ACP high value care recommendations in rheumat...
American College of physicians ACP high value care recommendations in rheumat...
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdfSGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
SGK LEUKEMIA KINH DÒNG BẠCH CÂU HẠT HAY.pdf
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
pA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacologypA2 value, Schild plot and pD2 values- applications in pharmacology
pA2 value, Schild plot and pD2 values- applications in pharmacology
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
historyofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusanguhistoryofpsychiatryinindia. Senthil Thirusangu
historyofpsychiatryinindia. Senthil Thirusangu
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 

DIAGNOSIS OF ENDOMETRIOSIS BY DR SHASHWAT JANI

  • 1. Diagnosis Of Endometriosis Dr. Shashwat Jani. M.S. ( Gynec) Diploma In Advance Endoscopy. Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College, Sheth V. S. General Hospital, Ahmedabad. Mobile : +91 99099 44160. E-mail : drshashwatjani@gmail.com
  • 2. Introduction  Endometriosis initially described by Von Rokitansky in 1860.  Endometriosis is a clinical and pathological entity.  It is characterized by the presence of tissue resembling functional endometrial glands and stroma outside the uterine cavity. 3-Sep-15 2Dr Shashwat Jani 9909944160
  • 3. 3-Sep-15 Dr Shashwat Jani 9909944160 3
  • 4. It is not a neoplastic condition, but malignant transformation is possible. 3-Sep-15 Dr Shashwat Jani 9909944160 4
  • 5. Incidence  3 – 10 % of women of reproductive age  20-40% in infertile women  5-20% with chronic pelvic pain  20-50% asymptomatic, found during laparoscopy and sterilization.  50% dysmenorrhea 3-Sep-15 5Dr Shashwat Jani 9909944160
  • 6. Etiology Estrogen dependent disease  Sampson’s theory Ectopic transplantation of endometrial tissue.  Meyer’s theory Coelomic metaplasia.  Halban's theory: Induction theory Genetic factors Immunologic factors Unknown factor Autoimmune Combination of the Above Environmental factors - dioxin No Single Theory Explains All Cases of Endometriosis 3-Sep-15 6Dr Shashwat Jani 9909944160
  • 7. Risk Factors Family history of endometriosis. Early age of menarche Short menstrual cycles (<27 d)  Long duration of menstrual flow (>7 d) Heavy bleeding during menses  Inverse relationship to parity  Delayed childbearing  Defects in the uterus or fallopian tubes  less use of OCs 3-Sep-15 7Dr Shashwat Jani 9909944160
  • 8. Diagnosis  Clinical Presentations  Clinical Examinations  Imaging Modalities  Histological Diagnosis  Biochemical Markers  Surgical Diagnosis 3-Sep-15 8Dr Shashwat Jani 9909944160
  • 10. Symptoms  PELVIC - Dymenorrhoea (50%), Abnormal menstruation (60%) Dyspareunia, Chronic Pelvic Pain, Premenstrual spotting  GASTROINTESTINAL- Constipation, Diarrhea, Hematochezia, Tenesmus  URINARY COMPLAINTS- Flank pain, Back pain, Abdominal pain, Urgency, Frequency,Hematuria  PULMONARY- Haemoptysis , Pneumothorax  INFERTILTY 3-Sep-15 10Dr Shashwat Jani 9909944160
  • 11. Dysmenorrhea  Most common symptom  Pain starts a few days prior to menstruation, gets worse during menstruation( secondary dysmenorrhoea)  Pain due to Increased secretion of PGF2α, Thromboxane β2 from endometriotic tissue. 3-Sep-15 11Dr Shashwat Jani 9909944160
  • 12. Abnormal Menstruation - Menorrhagia is a predominant abnormality. - Polymennorhoea, premenstrual spotting also occur. Dyspareunia It is usually deep, due to stretching of the structures of the Pouch of Douglas or direct contact tenderness found in endometriosis of rectovaginal septum or Pouch of Douglas and with fixed retroverted uterus. 3-Sep-15 12Dr Shashwat Jani 9909944160
  • 13. Lower Abdominal Pain Abdominal pain lower abdominal pain or backache May be due to inflammation in peritoneal implants due to cystic bleeding Irritation or invasion of nerve Action of inflammatory cytokines released by the macrophages. 3-Sep-15 13Dr Shashwat Jani 9909944160
  • 14. Infertility • Mechanical interference--- • Pelvic adhesions • Chronic salpingitis • Impaired oocyte pickup • Altered tubal motility • Distortion of tubo-ovarian relations • Alteration in peritoneal fluid • Increased concentration of prostaglandins • Increased number of macrophages • Increased production of cytokines • Phagocytosis of sperms 3-Sep-15 14Dr Shashwat Jani 9909944160
  • 15. • Abnormal Systemic Immune system • Increased cell-mediated gametes injury • Increased prevalence of autoantibodies • Hormonal or ovulatory dysfuntion • Defective folliculogenesis • Luteinized unruptured follicle syndrome • Hyperprolactinemia • Luteal phase deficiency • Implantation failure 3-Sep-15 15Dr Shashwat Jani 9909944160
  • 16. Clinical Examination General conditions- Pallor + due to Menorrhagia P/A - Mass may be felt in lower abdomen arising from the pelvis Enlarged chocolate cyst or tuboovarian mass, due to endometriotic adhesions. The mass is tender with restricted mobility. L/E- See Vulva and other structures P/S- See cervix, vagina for any deposits, discharge or growth. 3-Sep-15 16Dr Shashwat Jani 9909944160
  • 17. Bimanual Pelvic Examination o Tender uterosacral ligament o Cul-de-sac nodularity found o Induration of the rectovaginal septum o Fixed retroversion of the uterus o Adnexal masses and generalized or localized pelvic tenderness present o Uterosacral nodules may be found 3-Sep-15 17Dr Shashwat Jani 9909944160
  • 18. ASRM Classification 3-Sep-15 18Dr Shashwat Jani 9909944160
  • 20. ASRM staging has poor correlation with pregnancy rate. In 2009 new staging system was proposed called “ Endometriosis Fertility Index. “ EFI is numerical measure of functional anatomy based on assessment of tubes, fimbriae and ovaries. EFI score 0 to 10 (0 – poorest and 10 – the best prognosis). 3-Sep-15 20Dr Shashwat Jani 9909944160
  • 21. Imaging Modalities  TVS & TRS  CT SCAN  MRI 3-Sep-15 21Dr Shashwat Jani 9909944160
  • 22. USG First line tool for suspected endometriosis Detects ovarian cysts ( Endometrioma ) and rule out other causes  May have role in detection of involvement of Bladder & Rectum. Detection of Endometrioma using USG is excellent with 83 % Sensitivity and 98 % Specificity. 3-Sep-15 22Dr Shashwat Jani 9909944160
  • 23. Classical Appearance :  Homogenous , Hypoechoic mass with in the ovary with diffuse low level internal echoes with hyperechoic foci within the wall.  Wall nodularity should be differentiated from hyperechoic foci within the wall.  95% of endometriomas display low level of internal echoes. D/D : Dermoid , Hemorrhagic , Cystic neoplasm 3-Sep-15 Dr Shashwat Jani 9909944160 23
  • 24. TRS : - To look at Sigmoid for endometriotic infiltrates. - Rounded or triangular hypoechoic deposits. - Infiltration of bowel wall is seen as thickening of Muscularis Propria. Doppler : • Better studied in late follicular & early luteal phase. • Blood flow in Endometrioma is usually Pericystic with RI > 0.45. 3-Sep-15 Dr Shashwat Jani 9909944160 24
  • 25. CT Scan / MRI  MRI may detect even smallest of lesions and distinguish hemorrhagic signal of endometriotic implants; superior to CT scan in detecting limits between muscles and abdominal subcutaneous tissues  MRI demonstrated to accurately detect rectovaginal disease and obliteration in more than 90% of cases when ultrasonographic gel was inserted in the vagina and rectum 3-Sep-15 25Dr Shashwat Jani 9909944160
  • 26. Sensitivity 90 % Specificity 98 %  Major role is to help visualize laparoscopic blind spots such as retroperitoneal space and lesions obscured by dense adhesions or typical lesions. DPE is best diagnosed and located by TRS & MRI. 3-Sep-15 Dr Shashwat Jani 9909944160 26
  • 27. I.V. Urography : - Serosal deposits are seen at dome of bladder. - Involvement of Ureter is also seen. Barium Enema : Serosal deposits are causing thickening and fibrosis of Muscularis propria which is demonstrated as asymmetric narrowing or eccentric intramural filling defect. 3-Sep-15 Dr Shashwat Jani 9909944160 27
  • 28. Histological Diagnosis • Positive confirms But Negative doesn’t exclude. • Visual is usually adequate but histology of any one lesion is ideal • In > 4 cm endometrioma & Deep infiltrating disease – histology should be done to identify endometriosis and exclude malignancy. 3-Sep-15 Dr Shashwat Jani 9909944160 28
  • 29. • Microscopically : Implants consist of endometrial glands and stroma with or without hemosiderin laden macrophages. 3-Sep-15 Dr Shashwat Jani 9909944160 29
  • 30. Biochemical Marker CA - 125  Cancer Antigen-125, a high molecular weight glycoprotein expressed on the cell surface of some derivatives of embryonic coelomic epithelium.  It is elevated towards the end of the luteal phase and during menstruation.  In many other conditions elevated CA-125 concentration like PID, adenomyosis, uterine leiomyoma, menstruation, pregnancy, epithelial ovarian cancer, pancreatitis, chronic liver disease. 3-Sep-15 30Dr Shashwat Jani 9909944160
  • 31.  The result of most studies suggest that CA- 125 is not sufficiently sensitive to identify lesser stages of endometriosis. CA-125 is NOT reliable as a screening test. 3-Sep-15 31Dr Shashwat Jani 9909944160
  • 32. Surgical Diagnosis “ Diagnostic Laparoscopy is the Gold Standard investigation for Endometriosis…” 3-Sep-15 32Dr Shashwat Jani 9909944160
  • 33. For a definitive diagnosis of endometriosis, visual inspection of the pelvis at laparoscopy is the gold standard investigation, unless disease is visible in the posterior vaginal fornix or elsewhere… 3-Sep-15 Dr Shashwat Jani 9909944160 33
  • 34.  Can classify the extent and severity of disease.  A double puncture technique is essential.  The grasper placed through the lower abdomen sheath permits mobilization of the tube and ovaries. 3-Sep-15 34Dr Shashwat Jani 9909944160
  • 35.  Inspect the lateral side wall, all ovarian surface, both sides of the broad ligament, the bladder, bowel serosa, inferior aspect of cul-de-sac, evaluation of the uterosacral ligaments and rectal serosa.  To avoid under diagnosis it should not be performed during or within 3 months of hormonal therapy. 3-Sep-15 Dr Shashwat Jani 9909944160 35
  • 36. Findings are…  Typical “powder-burn or “gunshot” lesions on the serosal surface of the peritoneum. These lesions are black, blue or dark brown, nodules or small cysts containing old hemorrhage surrounded by variable degree of fibrosis.  White lesions are predominantly fibromuscular scarring with scattered glandular and stromal elements.  Brown lesions are mainly haemosiderin deposits. Peritoneal defect and subovarian adhesions contain endometriosis in 40% -70%. 3-Sep-15 36Dr Shashwat Jani 9909944160
  • 38.  For ovarian endometriosis- Large ovarian endometriotic cysts are usually located on the anterior surface of the ovary and associated with retraction, pigmentation and adhesions to the posterior peritoneum.  Ovarian endometriotic cyst contain a thick, viscous dark brown fluid. (Chocolate fluid) 3-Sep-15 38Dr Shashwat Jani 9909944160
  • 39. 3-Sep-15 39Dr Shashwat Jani 9909944160 Chocolate cyst– sometimes it is confused with hemorrhagic corpus luteum cysts and neoplastic cysts. Biopsy must be done.